KiwiRail culture slammed after near-miss
KiwiRail has been slammed for its "systems, supervision and culture", after a fatigued train controller working without toilet or meal breaks led to a near miss between a freight train and a maintenance vehicle.
A Transport Accident Investigation Commission (TAIC) inquiry into the incident has concluded train controller error nearly resulted in a mid-tunnel collision between the two rail vehicles on the Midland Line in 2011.
KiwiRail and the NZ Transport Agency have accepted the inquiry's findings and recommendations.
Here's what happened
A loaded coal train was travelling through the Craigieburn Staircase area from Lyttelton, when a KiwiRail track engineer called the female train controller to "on-track" his motorised maintenance cart.
Without checking and assuming the coal train had already passed through the area, the controller gave permission for the engineer to use the track.
A structures inspector overheard the radio call and alerted the coal train driver who then stopped his train, "narrowly averting" a collision.
Controller lacked training
The TAIC investigation criticised KiwiRail for the workload placed on the controller, her lack of training in the circumstances and management of employees working without breaks.
They said the near-collision was caused "in part by the systems, supervision and culture at KiwiRail's train control centre".
The woman had been working without any breaks, even to go to the toilet, and was on the understanding she "could not leave her room".
Recommendations included introducing electronic visibility of trains and other vehicles on the track, which KiwiRail had since adopted.
KiwiRail accepts findings
In a statement issued from KiwiRail today, chief executive Jim Quinn said they accepted the TAIC findings and had already "made significant changes within our network", which had lifted safety standards.
"Our safety record has improved since this incident as a result of the implementation of further safety initiatives across the business. The combination of staff requiring medical treatment and/ or requiring time off work because of injury has reduced by nearly 20 per cent in the last year alone."
An additional 21 train control staff had been employed in the last 27 months, they had improved support systems for train controllers with shift managers now checking on staff during their shifts, compulsory physical and mental medical assessments now available and a "step away for 5" programme to encourage breaks.
A fundamental rule change requiring trains to be completely clear of a control section before maintenance vehicles can get on the track has also been introduced.
A project to provide visibility of maintenance vehicles by train control and other staff was expected to be completed in 2014.
Quinn said they had also engaged with TAIC throughout the investigation.
Transport Agency welcomes findings
The NZ Transport Agency has welcomed the inquiry's findings, saying it would now work with KiwiRail to ensure all recommendations were put in place.
They had already strengthened its auditing of KiwiRail's train control procedures, NZTA rail safety director Celia Patrick said.
"Our top priority as a regulator is ensuring that rail travel is safe for passengers and rail workers, and it's important that the lessons learned from this incident are acted on so people can have confidence that all reasonable steps are being taken to avoid the possibility of a potentially serious collision between rail vehicles," Patrick said.
Chief Commisioner's comments
At a media conference earlier today, Chief Commissioner John Marshall QC said the train had stopped just 300 metres short of the maintenance cart.
If a collision had occurred, the likelihood of a casualty was high, and the cart driver jumping from the cart may have been one of the only way to avoid being hit.
The controller was no longer employed in train control at KiwiRail. Marshall was unsure if she was still a KiwiRail employee at all.
At the time of the incident, she had "reduced blood sugar" due to not having a break in the five hours she had been working.
She was also "clearly under stress" as that day two train control areas had been merged onto a single desk as a KiwiRail training programme was underway and there were not enough controllers to do all of the work.
Marshall said they had investigated a number of cases involving train control, "each case being different".
It was not the first time they had made recommendations to KiwiRail, either.
"Yes, we've made many recommendations to KiwiRail over the years, some have been acted upon some haven't.
"The thing you've got to remember about train control is it's a safety-critical function."
Marshall said he was "particularly pleased" a new system was recently introduced making all trains on 95 per cent of its network electronically visible to train controllers, but more work was needed to ensure a similar incident did not happen again.
He recommended better risk management of the train control operation, including chief executive and board oversight, an improved management of stress and fatigue ensuring controllers took rest, toilet and meal breaks and that track works should be better planned.
"The Commission has also asked the rail regulator, the New Zealand Transport Agency, to take all appropriate steps to ensure KiwiRail addresses our recommendations," Marshall said.
"This incident would have become a serious accident, but for the fortuitous intervention of the worker who overhead the radio communications.
"The underlying issues at train control identified during this inquiry meant that it could not be seen as a one-off event, and KiwiRail and the New Zealand Transport Agency need to take action to ensure something similar or worse does not happen again," Marshall said.
- © Fairfax NZ News
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