There were 2 safety issues identified with the Wellington maintenance depot processes:
- there were no individual task instructions on how each job was to be done
- there was no check sheet associated with each task to record that important steps and checks for the task had been completed.
Instead, the depot relied on the knowledge of the depot staff to complete each task satisfactorily.
These shortcomings in maintenance control could be indicators of other safety issues within the wider maintenance system at the Wellington maintenance depot.
On 13 August 2013 the Commission recommended that the Chief Executive of KiwiRail urgently address this safety issue by ensuring that at the Wellington maintenance depot, and other maintenance depots under KiwiRail control:
- maintenance is undertaken in accordance with good railway engineering practice
- manufacturers’ inspection, repair and maintenance instructions are documented and followed
- safety-critical components are identified and documented
- work instructions are issued for maintaining all equipment
- work on safety-critical components is signed off by someone other than the person responsible for carrying out the maintenance work
- all maintenance work is recorded.