Executive summary
At about 1150 on Thursday 28 December 2000, a diesel multiple unit Train 3134 collided head on with another diesel multiple unit Train 3130 on the up main line between Penrose and Ellerslie. Train 3130 had become disabled at Ellerslie and with the assistance of a relief diesel multiple unit was setting back to Penrose in a wrong line running movement on the up main line. Through a series of miscommunications the train controller unknowingly authorised the wrong line running, which resulted in Train 3134 and Train 3130 assisted by the coupled relief DMU, being in the same section of track while moving in opposing directions.
Two crew members and seven passengers suffered minor injuries.
The safety issues identified included:
• the inadequacy of verbal procedures to provide defences against human error
• the training and certification of new entrant train controllers on additional train control desks soon after their initial certification
• insufficient opportunity offered to train control trainees to view the various operating systems in use during their training
• the lack of a structured process for area familiarisation prior to or during certification on a train control desk
• the routine involvement of train controllers in (non-operational) work created by incidents
• the absence of clear communication between the locomotive engineers, maintenance staff and the train controller resulting in not everyone sharing the same concept of the plan to restore the train network
• the unreliable radio communications existing between the train controller and locomotive engineers at the time of the incident.
Related Recommendations
liaise with emergency services to ensure that existing contact procedures are adequate and that the training and ongoing certification of train controllers reinforces such procedures.
include an area familiarisation trip with an experienced train controller or similarly qualified person as part of the training and certification for any train control desk together with an unaccompanied field trip scheduled within an acceptable timeframe following certification as a follow up
ensure that staff are available in the train control centre to assist the train controller by liasing with Tranz Metro when suburban train services are disrupted
ensure that following initial training and certification, new entrant train controllers do not commence training on another train control desk until they have completed at least 12 months duty on their first train control desk
conduct a full audit of the Auckland train control radio system to ensure it meets required standards for communication between train controllers and locomotive engineers, including Tranz Metro services
increase the amount of information available in the existing site photography book to include street maps etc so that it becomes the major reference manual for train controllers in emergency situations and ensure that such books are made available on all train control desks
ensure that trainee train controllers view the operations of the various signalling systems on the Tranz Rail network during their initial training at the train control school