Executive summary
On Saturday 22 July 2000, at about 1927, express freight Train 378 derailed when it entered a crossover at the north end of Te Maunga while travelling too fast. The locomotive was severely damaged when it overturned following the derailment. The locomotive engineer suffered minor injuries. The train controller had incorrectly set a medium speed route to Mount Maunganui instead of the intended high speed route to Tauranga. The locomotive engineer did not react to the unexpected signal aspects displayed.
Safety issues identified included:
• non-adherence to basic train control techniques
• the distracting train control environment
• an emerging pattern of serious operating irregularities involving train controllers
• the potential for locomotive engineers to misinterpret unexpected medium speed signals.
Safety actions taken and recommendations made to the Land Transport Safety Authority and the operator address these issues.
Related Recommendations
Carry out an LTSA investigation, or initiate a specific audit, of Train Control operations, such investigation or audit to include: • the resources available to meet the workload demand • the suitability of the roster system • the maximum shift desirable • the adequacy of arrangements for meals and other breaks during shifts • the adequacy of the current training system • the suitability of staff trained under any other system • the effectiveness of the safety observation and compliance monitoring system • the suitability and control of the work environment
implement a revised signalling system controlling northbound trains approaching Te Maunga to provide enhanced advance warning to the LE of a train routed to the Mount Maunganui Branch, and develop and action a priority list of any similar locations where an enhanced advance warning would reduce an unacceptable risk of high speed entry to a medium speed route.