Annotated version of Fig 6 from TAIC report. (Image for illustration only to assist understanding, altered from original Fig 6 in TAIC report).
Loaded coal train 850, signal passed at danger, Cora Lynn, Midland line, 27 February 2024
Status
Closed
Occurrence Date
Report Publication Date
Jurisdiction
NZ
What happened
At about 0800 on 27 February 2024 a loaded coal train (Train 850 with locomotive DXC5385, operated by KiwiRail) departed Arthur’s Pass station and was travelling towards Lyttelton.
The locomotive engineer (LE) had taken over the train at Arthur’s Pass station. Before departure, train control had instructed the LE to cross another train at Cora Lynn, approximately 15 kilometres (km) east of Arthur’s Pass station.
A yellow intermediate signal on the approach to Cora Lynn indicated that the arrival signal was at stop. However, the LE did not take the necessary steps to bring the train to a standstill before entering Cora Lynn. The train continued past the arrival signal at stop and entered the main line at 44 kilometres per hour (km/h).
On this occasion the route was set for the train to enter the main line, not the loop where an opposing train was located, and a collision was avoided.
Why it happened
While the LE could offer no explanation for not stopping at the arrival signal, they had very recently been unwell with COVID-19 while on annual leave. The LE stated that in hindsight they should not have returned to work while still suffering the after-effects of a COVID-19 infection.
What we can learn
Acute illnesses, such as COVID-19, may impair cognitive functions such as memory and concentration for a period following recovery from the illness. Safety-critical workers should consider potential after-effects of an acute illness when self-assessing as being fit to return to work. Organisations employing safety-critical workers should also be aware that the after-effects of an acute illness may reduce a worker’s ability to reliably self-assess as being fit to return to work.
Who may benefit
Organisations involved in safety-critical work, all safety-critical workers and their managers may benefit from the findings in this report.
At about 0800 on 27 February 2024 a loaded coal train (Train 850 with locomotive DXC5385, operated by KiwiRail) departed Arthur’s Pass station and was travelling towards Lyttelton.
The locomotive engineer (LE) had taken over the train at Arthur’s Pass station. Before departure, train control had instructed the LE to cross another train at Cora Lynn, approximately 15 kilometres (km) east of Arthur’s Pass station.
A yellow intermediate signal on the approach to Cora Lynn indicated that the arrival signal was at stop. However, the LE did not take the necessary steps to bring the train to a standstill before entering Cora Lynn. The train continued past the arrival signal at stop and entered the main line at 44 kilometres per hour (km/h).
On this occasion the route was set for the train to enter the main line, not the loop where an opposing train was located, and a collision was avoided.
Why it happened
While the LE could offer no explanation for not stopping at the arrival signal, they had very recently been unwell with COVID-19 while on annual leave. The LE stated that in hindsight they should not have returned to work while still suffering the after-effects of a COVID-19 infection.
What we can learn
Acute illnesses, such as COVID-19, may impair cognitive functions such as memory and concentration for a period following recovery from the illness. Safety-critical workers should consider potential after-effects of an acute illness when self-assessing as being fit to return to work. Organisations employing safety-critical workers should also be aware that the after-effects of an acute illness may reduce a worker’s ability to reliably self-assess as being fit to return to work.
Who may benefit
Organisations involved in safety-critical work, all safety-critical workers and their managers may benefit from the findings in this report.