Executive summary
On Wednesday 7 August 2002, at about 1335, train control gave authority for westbound express freight Train 484 to depart Tauranga and enter a section of track already occupied by a hi-rail vehicle travelling towards the train.
Some minutes after the train departed, the train controller in-training realised he had set up a potential collision so he contacted the locomotive engineer and instructed him to stop the train. When the train stopped, about 300 m separated the train and the hi-rail vehicle.
The safety issues identified included:
* the incorrect procedures for handling track user inquiries
* the non-application of signal “blocking commands” to protect the hi-rail vehicle movement
* the training and certification of new entrant train controllers on additional train control desks soon after their initial certification
* the absence of a familiarisation site visit prior to certification on a train control desk.
Safety recommendations have been made to the managing director of Tranz Rail to address these issues.
Related Recommendations
Ensure that the following initial training and certification, new entrant controllers do not commence training on another train control desk until they have completed at least 6 months duty on their first train control desk.
Critically review policy for train control rosters with respect to allowable numbers of consecutive shifts and hours worked to ensure: · mini rosters are controlled within defined criteria compatible with the principles used in compiling base rosters. · defined criteria are met before offering additional shifts to train controllers. · actual hours are monitored and immediate corrective action taken when factors increase rostered shifts beyond acceptable limits.
Include a site familiarisation trip with the tutor train controller and an experienced operating or maintenance person as part of the training and certification for any train control desk together with at least one unaccompanied field trip scheduled within an acceptable timeframe following certification as a follow up.