TAIC Report 95-117

On Sunday 12 November 1995 at about 1240 hours Train 600, the Northbound "Bay Express" express passenger service between Wellington and Napier, derailed at Pukehou between Waipukurau and Hastings on the Palmerston North Gisborne Line. The train was travelling at approximately 90 km/h when the locomotive, power/baggage van and an empty passenger carriage left the tracks on a right hand curve. The two rear carriages carrying passengers remained on the rails. A member of the public riding in the cab of the locomotive was fatally injured and nineteen passengers or crew suffered shock or minor injuries. The causal factor was the excessive speed of the train.

TAIC Report 99-101

At approximately 2240 hours on Thursday, 25 February 1999, Train 230, a northbound express freight, was travelling on the up main just south of McKays Crossing when dragging brake gear on a wagon near the centre of the train hit the spreader bar of the safety turnout where the line converged to single track. The impact caused the facing points to open and derail 19 of the following wagons. The derailment brought down part of the 1500V overhead traction line and blocked State Highway 1. Fatigue breaks in a brake beam assembly caused it to fail allowing the brake gear to drop. Safety issues identified included quality control of the brake beams to withstand likely cyclic loading. Three safety recommendations were made to the operator.

TAIC Report 99-102

On Tuesday 9 March 1999, Train 523, a southbound New Plymouth to Palmerston North express freight, overran Whangaehu without a valid track warrant and continued approximately 18 km into the next section before the error was realised. There was no opposing traffic or obstruction and once the overrun was discovered a valid warrant was issued and a relief locomotive engineer completed the remainder of the journey. The overrun resulted from a lapse in concentration by the locomotive engineer.

TAIC Report 99-103

On Wednesday 11 March 1999, at approximately 1120 hours, a head-on collision occurred between the middle ferry shunt and the siding shunt at Wellington ferry terminal. The locomotive engineer's seat in the siding shunt locomotive was torn from its mountings, and the locomotive engineer was propelled to the front of the cab, sustaining lacerations and concussion. Two shunters riding on the leading ends of their respective shunts were able to jump clear before the collision.

The safety deficiencies identified included:
* the failure of existing procedures to prevent a head-on collision involving opposing shunt movements
* the lack of understanding of staff as to the application of the procedures to be adopted when entering the work area of another shunt.

Two safety recommendations were made to address these issues.

TAIC Report 99-104

On Saturday 3 April 1999, Train 1613, the southbound Masterton to Wellington passenger service, departed from Featherston while a scout party and an adult passenger were still loading their gear into the van. Three scouts were left on the platform and a fourth scout and the adult travelled to Upper Hutt in the unlit van. The scouts were at risk as they either alighted from, or attempted to board, the moving train during departure. The guard was unaware of the scouts' presence in the van. The incident occurred due to a failure to ensure passenger safety prior to the departure of the train. A safety issue identified was the lack of adequate procedures to ensure passenger safety prior to giving right of way. One safety recommendation was made to the operator.

TAIC Report 99-106

On Tuesday 27 April 1999, Train 8203, a southbound Porirua to Wellington electric multiple unit train, departed Takapu Road at about 0800 hours. Due to partially locked-on brakes on the fifth car of the six-car consist, acrid fumes given off from the composition brake blocks entered the three rear cars. The resulting strong smelling "haze" caused discomfort and anxiety to passengers as the train passed through two tunnels on the way to Kaiwharawhara.

Safety issues identified were the appropriateness of the training of passenger train staff in managing foreseeable operating irregularities and the lack of certification of part-time staff with respect to their role in such circumstances. Two safety recommendations were made to the operator.

TAIC Report 99-107

On Monday, 10 May 1999, at approximately 1825 hours, Train 211, a southbound express freight, pulled out of the Auckland Freight Centre and stopped to have a defective tail end monitor replaced. While it was stopped, a DSG shunt locomotive that was operating on a converging road ran into the rear of the train. The remote control operator who was operating the shunt from the rear refuge of the locomotive was thrown off by the impact. Safety issues identified included the suitability of the procedures, and compliance monitoring in place to ensure safe operation of remote control locomotives, and the suitability of procedures to control conflicting movements in the Auckland Freight Centre. Three safety recommendations were made to the operator.

TAIC Report 99-108

t approximately 1215 hours on Tuesday, 18 May 1999, a collision occurred between the north yard shunt and No. 1 shunt in Middleton yard. No injuries occurred but the locomotives sustained some damage and 3000 litres of diesel leaked from a ruptured fuel tank.

The safety deficiencies identified included:
* the suitability of the procedures and compliance monitoring in place to ensure the safe operation of remote control locomotives
* the failure of staff to follow defined procedures regarding the berthing of a main line shunting service into the defined work area of a yard shunting service.

TAIC Report 99-109

At approximately 1140 hours on Friday, 21 May 1999, northbound Train 902 operating as the Southerner passenger express overran its track warrant limit by approximately 2 km between Mosgiel and Wingatui on the main south line. The overrun occurred when the locomotive engineer was possibly distracted by other events after planning a track warrant renewal for a location which differed from the normal pattern. The safety issues addressed in this report include the resilience of the track warrant system to accommodate deviations from established patterns, and the relieving of staff involved in operating irregularities.

Two safety recommendations were made to the operator.

TAIC Report 99-111

On Wednesday 26 May 1999, at approximately 0730 hours, a rake of empty log wagons was being propelled from the Kinleith railway yard into Carter Holt Harvey Limited's siding when the leading wagon hit the "bull-bars" of a logging truck parked foul of the running road. The remote control operator who was on the leading wagon jumped clear just prior to the collision but stumbled and fell against the wagon and was dragged for approximately 10 m before rolling clear. He received broken ribs and abrasions as a result of the accident. Causal factors were the positioning of the truck foul of the running road and the lack of adequate control of the shunt. Safety issues addressed in this report include the lack of a suitable integrated operational agreement for the site and the effectiveness of the current procedures, training, and compliance monitoring of shunting practices to ensure safe operation. Five safety recommendations were made to the operator.

TAIC Report 99-113

t approximately 0720 hours on Sunday, 13 June 1999, Train 3612, a Wellington to Upper Hutt electric multiple unit service, collided with an empty cable drum which had been moved alongside the track by persons unknown. The cable drum had been in close proximity to the line for at least 2 weeks. There were no injuries. The leading unit suffered minor damage.

Safety issues identified were the lack of effective reporting and follow-up procedures for potential obstructions alongside the track.

One safety recommendation was made to the operator.

TAIC Report 99-114

On Tuesday 22 June 1999, at about 0245 hours, the high leg rail at 93.707 km North Island Main Trunk broke under the passage of Train 225, a southbound express freight. The break caused the tenth wagon of the train to derail one axle which re-railed itself at the Roslyn Road level crossing 530 m further to the south and the locomotive engineer continued on unaware of what had happened.

A safety issue identified was the lack of an effective system for detecting and actioning rail defects located between rail ends.

TAIC Report 99-115

t about 1345 hours on Saturday, 26 June 1999, a vintage steam train operated by the Bay of Islands Vintage Railway was on a scheduled passenger trip from Opua to Kawakawa when the track spread and the locomotive and the following two carriages derailed at low speed. No injuries to the crew or passengers resulted. Safety issues identified included the standard of track maintenance and the adequacy of the track inspection. Two safety recommendations were made to the operator, and two to the Director of the Land Transport Safety Authority to address the safety issues.

TAIC Report 99-116

On Tuesday, 29 June 1999 at approximately 1400 hours, an empty diesel multiple unit which had been parked on the suburban platform road at Papakura ran away towards the down main line at the north end of the station into the path of Train 3149, which was approaching from the north to the suburban platform road. The locomotive engineer of Train 3149 was able to stop his train before any collision occurred. No injuries resulted and there was no damage sustained.

The safety deficiency identified was the lack of security when diesel multiple units were left unattended.

One recommendation was made to the operator.

TAIC Report 99-117

On Tuesday, 6 July 1999, a loaded petrol wagon on Train 230, a northbound Wellington to Auckland express freight, derailed approximately 4 km south of Paraparaumu when a wheel on the leading bogie moved in on its axle. The brakes on the wagon had failed to release which caused the wheels to overheat. This overheating had been reported by a passing motorist and the train duly stopped just short of Paraparaumu, but not before the wagon had derailed. An incorrect tolerance fit of the wheel on the axle allowed the wheel to move inwards on the axle and derail the wagon. Safety issues identified were the absence of accepted engineering practices in fitting the wheel and inadequate checkout procedures. One safety recommendation was made to the operator.

TAIC Report 99-119

On Sunday, 15 August 1999, Train 281, a southbound Te Rapa to Palmerston North freight, stalled as it ascended steep grade up the Owhango bank. After the stalling the locomotive engineer moved to and from the lead locomotive and brought into operation an unmanned trailing diesel-electric locomotive in an attempt to assist the train up the gradient. On finally returning to the moving lead locomotive he slipped while entering the cab and suffered serious injuries. The train was brought to a stop by another person riding in the cab of the lead locomotive.

Safety issues identified were:
* the locomotive engineer's deliberate use of an unauthorised and unsafe manner of train operation
* the train control officer's failure to appreciate and prevent the unauthorised operation
* the ineffective procedure for matching locomotive power to load
* the timeliness of the emergency response.

Five safety recommendations were made to the operator to address these safety issues.

TAIC Report 99-120

At approximately 2215 hours on Tuesday 24 August 1999, northbound Train 474 struck a derailed wagon while passing southbound Train 227 between Te Rapa and Horotiu on the North Island Main Trunk line. The incident occurred when a UK wagon conveying a 40-foot container on Train 227 became derailed shortly after passing through Horotiu as a result of a tyre working loose on a wheel. The wagon continued in a derailed state, obstructing the parallel up main line as Train 474 approached. The derailed wagon and container struck the locomotive of Train 474 as it passed, damaging the front side of the locomotive and the cab side window. No injuries were sustained.

The safety issues identified were the susceptibility of tyred wheels to loosening due to excessive heat, and the potential consequences of derailed wagons on double line track.

TAIC Report 99-121

At approximately 0700 hours on Friday, 1 October 1999, a rail operator fell from a slow moving wagon during shunting operations at Stillwater, when a handgrip detached as he was boarding the wagon. The rail operator fell backwards away from the wagon and landed alongside the track, sustaining minor injuries as a result.

The safety issues identified included:
* the inability of the inspection regime to identify the defective handgrip
* the unreported damage to, and unauthorised reinstatement of, handgrips arising from load handling and inappropriate shunting methods
* the susceptibility of repair welded handgrips to sudden failure
* the control of shunting in rail sidings.

Four safety recommendations were made to Tranz Rail Limited, and three to the Land Transport Safety Authority, to address these issues.

[The 3 safety recommendations to the LTSA were reaffirmed as a result of the Commission's investigation into another incident at Stillwater on 13 September 2001. Refer report 01-112.]

TAIC Report 99-122 Addendum

[Introduction] Following the publication of Railway Occurrence Report 99-122 the Commission received additional information based on a new recorded departure time of Train 919 from Clinton. This strengthened some previously expressed concerns at the interpretation which could be placed on sections of the report covering actions open to the locomotive engineer of Train 919 (LE2) on the day. The Commission considers the new information does not affect the findings and recommendations of the report, but does warrant this addendum to clarify the time restraints applicable to Train 919 and LE2.

TAIC Report 99-122

At about 0702 hours on Wednesday, 20 October 1999 Train 938, a northbound express freight, collided with Train 919, a southbound intercity express freight, which was stationary on the main line within station limits at Waipahi on the Main South Line.

The locomotive engineer of Train 919 was fatally injured, and the locomotive engineer of Train 938 was seriously injured.

The two locomotives on Train 919 and the single locomotive on Train 938 were extensively damaged, as were a number of wagons and containers.

Causal factors included one locomotive engineer?s misunderstanding of his track warrant limit and the limited effectiveness of the action taken by the operator and the regulator to minimise the possibility of such misunderstandings.

Recommendations were made to the operator and the regulator to address the safety issues identified.

[The following paragraph was added by addenda finalised on 7 December 2001.]

Following the publication of Railway Occurrence Report 99-122 the Commission received additional information based on a new recorded departure time of Train 919 from Clinton. This strengthened some previously expressed concerns at the interpretation which could be placed on sections of the report covering actions open to the locomotive engineer of Train 919 (LE 2) on the day. The Commission considers the new information does not affect the findings and recommendations of the report, but does warrant this addendum to clarify the time restraints applicable to Train 919 and LE2.

TAIC Report 99-125

At approximately 1010 hours on Wednesday 24 November 1999, the Wellington to Auckland Overlander passenger express, Train 200, proceeded past a conditional stop board between Ohau and Levin without authority. Some 5 kilometres later Train 200 unexpectedly met a track maintenance gang, which had just cleared the track to allow the passage of the train. There were no injuries.

The safety issues identified were:

* the incomplete radio procedures for communication between locomotive engineers and track gangs working under conditional stop board protection
* the locomotive engineer passing the conditional stop board without authority
* the availability of an expired information bulletin
* the decision by the ganger in charge of the work to not arrange for fixed signals controlling entry of trains into the work area to be held at Stop
* the need for better understanding by train control officers and track gangers of responsibility for control of track and better communication.

Five safety recommendations were made to the operator.

TAIC Report 99-127

At approximately 1630 hours on Friday 17 December 1999, a rake of wagons being propelled from Fletcher Paper private siding in Mt Maunganui derailed as a result of being pushed over a derailing block. The wagons slewed from the track and crossed a public road level crossing before colliding with a building and coming to rest on the opposite side of the road. The safety deficiencies identified included:

* the use of motorcycles by staff during shunting of sidings
* the lack of formalisation of local speed limits
* the positioning of staff during the propelling movement.

Two safety recommendations were made to address these issues.

TAIC Report 00-102

At about 2000 on Wednesday 23 February 2000, Train 228, a Wellington to Auckland express freight service, passed a signal at Stop and entered Plimmerton station limits. An electric multiple unit, which had been running ahead of Train 228 and terminated at Plimmerton, was standing at the platform on the up main line ready to depart on its return journey to Wellington.

Train 228 stopped about 180 metres short of colliding with the electric multiple unit.

Six safety issues were identified:

* the visibility of signals at authorised line speed
* the failure of the Locomotive Engineer to respond to an Intermediate signal warning him that the next signal in advance, 18 up home signal at Plimmerton, was at Stop
* the absence of any defences to protect a level crossing if a locomotive engineer did not respond to a Stop and Proceed signal in advance
* the lack of warning to road users when signals in close proximity to level crossings are passed at Stop
* the absence of a safe signal overrun distance at Plimmerton
* the locomotive engineer not being immediately relieved after having been involved in a serious operating irregularity.

Three safety recommendations were made to the operator.

TAIC Report 00-103

On Wednesday, 15 March 2000, at approximately 1928 hours, Train 2139, a diesel multiple unit passenger service, suffered a partial brake failure while descending the grade from Newmarket to Auckland. A permanent 25 km/h speed restriction on curved track approaching the station was negotiated at about 45 km/h before the service came to a stop some 40 m past its normal stopping place.

The partial brake failure was caused by a combination of a broken air pipe and a seized air valve.

A safety issue identified was the ability of brake efficiency tests to identify triple-valve defects. Tranz Rail took action to address the safety issue, and no recommendations were made arising from this investigation

TAIC Report 00-104

At approximately 0942 hours on Thursday, 6 April 2000, Train 326, a northbound express freight, was travelling on the up main through Pukekohe when dragging brake gear on a wagon near the centre of the train hit the spreader bar of the south-end turnout from the up main line to the loop. The impact caused the facing points to open and derail 13 of the following wagons.

Safety deficiencies identified were the limitations of the clevis pin retaining the wagon brake rod, and the worn condition of the brake rod safety chains.

Tranz Rail Limited took immediate steps to address the safety deficiencies identified and no safety recommendations were required.

TAIC Report 00-106

At approximately 1010 hours on Thursday, 4 May 2000, Y35 shunt overran its track warrant limit at Mataura by 15 km. There was no opposing traffic.

Safety issues identified included:

* the need for better communication between train controllers and remote control operators when track warrants issued for main line shunts did not reflect work-between localities requested
* the need for more effective ways of communicating, and monitoring compliance with, amendments to rules and regulations to improve safety
* the need for formalised crew resource management training for Tranz Rail operational staff.

A safety action taken by Tranz Rail and 3 safety recommendations address these issues.

TAIC Report 00-107

On Tuesday, 9 May 2000, at about 1430, a collision occurred between a rail-mounted excavator, operating as a hi-rail vehicle, and Train 688 at 216.5 km between Waipunga and Waikoau on the Palmerston North - Gisborne Line. The excavator was operating outside its authorised work area and beyond the agreed "check call" time with the train controller when the collision occurred.

There were no injuries.

Safety issues identified included the accepted use of check calls between train controllers and track users instead of the required off track and clear times when authorising time on track, and the appropriateness of the training and experience of contract staff operating hi-rail vehicles.

Two safety recommendations were made to the operator.

TAIC Report 00-108

On Wednesday 10 May 2000 at about 1130, while the Middleton yard shunt was propelling a rake of 5 wagons into the freight centre grid, the shunter fell under the leading wagon of the rake as he tried to board it and was killed instantly.

Safety issues addressed in the report are:

* the potential for inexperienced staff to be involved in shunting fatalities
* the lack of a support programme for newly qualified entrants into safety-critical areas such as the shunting environment
* the rostering process not recognising experience levels when grouping individuals into work groups in safety-critical areas
* the suitability of footsteps on over-width wagons.

Two safety recommendations were made to the operator.

TAIC Report 00-111

On Wednesday 14 June 2000 at about 0100, Train 630 Wellington to Napier express freight overran its track warrant limit by about 1100 m. The overrun occurred when the locomotive engineer did not identify and stop at the limit of his track warrant authority at Tapuata and continued on before coming to a stop about 100 m from No 3 FI points indicator at the south end of Dannevirke station.

Factors which may have contributed to the incident included the possibility that the locomotive engineers lost situational awareness, and the resilience of the track warrant system to accommodate deviations from established patterns.

Safety issues identified included the effectiveness of procedures in place to monitor road knowledge on infrequently travelled routes and the cancellation of this certification where this knowledge was not maintained.

One safety recommendation was made to the operator.

TAIC Report 00-113

On Saturday 22 July 2000, at about 1927, express freight Train 378 derailed when it entered a crossover at the north end of Te Maunga while travelling too fast. The locomotive was severely damaged when it overturned following the derailment. The locomotive engineer suffered minor injuries. The train controller had incorrectly set a medium speed route to Mount Maunganui instead of the intended high speed route to Tauranga. The locomotive engineer did not react to the unexpected signal aspects displayed.

Safety issues identified included:

* non-adherence to basic train control techniques
* the distracting train control environment
* an emerging pattern of serious operating irregularities involving train controllers
* the potential for locomotive engineers to misinterpret unexpected medium speed signals.
Safety actions taken and recommendations made to the Land Transport Safety Authority and the operator address these issues.