Executive summary
At about 1640 on Tuesday 19 September 2000, Train P28 Pahiatua - Palmerston North shunting service passed signal 4R at Danger and entered the main line at Woodville which was occupied by opposing Train 601 Bay Express passenger express. Train 601 had a Clear Proceed signalled route and was not expecting to stop. The conflict was soon realised and both trains were brought to a stop about 750 m apart. Train P28 derailed when its locomotive engineer tried to reverse off the main line through a set of points that had been "run through" when the signal had been passed at Danger.
The safety issues addressed in this report are:
• the site knowledge, training and certification of the rail operator
• the ability of the rail operator to identify and understand the indications of a low speed signal
• the lack of documented procedures for the advancing of trains which have stopped after overrunning a signal which reverted to Danger in front of the locomotive engineer
• the total reliance placed on locomotive engineers to follow signal indications to avoid conflicts.
Two safety recommendations have been made to the operator.
Related Recommendations
introduce a signals qualification into the certification process for second persons to assist with the identifying and understanding of signal indications, particularly when acting as the eyes of the LE in long hood running situations.
introduce check procedures for staff involved with the signalling of trains before authorising a train to continue after it has overrun a signal which reverted to Danger as it approached