Executive summary
On Tuesday 19 June 2007 at about 1105, express freight Train MP2 was travelling between Huntly and Te Kauwhata when it struck a gantry crane from Work Train 22. Work Train 22 was stationary and was working on the adjacent Down Main line with its cranes fouling the Up Main line. The gantry swung around and struck one of the crane operators, knocking him from the wagon and under the passing train. The operator was fatally injured.
The safety issues identified included:
• the unfamiliarity of staff working in double-line territory
• the absence of an appropriate induction for the person-in-charge and the rail recovery unit operators prior to working in double-line territory
• the absence of a hazard analysis and task briefing prior to starting work on the day
• the absence of any worksite protection on the adjacent main line
• unclear procedures regarding the application of appropriate protection rules
• the level of auditing or regulatory oversight of the safety system.
Seven safety recommendations covering these issues have been made to the Chief Executive of the New Zealand Transport Agency (formerly Land Transport New Zealand).
Related Recommendations
The rules-based system adopted by the rail industry in New Zealand is overly complex and relies heavily on employees’ knowledge of it. The training and assessment programme for ensuring compliance did not in this case result in a safe operation. The lessons about rule complexity learned from the Glenbrook inquiry, and the similarities to the New Zealand railway rules system, suggest that the rule complexity issue might be widespread throughout the New Zealand rail system.
There is no standard system of hand signals across the rail industry for use when directing operations involving cranes and other lifting devices, such as on the rail recovery unit.
Trains passing through or adjacent to work sites in double-line territory can, under some circumstances, do so at maximum line speed, up to 80 km/h in the case of freight trains, and up to 100 km/h in the case of passenger trains, putting track workers at significant risk.
Ontrack’s system for ensuring staff competency and currency with rules and operating procedures has not been audited for 2 years, and in spite of the person-in-charge of the accident site at Ohinewai holding current Ontrack certification for his duties, he had not been properly inducted into a new work environment, he was not following documented procedures, and he together with other crew in similar roles was routinely violating documented procedures for work site protection.
The track protection matrix contained in the Rail Operating Rules and Procedures is not clear on requirements for work site protection in some cases, the rail recovery unit being one example.
The level of compliance monitoring of Ontrack does not appear to be appropriate given the size and complexity of its safety system and the safety issues raised in this report.
Communication between members of work gangs in noisy environments can be seriously hampered by noise and the ear defenders worn by crew to protect against that noise, often making visual contact the sole method available for communicating. The uptake by the rail industry of technological advances such as radio equipment integrated into safety equipment has been progressed but has been slow.
The quality of crew resource management to achieve outcomes in this case, including the management of resources at different locations such as the train control centre, locomotive cabs and track work sites, sometimes using different communication methods, was of a poor standard, and previously published occurrence reports, as well as other, still open investigations, indicate that the standard of crew resource management across the rail industry is not adequate.