Executive summary
Between June 2006 and April 2007 the Transport Accident Investigation Commission (the Commission) launched inquiries into 5 separate platform overrun events on the Auckland suburban rail network. Because there appeared to be a number of common factors contributing to the overruns, they have been combined into this one report.
All overruns involved push/pull train sets designed and modified in New Zealand from 2003 to cater for the growing needs of the Auckland transport network, pending expansion and modification of the rail infrastructure to cater for new electric train sets within 7 to 9 years. In all cases the trains were being driven by Toll Rail locomotive engineers in the push mode.
There were no injuries and no damage resulting from any of the 5 incidents. In 4 of the 5 incidents the procedures for dealing with a platform overrun were followed correctly.
In one of the incidents, the driver reversed his train to the platform without the required authority from train control.
The driving technique of the Toll Rail locomotive engineers was a significant factor leading to the platform overruns. In particular, there was no standardised methodology taught for braking and other train-handling techniques. Trainer drivers were not taught how to teach trainee drivers and were themselves not subject to minimum levels of experience and competency before undertaking trainer duties.
The Commission found that the brake system design was not ideally suited for outer-urban commuter train operations, but it was considered fit for the trains' intended purpose of outer-urban, limited-stop operations that existed in Auckland at the time.
The Commission determined that the National Rail System Standard for passenger train braking distance was not relevant to the design of the network at the time, so the fact that the trains did not comply with that Standard for stopping distance was not in itself a significant safety issue. However, the fact that the trains were signed off as being compliant while they technically did not meet the Standard was a safety issue that needs addressing by the industry.
The Commission has also determined that the National Rail System Standard needs to be reviewed to ensure it is consistent with good rail operating practice and is applicable to the New Zealand rail industry, and that the regulator needs to maintain a tight control over the Standard that are currently governed by the industry.
This report should be read in conjunction with the Commission's previous Report 05-123, Empty passenger Train 4356, overrun of conditional stop board without authority, following an automatic air brake valve irregularity at Meadowbank on 6 October 2005. In that report the Commission commented on the design, performance and maintenance of the brake system on the push/pull fleet. Some of the findings and recommendations in Report 05-123 are equally applicable to this report.
Toll Rail's interpretation of the National Rail System Standard and its decision to test the stopping performance of the push/pull sets based on single-car breakaway tests, rather than as a complete train, resulted in the Standard as written not being complied with.
There was, however, an error within the Standard that had not been detected by either the operating company or the regulator until the trains had been in service for 4 years.
The report makes comments on what level of regulatory oversight should be applied to the design, build and sign off for the push/pull train sets.
Two recommendations have been made to the Chief Executive of the New Zealand Transport Agency to address the safety issues identified in this report about the standards of driver training and compliance with the National Rail System Standard.
Three recommendations have been made to the Secretary for Transport about the status of the National Rail System Standard.
The report includes inquiries 06-105 and 06-107.
Related Recommendations
The National Rail System Standard has not been fully reviewed since they were established in 2004. Once the status of the standards and its Committee has been established then an independent review of the standards should be conducted to determine if they are still applicable to the New Zealand rail industry, and to ensure if they are representative of standards set in other comparative countries operating modern rail systems.
The training system for drivers of the push/pull sets on the Auckland rail network did not use standard training techniques, did not teach standard best practice methods for train operations, and did not include appropriate standards for minder drivers to achieve before being certified to teach trainee drivers.
The push/pull train sets were signed off as fit for purpose and commissioned to the Auckland passenger train network when they did not comply with the National Rail System Standard with regard to maximum allowable stopping distance as a complete train, and it has not yet been proven that they do so under all conditions of loading and track condition.
It was recommended to the Secretary for Transport that he address the following safety issues: The status of the NRSS Committee, the rights to membership of that committee and the responsibilities of each Committee member, and the terms of reference of the Committee is currently unclear. (034/10)
It was recommended to the Secretary for Transport that he address the status of the National Rail System Standard and the relationship between these standards and rail participants' safety cases and underlying safety systems is not clear. For example, it is not clear whether KiwiRail's safety case and its underpinning safety system can be required to comply with the NRSS as a minimum, or whether the NRSS is subservient to KiwiRail's safety system. An approved (by the regulator) change to KiwiRail's safety system could then by default become an approved change to the NRSS.