Executive summary
On Saturday 12 May 2007, at 0400, northbound express freight Train 720 travelled past Seddon towards Vernon on the Main North Line without the authority of a track warrant issued from train control.
The locomotive engineer did not stop on the main line at Seddon as required and obtain a new track warrant to travel beyond Seddon. Southbound Train 723 was sitting on the loop when Train 720 passed through Seddon. There were no other conflicting movements and as a result there was no damage or injury.
Safety issues identified were:-
• management of fatigue in train operations
• detecting sleep disorders
• locomotive engineer vigilance systems
• crew resource management
• monitoring of rail vehicles on non-track-circuited sections of the controlled network.
Four safety recommendations have been made to the Chief Executive of the New Zealand Transport Agency to address theses issues.
Related Recommendations
The terms of reference for Project Kupe do not currently include further development into full positive train control capability. The Commission recommends the New Zealand Transport Agency takes action to ensure that any project to enhance train control functionality results in a progressive move to achieving positive train control (005/09).
The development of Project Kupe system has the potential to reduce the risk of collision on the network but, due to resource and funding restraints without a cost/safety benefit analysis being undertaken, the project has extended out by 2½ years and has still not been approved. The Commission recommends the New Zealand Transport Agency takes action to address the safety issue (004/09).
The modern computerised Tranzlog vigilance system is capable of increased alertness monitoring beyond that currently exploited. The Commission recommends the New Zealand Transport Agency takes action to address the safety issue whereby for about 5 years after the technology had become available that could reduce the risk of fatigue related occurrences; the rail industry has not exploited this opportunity (002/09).
The Commission recommends the New Zealand Transport Agency takes action to address the safety issue whereby locomotive engineer medical tests procedures that could increase the likelihood of detecting sleep and other associated disorders do not currently include the use of modern diagnostic monitoring systems (003/09).