Executive summary
On Monday 9 October 2006 at 0806, passenger Train 4045 travelled 526 metres between Britomart station and Quay Park junction with the locomotive engineer not at the controls of the train. The locomotive engineer had left the train to operate a valve to restore air-brake pressure following an uninitiated emergency brake application. Once air-brake pressure had been restored, the train began to move before the locomotive engineer re-boarded the train.
There was no damage and none of the 3 crew and 12 passengers on board at the time was injured.
Safety issues identified included:
- adherence to standard operating procedures
- maintenance and testing of passenger emergency stop mechanisms
- diagnosing and correcting intermittent faults on old passenger rolling stock
- the provision of event recorders
- monitoring fault trends for safety-critical equipment
- audit performance
Four safety recommendations have been made to the Chief Executive of the New Zealand Transport Agency to address these issues.
Related Recommendations
There is recurring evidence indicating that standards of maintenance of rolling stock on the national rail network as demanded in Veolia's and KiwiRail's safety cases is lower than preferable and reasonable in that for example: - manufacturers' inspection, repair and maintenance instructions are not always documented and followed - safety critical components are not always identified and documented - work instructions for maintaining safety-critical equipment are not always issued and work on safety-critical components is not always signed off by someone other than the maintainer
The scope and depth of the New Zealand Transport Agency Programme for rail participants might now be appropriate for the license hodlers being assessed, audited or otherwise and auditors do not make full use of the information available that signals potential area of system weaknesses; information from accident and incident reports and recommendations being examples of some of the information available.
There is no requirement for operators of passenger trains to have effective communication between the locomotive engineer and the on-board person in chage of passenger operations that will facilitate good crew resource management and be effective in emergency situations.
The date by which all passenger trains were required by the NRSS to be fitted with event recorders was extended by the rail participants without consulting with and getting spproval from New Zealand Transport Agency.