Executive summary
At about 1915 on Saturday 22 September 2007, southbound express freight Train 239 parted between the 22nd and 23rd wagons while the train was travelling on the North Island Main Trunk line between Te Awamutu and Te Kawa. The emergency brakes applied automatically as the air pressure in the brake pipe reduced and both portions of the train rolled to a stop, some distance apart.
The locomotive engineer went back to examine the train and saw that there was no train end monitor attached to the last wagon. Thinking this was the last wagon on the train and that the loss of the train end monitor was responsible for the loss of air in the brake pipe, he advised train control and continued, leaving behind the rear 10 wagons. These wagons were found some time later by the locomotive engineer of a following train who was following at caution on instruction from train control, because the section of track was showing as occupied on the train control centralised traffic control panel.
There were no injuries and no damage to the train or infrastructure.
The safety issues identified included:
- the manual overriding of a correctly operating signalling system
- failure to establish beyond reasonable doubt the cause of the brake pipe air loss
- failure to ensure beyond reasonable doubt that the Te Awamutu – Te Kawa block section was unoccupied before a train was authorised to enter the block section
- the poor level of training in and application of crew resource management within the rail industry
- the response of train controllers to operating incidents.
One safety recommendation covering these issues has been made to the Chief Executive of the New Zealand Transport Agency.
Related Recommendations
Ensure that a review is undertaken of current crew resource management training by all participants in the rail industry, including how the principals of crew resource management are being implemented. The outcome of the review and any corrective action should ensure that staff are equipped with the skills necessary to effectively use crew resource management techniques to reduce operational occurrences.
Ensuring the completeness of a train following a train parting or similar event is a safety-critical procedure for protecting against wagons being inadvertently left behind and creating the potential for a high speed collision in track warrant territory. The Commission believes that the circumstances where the procedure for ensuring the completeness of the train was so easily by-passed on this occasion is a safety issue. The Commission recommends that the New Zealand Transport Agency addresses that safety issue.