TAIC Report 03-102

On Monday 10 February 2003, at about 1600, hi-rail vehicle 67425 derailed near Fordell during a special hot weather track inspection on the Marton-New Plymouth Line. The vehicle rolled and came to rest on its side, clear of the track. The driver sustained serious injuries and the vehicle was extensively damaged. As a result, about 90 minutes passed before the driver was able to use his cellphone to alert the Police, and subsequently train control, to his situation. Meanwhile, the designated time of 1615 for the hi-rail vehicle to be off track had elapsed, and the train controller authorised express freight Train 545 to enter the same section of track. The train controller was able to alert the locomotive engineer of Train 545 before he reached the accident site.

The safety issues identified included:

• the training and certification of drivers to operate a hi-rail vehicle
• the operating rules that allowed a train controller to authorise a train to enter a section of track that was already occupied
• the wearing of seatbelts when operating a hi-rail vehicle on track.

In view of the safety actions taken to address the track occupancy procedures, no safety recommendations have been made regarding that issue.

One safety recommendation has been made to the Chief Executive of Toll NZ Consolidated Ltd regarding the wearing of seatbelts and one safety recommendation has been made to the General Manager of Transfield Services (New Zealand) Limited regarding training and certification of hi-rail vehicle drivers.

TAIC Report 09-103

On the evening of Thursday 23 July 2009, the Wellington region was experiencing a storm that brought heavy rain and strong winds. At 1817, a scheduled commuter train travelling from Wellington to Masterton with approximately 240 passengers and crew in 5 carriages, collided with a slip that partially blocked the northern portal of Tunnel 1 on the Wairarapa Line. This point was about 4 km north of Upper Hutt station and about 1 km before the Maymorn station. The locomotive and generator carriage were embedded in the slip and derailed, while the remaining carriages were still on the track but standing within the tunnel. Emergency services were called to rescue the passengers and crew.
The damage to the train was minimal and no injuries were reported. The Wairarapa Line was closed for approximately 5 days while the mud was cleared and the track repaired.

Police assumed management of the accident?s rescue phase using the New Zealand Coordinated Incident Management System (CIMS) and activated a full tunnel response. The locomotive from a following Masterton-bound passenger train was used to haul the rear 3 carriages from the disabled train back to Upper Hutt with all passengers on board.
The landslide had occurred suddenly, less than one hour before the train collided with it. It had partially blocked the northern end of Tunnel 1. The landslide was a first-time occurrence on a risk-prone slope that was covered in regenerating bush. The Transport Accident Investigation Commission determined that the landslide occurred from natural causes after 62 millimetres (mm) of rainfall fell in the area during a 6-hour period.
Train 1608 had been travelling at normal speed when the driver saw the landslide, but he had had insufficient clear distance ahead to stop the train before impact. Network control had not warned the driver that the Wairarapa Line was subject to both ?heavy rain? and ?strong wind? warnings at the time.
Network control had received an updated severe weather warning message to the active severe weather event 24 hours before the accident, but network control had not distributed this  message and several following messages to area managers. Even if it had, the area manager for the Maymorn area would not have received them because he was new to the job and his contact details had not been recorded in the system.
The track inspection regime was based upon checking specific items along the track, so was not capable of assessing the potential risk of slope failures, although this type of risk was common in the Wellington area and documented in a railway structures guidance manual.
The severe weather warnings and track inspection systems, if followed, could have mitigated the consequences of a slip falling across the track but would not necessarily have prevented trains running into it.
The passengers were kept in the carriages within the tunnel for some 3 hours. Improvements in the communications around the emergency response and rail recovery operations could have reduced this time by up to 30 minutes, but the recovery was safely coordinated and resulted in no injuries to the passengers and crew. The location of the derailment and the general disruption to transport services throughout the region due to the severe weather meant the response to this event was reasonable.
Four safety recommendations have been made to the NZ Transport Agency to address issues around the track inspection process, the severe weather warning system and the National Rail System Standard (NRSS) for incident response.
During the course of this inquiry, KiwiRail initiated several safety actions that were directly relevant to the Commission's findings. The safety actions are described in section 6 of this report and include the development of a slope hazard risk assessment for the rail network, improvements to the train control facilities and changes to the failure mode of the internal 'S' Car pneumatically operated passenger doors.

TAIC Report 09-102

On Wednesday 1 July 2009, an elderly male passenger who was vision-impaired had just alighted from passenger Train 8125 on the Down platform at Newmarket West station. He was walking along the platform as the train left and he veered into the side of the moving train, spun around and fell through the gap between the train and the platform edge onto the track below. The passenger was fatally injured.
No conclusive reason for the passenger veering into the side of the train could be established, but it was likely related to his impaired vision or, distraction, or a combination of both.
The Transport Accident Investigation Commission (Commission) determined that the passenger exchange at Newmarket West station had been made in average time and in accordance withthe operating company?s procedures, and that it had been appropriate for the train to move away from the platform when it did.
The design of the platform met the New Zealand and international guidelines for assisting vision-impaired and blind persons.
Newmarket West station was a temporary constructed station pending the build of a new station at Newmarket, and consequently part of the Down platform was constructed on a curved section of track, which meant the gap between the train and the platform edge was wide enough for the passenger to fall through when he walked into the side of the train.
The Commission determined that the gap was as small as practicably achievable within the physical constraints of the station, and that warning signage and operating procedures were reasonable defences against this type of accident occurring.
No practicable safety recommendations were identified that would prevent this type of accident happening again, but the report notes that the trend towards an ageing population with a likely increase in mobility-impaired people travelling on public transport will require designers of transport systems to remain vigilant to this trend. The safety actions noted in this report acknowledge this trend and propose strategies to meet future demand.
The 2 platforms (including an adjacent Up platform) at Newmarket West station were demolished during the 2009/2010 Christmas/New Year holiday period concurrent with the opening of the redeveloped Newmarket station.

TAIC Report 08-113

On 19 December 2008, Train 5250 was an empty push/pull service being repositioned to start passenger operations when it collided with the stop block at Britomart station, Auckland. Some damage occurred to the coupler on the front of the train and the stop block, but neither the  locomotive engineer (driver) nor the train manager was injured.
The primary factor contributing to the collision was the failure of an electrical contactor within the locomotive brake system that prevented the locomotive brakes applying. Safety issues discussed include the speed of the train during the approach to Britomart station and the use of a power braking technique during emergency stop applications.

TAIC Report 08-112

On Saturday 8 November 2008, eastbound express freight Train 848, conveying 30 loaded coal wagons, overran the fouling board2 on the main line during a scheduled crossing movement at Cass Station on the Midland Line. Westbound express freight Train 845 entered the loop before the locomotive engineer on Train 848 radioed to confirm that he had stopped his train short of the fouling board.

The lead locomotive on Train 848 struck the second wagon on Train 845 and damaged the next 3 wagons before Train 845 was stopped by an automatic application of the train brakes after the train parted. The fourth and fifth wagons on Train 845 derailed.

Neither locomotive engineer was injured.

Following the collision, KiwiRail introduced revised operating procedures for the working of crossing stations in single-line automatic signalling (SLAS) territory on the Midland Line.

No new safety recommendations have been made in this report.
Safety recommendations made in a previous Transport Accident Investigation Commission Commission) report were relevant to this inquiry and when implemented will remove the potential for this type of accident at crossing stations.

TAIC Report 08-111

On Saturday 3 October 2008, the second-to-last wagon on express freight Train 524, wagon UK9007, conveying 2 loaded liquid petroleum gas (LPG) tanks, derailed between Puketutu and Te Kuiti on the NIMT while travelling around a 260-metre (m) radius right-hand curve at the posted line speed of 60 kilometres per hour (km/h).
The locomotive engineer stopped the train after hearing an automated voice alert from a dragging equipment detector, located about 500 m past the point of derailment (POD). The derailed wagon remained upright and connected to the train. None of the other 27 wagons on the train derailed.
The LPG tanks were examined and certified as safe by Fire Service personnel and a representative of the consignee before recovery work got underway.
The cause of the derailment was attributed to a combination of the wagon condition and track condition.
The Transport Accident Investigation Commission (Commission) has made previous safety recommendations to the regulator to adjust the allowable track and wagon maintenance tolerances to reduce the potential for derailments caused by dynamic interaction.
The Commission has made one new safety recommendation in this report relating to the way with which temporary speed restrictions are set when multiple track geometry faults within a common section of track are identified.

TAIC Report 08-110

A train controller starting his morning shift on 23 September 2008 unknowingly planned to direct a freight train along a line that was occupied by another freight train, which was standing awaiting routing through an area where a signalling fault was under repair. He was not aware the second train was stationary on the line. A potential low-speed, head-on collision was avoided when the first train was subsequently routed along the adjacent line after the signal failure had been partially corrected.
The existence of the second train was not known to the train controller because the senior controller in charge of the previous shift had omitted to record the movement of the train on the train control diagram, and it was not showing on the mimic screen in the national train control centre owing to the signal failure. Neither the current train controller, nor the previous controller and a trainee controller he was mentoring had noticed that the second train, which was a scheduled service, was not displayed on the train control system.
The train controller who omitted to record the second train on the train control diagram was suffering from fatigue caused by an excessive planned and unplanned work roster that offered limited opportunity to sleep, in spite of his working hours closely conforming to the minimum requirements of the network service provider.
Investigations into previous train control incidents have led to recommendations about the potential use of existing onboard train technology to give train control live tracking of train locations, which could have helped avoid this incident by showing the existence of the second train in spite of the signalling failure.
KiwiRail management has introduced a new fatigue policy since the incident, and it has previously responded to fatigue related recommendations resulting from investigations into previous incidents. Since this incident the Transport Accident Investigation Commission has made 3 new recommendations to the rail regulator concerning train controller rostering, shift handover procedures and the retraining of train controllers after extended breaks from operating critical systems.
(Note this executive summary condenses content to highlight key points to readers and does so in simpler language and with less technical precision than the remainder of the report for the benefit of a non-expert reader. Expert readers should refer to and rely on the body of the full report.)

TAIC Report 08-109

On Thursday 4 September 2008 at about 0827, push/pull commuter passenger Train 9113, travelling on the Down Main North Auckland line from Waitakere to Britomart, overran Fruitvale Road Station platform. The train was travelling at 36 kilometres per hour (km/h) when it passed the end of the platform and had slowed to 31 km/h when it passed Stop and Proceed Signal 2097 displaying a Stop indication. The train was still travelling at 29 km/h when it entered Fruitvale Road level crossing, 38 metres (m) past the end of the platform and 27 m past Signal 2097.

The train stopped with the rear door of the fourth carriage alongside the station platform. All doors on the platform side of the train were opened and alighting passengers were allowed to step down onto the track formation and the level crossing. The train continued on towards Britomart after those passengers waiting at the platform had boarded through the rear passenger car.

Trains approaching Fruitvale Road Station on the Down Main line were restricted to a maximum speed of 65 km/h because of the track alignment. Therefore, the non-stopping approach distance for trains was 436 m from the Fruitvale Road kerb line to provide motorists with 24 seconds? warning time on the flashing lights and bells and barrier arms protecting the level crossing. Because nearly all trains travelling on the Down Main line stopped at Fruitvale Road Station, a "vital timer" delay was set at 30 seconds to delay the activation of the flashing lights and bells. This time delay was built into the level crossing control system to minimise the waiting time for motorists while the train was stopped at the station for passenger work.

The barrier arms at Fruitvale Road level crossing were fully extended into the horizontal position just as Train 9113 passed Signal 2097. The level crossing protection had been activated by Train 8110, approaching Fruitvale Road on the parallel Up Main line. Had Train 8110 entered Fruitvale Road level crossing more than 12 seconds later than it did, Train 9113 would have entered the level crossing with the flashing lights and bells having only been operating for 1.3 seconds and the barrier arms would still have been in the vertical position. The Commission has made a recommendation to the Chief Executive of the NZ Transport Agency to conduct a risk assessment of the level crossing control system at those locations where station platforms are located between level crossings and the start of level crossing approach track circuits.

The platform overrun at Fruitvale Road Station was similar to other events investigated in Commission report 07-105.

At the time of the overrun at Fruitvale Road Station, KiwiRail had not trained locomotive engineers in a "best practice" train handling technique for stopping push/pull passenger trains fitted with graduated release brakes. The Commission would have made such a recommendation had KiwiRail not developed an operating instruction and started retraining locomotive engineers.

TAIC Report  08-108

On Wednesday, 13 August 2008 at 0941, express freight Train 845, a westbound Lyttelton to Ngakawau empty coal service, overran its track warrant limit at Reefton. The locomotive engineer continued to drive the train for a further 8.75 kilometres before he realised what had happened and stopped the train.
There were no conflicting movements or track engineering occupations.
Two employees of the operator had been authorised to ride in the cab and were travelling with the locomotive engineer at the time to familiarise themselves with coal route operations. The investigation has determined that onboard discussion most likely distracted the locomotive engineer, meaning that he forgot the limit of his track warrant as it approached and passed.
While the cab pass holders were properly authorised and the passes carried contained appropriate
warnings, the locomotive engineer was the only person available to give the information they needed to fulfil the purpose of their trip, which left him vulnerable to distraction. The operator has revised its procedures following its own investigation into this incident.
The Transport Accident Investigation Commission (the Commission) concluded that in spite of existing defences in the track warrant control system to prevent overruns, the system was still vulnerable to the weakest link, limitations of human performance. Previous safety recommendations the Commission has made about using advances in technology to mitigate the risk of track warrant overruns are equally applicable to this report.

TAIC Report 09-101

Between 21 June 2008 and 7 May 2009, 3 express freight trains derailed at various locations on the North Island Main Trunk (NIMT) line. All 3 derailments were caused by the failure and collapse of bogie side frames on wagons. The side frame failures were all similar in that they started with a fatigue crack that propagated over a period of days rather than weeks, through the box section of the side frame, until the remaining material failed in overload during normal train operations.
The side frame failures were also similar to previous side frame failures investigated and reported on by the Commission.
The cracks started in an area that would have been difficult to detect during normal operational and maintenance wagon checks. The side frames sometimes lacked identifying marks and historically there had been no records kept of their age and maintenance history, so the operator had started a programme of magnetic particle inspections (MPIs) to detect the presence of fatigue cracking in the side frames when the bogies were brought in for overhaul.
The inspection programme found over 4 years an average 60% of side frames with cracks that required repair. At the current inspection rate, all side frames will not be inspected before 2020. Until all side frames are tested for cracks and repaired, the potential for main-line derailments attributed to bogie side frame failures remains. Given the risk that main-line derailments pose to people and infrastructure, the Commission has made a recommendation to the Chief Executive of the NZ Transport Agency to conduct a risk assessment and if necessary require the inspection rate of side frames to be accelerated.

TAIC Report 08-103

Electric multiple unit passenger Train 6294 was stationary but attempting to depart from Mana station when an electrical fault on one of the traction motors caused a short circuit and fire in the train?s main electrical equipment case. High current being drawn by the short circuit caused the overhead traction lines to part and fall onto the train.
The train was travelling between Paremata and Mana stations on the North Island Main Trunk, en route from Wellington to Paraparaumu, when the driver experienced problems with the traction motors. The train was a 2-car train set with one motor car and one trailer car and was being driven in the reverse direction from the trailer cab. After passenger exchange at Mana, the driver attempted to depart the platform but the train did not move. Each attempt to move the train resulted in an immediate traction motor overload. The driver was leaving the train to walk along the platform to the rear motor car when there was a brilliant flash above his head. The overhead traction lines parted and the loose ends dropped onto the train and the platform. The electrical equipment cabinet, just below the level of the platform on the motor car, was on fire.
Train 6294 was evacuated and the public were cleared from the area while the potentially live overhead lines were isolated and made safe. There were no injuries and the fire was extinguished before the Fire Service arrived at the scene.
The fault in the traction motor had been developing throughout the previous week, yet weaknesses in the fault-reporting system meant the developing fault went unnoticed, and frequent re-setting of the circuit breaker eventually resulted in it, together with the then-unprotected electrical line contactors, failing.
With no electrical protection between the fault in the traction motor and the power supply, a very high electrical current passed between the overhead traction line and the train?s pantograph, causing the line to melt and part.
(Note this executive summary condenses content to highlight key points to readers and does so in simpler language and with less technical precision than the remainder of the report for the benefit of a non-expert reader. Expert readers should refer to and rely on the body of the full report.)

TAIC Report 08-101

At about 1149 on Friday 14 March 2008, southbound express freight Train 923 collided with a truck on Hawke Road level crossing, Orari, between Rangitata and Temuka on the Main South Line, when the truck moved into the path of the approaching train. The level crossing had passive control "Stop" signage. All signage and road markings were in place and in good condition.
The collision caused the locomotive to derail and roll before coming to rest 172 metres (m) past the level crossing. Twelve wagons directly behind the locomotive also derailed. The locomotive and 10 wagons were extensively damaged. The other two derailed wagons sustained moderate damage. The truck was extensively damaged.
The truck driver was fatally injured and the locomotive engineer suffered serious injury.
No safety deficiencies in the rail operating system were identified that contributed to the collision.
A safety recommendation was made to the Chief Executive of the NZ Transport Agency to address the issue of the capability of the locomotive event recorder to transmit in the event of an accident.

TAIC Report 07-115

On Wednesday 7 November 2007, at about 0140, the trailing bogie of wagon UK10696, on Auckland to New Plymouth express freight Train 533, derailed at 103.848 kilometres (km) on the Stratford - Okahukura Line. The derailed wagon was dragged a further 2.75 km until the leading bogie also derailed.
The wagon tipped on its side, derailing the wagon immediately in front and behind it.
There were no injuries.
The cause of the derailment was not conclusively established, but the circumstances point to dynamic interaction between the track and the wagon, with the condition of both being at the upper limits of their working tolerances being a factor.
Safety issues identified included:
* recurrent derailments resulting from a combination of track geometry and wagon bogie condition at
or near current maintenance limits
* the quality and consistency of documented standards, rules and codes relating to the handling of
derailed wagons conveying liquid petroleum gas tanks
* the emergency response to the derailment.
Three safety recommendations have been made to the Chief Executive of the New Zealand Transport Agency to deal with these safety issues.

TAIC Report 07-114

Between Friday 19 October 2007 and Sunday 5 October 2008, there were 12 occurrences when wheel-bearings failed on wagons travelling on express freight trains at various locations in the North and South Island.
Seven of the 12 wheel-bearing failures resulted in the affected wagon derailing, and causing a number of following wagons to also derail. The derailments caused extensive damage to the rolling stock, freight it was conveying and the rail network. On 2 occasions, molten metal from the failed wheel-bearings resulted in fires in trackside foliage and across adjacent land.
No-one was injured in any of the derailments.
The Commission determined that wheel-bearings were critical items, the failure of which had the potential to result in a derailment. The derailments usually resulted in substantial damage to track and infrastructure, and have the potential to cause injury to third parties if the derailment occurs adjacent to populated areas or other infrastructure.
The reason for the failures of the wheel-bearings could not be conclusively determined because the bearings had usually catastrophically failed, destroying the evidence and historically inadequate record-keeping for maintenance and service life of the bearings that could not support probable cause investigation.
Because the impending failure of wheel-bearings can be difficult to detect through traditional inspection procedures, the Commission recommended to the Chief Executive of the Land Transport NZ (predecessor to NZ Transport Agency) on 8 March 2008 that he address the safety issue where the New Zealand rail network had not been protected with a track-side acoustic wheel-bearing monitoring system in line with current international best practice.
In the latter half of 2010, KiwiRail was completing the installation of an integrated acoustic wheel-bearing monitoring, coupled in motion weighbridge, wheel impact and automatic vehicle identification system at strategic sites on its network. The Safety Action section of the report shows a number of other initiatives that have been taken by KiwiRail since 2008, which together with the acoustic wheel-bearing monitoring system appears to have reduced the number of reported bearing related occurrences.

TAIC Report 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.

TAIC Report 07-110

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).

TAIC Report 07-108

On Saturday 12 May 2007, at 0400, northbound express freight Train 720 travelled past Seddon towards Vernon on the Main North Line without the authority of a track warrant issued from train control.
The locomotive engineer did not stop on the main line at Seddon as required and obtain a new track warrant to travel beyond Seddon. Southbound Train 723 was sitting on the loop when Train 720 passed through Seddon. There were no other conflicting movements and as a result there was no damage or injury.
Safety issues identified were:-
* management of fatigue in train operations
* detecting sleep disorders
* locomotive engineer vigilance systems
* crew resource management
* monitoring of rail vehicles on non-track-circuited sections of the controlled network.
Four safety recommendations have been made to the Chief Executive of the New Zealand Transport Agency to address theses issues.

TAIC Report 07-103

On Wednesday 21 March 2007, passenger express Train 200 collided with the rear of stationary passenger express Train 201 during a planned setback manoeuvre at National Park when radio communication failed.
One passenger travelling in the rear passenger carriage on Train 200 received a minor injury. The buffer at the rear of the train was damaged.
A safety issue identified was the reliance, during the setback movement, on a single line of communication between the locomotive engineer and the train manager piloting the train from the rear carriage. Safety actions have been taken to address the safety issue.

TAIC Report 07-101

On Friday 5 January 2007, at about 2200, the leading bogie of UK6765, the rear wagon on Christchurch to Picton express freight Train 736, derailed at 309.643 kilometres (km) on the Main North Line. The derailed wagon was dragged a further 3.5 km until it struck the south end main line points at Vernon, derailing the wagon immediately in front.

The derailed wagons were pulled another kilometre before the locomotive engineer became aware of the derailed wagons and brought the train to a stop.

There were no injuries.

A safety issue identified was the current track and mechanical tolerance standards.

In view of the safety actions since taken by Toll NZ Consolidated Limited and Ontrack in response to safety recommendations made following similar investigations by the Commission, no further safety recommendations were made.

TAIC Report 06-112

TAIC Report 06-111

At about 0640 on 20 October 2006, the sixth wagon on express freight Train 237 derailed and entered a crossing loop at Utiku, derailing 9 other wagons and bringing down a section of the overhead electric traction line as well.
The derailment was caused by the dynamics of a permanently coupled pair of wagons and the design of the modified solid drawbar arrangement when the wagons behind bunched and ?ran-in? while the train was under braking on a descending gradient.
A safety issue identified was the incomplete process for approving a new design of coupling and monitoring its performance in service.
No new safety recommendations have been made in this report as the safety issue has been raised in previous reports and safety recommendations are still currently open pending corrective action.

TAIC Report 06-110

On Monday 9 October 2006 at 0806, passenger Train 4045 travelled 526 metres between Britomart station and Quay Park junction with the locomotive engineer not at the controls of the train. The locomotive engineer had left the train to operate a valve to restore air-brake pressure following an uninitiated emergency brake application. Once air-brake pressure had been restored, the train began to move before the locomotive engineer re-boarded the train.

There was no damage and none of the 3 crew and 12 passengers on board at the time was injured.

Safety issues identified included:
- adherence to standard operating procedures
- maintenance and testing of passenger emergency stop mechanisms
- diagnosing and correcting intermittent faults on old passenger rolling stock
- the provision of event recorders
- monitoring fault trends for safety-critical equipment
- audit performance

Four safety recommendations have been made to the Chief Executive of the New Zealand Transport Agency to address these issues.

TAIC Report 06-108

On Saturday 26 August 2006, at 0907, the lead bogie on passenger Train 9328 derailed when it ran into landslide debris covering the track at 2.474 kilometres (km) on the Johnsonville Line between Wellington and Wadestown. Heavy rain had been falling in the area prior to the derailment.

There were no injuries and only minor damage to the train and track.
Safety issues identified included:

regolith nature of the steep terrain above the Johnsonville Line

train control role and responsibilities

routine and special track inspections on the Johnsonville Line

risk management of the Johnsonville Line during periods of heavy rainfall.

Four safety recommendations have been made to the Director of Land Transport New Zealand to deal with these issues.

TAIC Report 06-106

On Monday 31 July 2006 at about 2054, eastbound express freight Train 826 stopped at Cora Lynn
Arrival Signal 10244 on the Midland Line. The arrival signal was displaying a green aspect, while at the same time the facing points were set in the reverse position and the "L" light was not illuminated.
The locomotive engineer suspected a signalling irregularity because about 2 hours earlier he had set and locked the west-end points in the reverse position when he departed from the crossing loop on westbound Train 841. He had monitored the radio channel during the intervening time and was aware that no other trains had since passed through Cora Lynn.
Safety issues identified included:
- the suitability of the single-line automatic signalling system for the Midland Line
- the inspection and testing of the universal switch controller units
- the procedures for communicating the status of main-line points at crossing stations within single-line automatic signalling territory.
One safety recommendation has been made to the Chief Executive of the New Zealand Transport Agency to address these issues.

TAIC Report 07-105

etween June 2006 and April 2007 the Transport Accident Investigation Commission (the Commission) launched inquiries into 5 separate platform overrun events on the Auckland suburban rail network. Because there appeared to be a number of common factors contributing to the overruns, they have been combined into this one report.
All overruns involved push/pull train sets designed and modified in New Zealand from 2003 to cater for the growing needs of the Auckland transport network, pending expansion and modification of the rail infrastructure to cater for new electric train sets within 7 to 9 years. In all cases the trains were being driven by Toll Rail locomotive engineers in the push mode.
There were no injuries and no damage resulting from any of the 5 incidents. In 4 of the 5 incidents the procedures for dealing with a platform overrun were followed correctly. In one of the incidents, the driver reversed his train to the platform without the required authority from train control.
The driving technique of the Toll Rail locomotive engineers was a significant factor leading to the platform overruns. In particular, there was no standardised methodology taught for braking and other train-handling techniques. Trainer drivers were not taught how to teach trainee drivers and were themselves not subject to minimum levels of experience and competency before undertaking trainer duties.
The Commission found that the brake system design was not ideally suited for outer-urban commuter train operations, but it was considered fit for the trains' intended purpose of outer-urban, limited-stop operations that existed in Auckland at the time.
The Commission determined that the National Rail System Standard for passenger train braking distance was not relevant to the design of the network at the time, so the fact that the trains did not comply with that Standard for stopping distance was not in itself a significant safety issue. However, the fact that the trains were signed off as being compliant while they technically did not meet the Standard was a safety issue that needs addressing by the industry.
The Commission has also determined that the National Rail System Standard needs to be reviewed to ensure it is consistent with good rail operating practice and is applicable to the New Zealand rail industry, and that the regulator needs to maintain a tight control over the Standard that are currently governed by the industry.
This report should be read in conjunction with the Commission's previous Report 05-123, Empty passenger Train 4356, overrun of conditional stop board without authority, following an automatic air brake valve irregularity at Meadowbank on 6 October 2005. In that report the Commission commented on the design, performance and maintenance of the brake system on the push/pull fleet. Some of the findings and recommendations in Report 05-123 are equally applicable to this report.
Toll Rail's interpretation of the National Rail System Standard and its decision to test the stopping performance of the push/pull sets based on single-car breakaway tests, rather than as a complete train, resulted in the Standard as written not being complied with.
There was, however, an error within the Standard that had not been detected by either the operating company or the regulator until the trains had been in service for 4 years.
The report makes comments on what level of regulatory oversight should be applied to the design, build and sign off for the push/pull train sets.
Two recommendations have been made to the Chief Executive of the New Zealand Transport Agency to address the safety issues identified in this report about the standards of driver training and compliance with the National Rail System Standard.
Three recommendations have been made to the Secretary for Transport about the status of the National Rail System Standard.

TAIC Report 06-102

On Friday 31 March 2006 at about 0520, the locomotive engineer of empty passenger Train 4306 noticed the air brake system operating below normal performance while driving the train between Westfield and Otahuhu at the start of operations for the day. After the train had reached Otahuhu, the locomotive engineer examined the brake system and decided to return to Westfield rather than continue passenger operations.
There was no damage or injuries.
Safety issues identified included:
* purging of contaminants from a locomotive?s air brake piping
* scheduling the reconditioning of brake control valves
* standards for tracking and monitoring safety-critical components.
Because of safety actions taken by Toll NZ Consolidated Limited, no safety recommendations have been made. The Commission made a safety recommendation to the Director of Land Transport New Zealand as a result of Rail Occurrence Report 06-101, relating to the tracking and monitoring of safety-critical components. This recommendation is equally applicable to this occurrence, so no new safety recommendation has been made to address this issue.

TAIC Report 06-101

On Wednesday 15 March 2006 at about 1710, the auxiliary diesel engine beneath the rear car of diesel multiple unit passenger Train 3163 caught fire when lubricating oil sprayed from a loose hose connection onto the hot surface of the turbo charger. The train manager became aware of the fire when the train stopped at Manurewa station. The train was evacuated and the fire extinguished by the New Zealand Fire Service. There were no injuries.

TAIC Report 05-128

On Monday 31 October 2005, at about 0827, a set of bi-parting doors on Train 3056, a Connex Papakura to Britomart diesel multiple unit passenger service, closed on a passenger boarding at Papatoetoe. The passenger became trapped, but was freed when the doors were prised open by a locomotive maintainer who was travelling on the train.

The passenger suffered minor leg injuries.

Safety issues identified included:

* the door control and operating mechanisms
* the use of a defective safety critical component
* the fault recording processes.

Safety recommendations have been made to the General Manager of Veolia Transport Auckland Limited and the Chief Executive of Toll NZ Consolidated Limited to address these issues.

TAIC Report 05-126

On Sunday 30 October 2005 at about 1820, wagon UKR84 on Train 246, a Wellington to Auckland express freight service, derailed at 32.08 km, South Junction, between Pukerua Bay and Paekakariki, on the North Island Main Trunk. The wagon derailed as its leading bogie passed over a set of trailing points.

The left-hand leading bogie side frame had fractured through the top end pedestal and collapsed at about 28.733 km. The underside of the wagon then rested on the flange of the wheel and the brake rigging beneath the wagon dropped until the brake shoe rested on the head of the rail until the wagon derailed some 3.35 km further on. The derailed wagon was then dragged an additional 3.3 km before the train stopped at 35.38 km.

The collapsed bogie side frame damaged trackside structures at Pukerua Bay (30.295 km) and Muri (31.300 km) and, after the wagon derailed at 32.08 km, damaged the track from there to 35.38 km.

Safety issues identified included:

* the reporting and tracking of bogie component replacement

* the non-visual inspection of bogie components.

A previous safety recommendation covering the reporting and tracking of bogie components arising from another derailment has already been made to the Chief Executive of Toll NZ Consolidated Limited. A new safety recommendation has been made regarding the non-visual inspection of bogie components.

TAIC Report 05-125

On Friday 28 October 2005, at about 1547, Taieri Gorge Railway passenger Train 1910, travelling from Middlemarch to Dunedin with a crew of 4 and 21 passengers, parted between the leading passenger car XPC412 and passenger car XPC562 as the train approached Dunedin Station.

After the train parted, the brakes applied automatically and the 2 sections of the train stopped about
40 metres (m) apart.

The train parting resulted from the catastrophic failure of the buffer at a flash butt weld that connected the cast coupler head and forged tail.

There were no injuries to passengers or crew.

The safety issues included:

* the identification and tracking of buffer components
* the non-visual inspection of buffer components.

In view of the safety actions taken by Taieri Gorge Railway Limited, no safety recommendations have been made to the operator. One safety recommendation has been made to the Director, Land Transport New Zealand to distribute this report to all heritage operators with gangway-connected rolling stock, and direct all mainline heritage operators to crack test non-alliance buffers on all their operational passenger carriages and guards? vans