Express freight Train 239, wagons left in section at 514.9km, between Te Awamutu and Te Kawa, 22 September 2007
Status
Closed
Occurrence Date
Report Publication Date
Jurisdiction
NZ
Legacy Inquiry Number
07-113
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.
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.
Location
Te Awamutu - Te Kawa (-38.028006,175.307066) [may be approximate]