Press Release – Transport Accident Investigation Commission
An error by a train controller, which nearly resulted in a mid-tunnel collision between a freight train and a maintenance vehicle in 2011, was caused in part by the systems, supervision and culture at KiwiRail’s train control centre, a Transport Accident Investigation Commission inquiry has found.
The report released today (17 Oct 13) describes how a mid-tunnel accident was “narrowly averted” when a worker inspecting rail structures in the area overheard radio calls, realised a collision could result, and radioed the train to stop. The train controller had not made required checks and assumed the freight train had already passed the area when she gave a motorised maintenance cart permission to use the track.
“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,” said Chief Commissioner John Marshall QC.
The report’s 20 findings described how:
• KiwiRail had made an inadequate risk assessment of the extra workload given to the controller on the day.
• The controller “was stressed, mentally fatigued and operating well below an optimal level when she made her error”.
• No one was aware of her state, and she had not received training to recognise and deal with it.
• KiwiRail did not have proper systems in place to manage stress and fatigue of train controllers.
• There was a lack of support and minimal supervision of the controller during her shift.
• Controllers worked without scheduled rest, toilet, or meal breaks – and the controller believed her workload meant she could not leave her room.
• Poor planning and co-ordination of track works made the situation unnecessarily worse.
• Electronic visibility of trains and other vehicles on tracks would have made the controller’s job easier.
“KiwiRail has done a number of things since the incident to address issues identified during the inquiry, and the Commission is particularly pleased that it has recently introduced a system that makes all trains on 95% of its network electronically visible to train controllers. However the Commission believes more action is needed in four specific areas,” Mr Marshall said:
• “There needs to be better risk management of the train control operation, including chief executive and board oversight.
• “KiwiRail needs to improve its management of stress and fatigue and ensure controllers are always able to take rest, toilet and meal breaks.
• “Track works should be planned with the impact on train control in mind.
• “Finally, KiwiRail should ensure train controllers have electronic sight of all trains and other rail vehicles as this would further reduce the opportunity for error.
“The Commission has also asked the rail regulator, the New Zealand Transport Agency, to take all appropriate steps to ensure KiwiRail addresses our recommendations.
“KiwiRail and the New Zealand Transport Agency have accepted our recommendations.
“This inquiry drew out key lessons for any organisation with safety-critical functions: to take risk management seriously, to supervise staff properly, to ensure a supportive culture exists, to insist staff get breaks and food, to manage workloads carefully, and to ensure communication is clear,” said Mr Marshall.
Inquiry Report .pdf. http://www.taic.org.nz/LinkClick.aspx?fileticket=evczSOCjaGA%3d&tabid=36&mid=613&language=en-US (scroll down .pdf that opens for report title)
Scoop Copy: 11102_Final.pdf