Executive summary
On Friday, 26 July 2002, at about 0150, Train 533, a westbound express freight, derailed as it negotiated a 45 km/h speed restricted curve after descending a 1 in 51 gradient between Whangamomona and Te Wera. The train plunged about 12 m down the side of the track formation killing the locomotive engineer. A second crew member sustained serious injuries.
The 2 locomotives and several wagons on the train were extensively damaged, but the track sustained minor damage only.
Causal factors included:
· the locomotive crew’s loss of attention and situational awareness consistent with their having fallen asleep
· consuming alcohol prior to commencing duty
· the accepted non-compliance with track warrant instructions
· the inability of the locomotive vigilance system to overcome such short-term attention deficits in time to prevent this type of accident.
Safety recommendations have been made to address these issues.
Related Recommendations
Redevelop the current emergency response training programme for train controllers and network control managers, in conjunction with appropriate external agencies, to include but not limited to: · responding to emergency notifications · dealing with potentially distraught people reporting emergencies · procedures for ensuring emergency sites are identified and confirmed · the use of maps and map grid references when establishing such sites · procedures for contacting emergency services
Introduce the use of flashing red lights to identify the rear of all trains, not only those operating under ATC conditions.
Provide train controllers with documentation clearly defining and illustrating the boundaries of radio repeaters in use on the respective routes of the network.
Ensure that all employees who carry out safety-critical duties within the operations area receive formal training in fatigue awareness and management with priority being given to shift workers. Such courses should also be made available to staff members’ families and be completed by the end of 2004.
Take steps to identify and correct the repetitive non-compliance with Tranz Rail's rules and procedures for safe operation identified during the investigation of this accident.
Ensure that all employees who carry out safety-critical duties within the operations area receive formal training in fatigue awareness and management with priority being given to shift workers. Such courses should also be made available to staff members’ families and be completed by the end of 2004.
Investigate train operations and route management on the Stratford to Okahukura Line, and other routes through remote areas; such investigation to include: • the performance of the train control radio system • the suitability of, and compliance with procedures, for tracking the progress of trains en-route • the procedures when en-route track warrant clause 10 radio check calls are not acknowledged by train control • the effectiveness of any existing emergency response plan • crew arrangements and rostering and initiate the action necessary to address any deficiencies found.
Either invoke Section 6F (1) of the Transport Services Licensing Act 1989 or, alternatively, procure changes to legislation or, alternatively, by any other process you judge suitable, ensure that the approved safety system for all operators operating on the principal lines, loops and sidings of the national rail network includes a requirement for a train control voice-recording facility and a train control radio log capable of being downloaded for analytical purposes.
Either invoke Section 6F (1) of the Transport Services Licensing Act 1989 or, alternatively, procure changes to legislation or, alternatively, by any other process you judge suitable, ensure that the approved safety system for all operators operating on the principal lines and loops of the national rail network, includes a requirement for the use of locomotive event recording devices in any locomotive, railcar, electric multiple unit or diesel multiple unit operated on a principal line or loop , together with the facilities to extract, store and print such information within an acceptable time
Take steps to improve the effectiveness of Tranz Rail’s track warrant compliance monitoring regime in identifying repeated non-compliances at an early stage, and initiating appropriate follow-up action.
Introduce procedures that define permanent, pre-determined call locations on routes under track warrant control, from where locomotive engineers must call train control to confirm their whereabouts; together with a requirement that if such calls are not acknowledged by train control, the train must stop at the next track warrant station or designated intermediate board until communication is established.
Either invoke Section 6F (1) of the Transport Services Licensing Act 1989 or, alternatively, procure changes to legislation or, alternatively, by any other process you judge suitable, ensure that the approved safety system for all rail operators includes a policy for managing the risks associated with substance induced performance impairment. Such a policy should: · be focused on education · include all levels of staff and be collaborative between them · include major contractors working for the licence holder