Executive summary
On Tuesday 18 January 2005, a track warrant control irregularity occurred at Woodville when a track warrant was issued to a locomotive engineer authorising his train to berth on the main line at Makotuku to cross an opposing train. The locomotive engineer of the opposing train was already in possession of a track warrant authorising his train to berth on the main line at Makotuku.
On the same day a second track warrant irregularity occurred when a track warrant was issued to a locomotive engineer authorising his train to proceed from Otane to Takapau to cross an opposing train. The locomotive engineer of the opposing train was already in possession of a track warrant authorising his train to travel to Waipukurau for the same crossing. He brought this to the attention of the train controller and a potential head-on collision between the trains was averted.
There were no injuries.
Safety issues identified included:
· fatigue arising from rostering procedures for train controllers
· the use of rostered off duty train controllers to meet short-term staff shortages in the train control office
· the inability of the locomotive engineer to check the detail of issued track warrants against the preparation details.
Because of the similarities arising from each incident they have been combined into one report.
Five safety recommendations have been made to the Chief Executive of ONTRACK.
Related Recommendations
introduce into existing train control rostering procedures a defined maximum number of consecutive at-risk (night) shifts that may be worked together with provision for a mandatory rest period before commencing the next shift rotation.
ensure that where a train control shift is extended beyond 8 hours a mandatory break of at least 15 minutes is available to the train controller as close as practicable to the start of the shift extension.
ensure that adequate appropriately trained staff are available to enable relief for vacancies amongst train controllers as a result of sickness etc to be undertaken without calling on staff rostered for or already on mandatory rest periods between shifts.
ensure that existing fatigue management training programmes include, but are not limited to, issues such as sleep practices, lifestyle, family commitments and the use of drugs including alcohol and stimulants etc.
initiate changes to the Track Warrant computer System to introduce a cross check function in the Clause 3 "to location" field when train controllers are issuing previously prepared track warrants.