This page displays a list of safety recommendations that relate to the rail mode. You can use the filter tool to refine the results and to search for keywords within the text of each recommendation.
Safety Recommendation
018/11
Issued To
NZTA
on 23 Jun 11
Temporary speed restrictions are used to manage the safety of train operations when a general deterioration in track condition is identified. KiwiRail Network?s codes and standards consider track geometry faults such as cant, twist, line, top and rate of change of cant deficiency separately when determining the appropriate speed value.
The Commission recommends that the Chief Executive of the NZ Transport Agency work with KiwiRail to make changes to the codes and standards relating to imposing temporary speed restrictions. Multiple track faults within the same section of track should be considered collectively when determining if a temporary speed restriction needs to be imposed before track repairs are made. (018/11)
Implementation Status:
Open
Reply:
We intend to work closely with KiwiRail with an aim to implementing and closing this recommendation as soon as practicable.
Discussion on it will commence on publication of the final report and will be ongoing.
When implementation is effected and the appropriate evidence has been gathered, we will be liaising with TAIC with a view to closing this safety recommendation.
Safety Recommendation
044/10
Issued To
NZTA
on 25 Nov 10
The location of the Fruitvale Road level crossing close to the Fruitvale Road Station platform represents a risk to level-crossing users in the event of a platform overrun for whatever the reason. There is a delicate balance between the signalling ensuring the level crossing is protected in the event of a platform overrun and ensuring road users are not kept waiting for so long as to engender the known unsafe practice of road users ignoring signals and barriers and entering the level crossing ahead of passing trains.
Speed restrictions are often used around the rail network as a method of supplementing signals to ensure trains can stop within the available distance ahead without passing signals at danger.
The Commission recommends that the Chief Executive require KiwiRail Network to review the Fruitvale Road Station and associated arrangements for protecting the adjacent level crossing, to see if speed restrictions or other changes to the signalling system can be made to minimise the possibility of an overrunning train entering an unprotected level crossing, without compromising the waiting time for motorists using the level crossing. This review should be extended to other stations where the distance between the stations and level crossings is less than the recommended 150 metres.
Implementation Status:
Closed acceptable
Reply:
We intend to work closely with KiwiRail to oversee the internal review recommended in this report with an aim to implementing and closing this recommendation as soon as practicable.
We note and agree with the comments in Para 4.13 of the draft final report and the comment that it is a delicate balance between the protection of the level crossing and increasing waiting time at the level crossing for motorists leading to unsafe practices.
Discussion on this review will commence on publication of the report and will be ongoing. All outstanding Transport Accident Investigation Commission (TAIC) recommendations also form an integral part of our annual safety assessments of the rail industry.
When this review is concluded and the appropriate evidence has been gathered, we will be liaising with TAIC with a view to closing this safety recommendation.
Safety Recommendation
043/10
Issued To
NZTA
on 04 Oct 10
The most likely reason for the side frame failures is that they had reached the end of their fatigue lives. A lack of identifying marks and records of side frame age and maintenance history means that it will be difficult to predict the onset of fatigue cracking in bogie side frames. The presence of fatigue cracking initiating in the region of the radius, just beyond the wear plate of the side frames, is difficult to detect by normal visual inspections, and at the current rate of MPIs the entire inventory of bogie side frames will not be completed until 2020. With 60% of the side frames tested consistently requiring weld repairs before being returned to service, the failure and collapse of a bogie side frame have resulted, and will continue to result, in significant damage to rolling stock and track infrastructure and the risk of serious harm to people.
The Commission recommends that the Chief Executive of the NZ Transport Agency give high priority to working with industry to conduct a formal assessment of the risks that main-line derailments pose to rolling stock and track infrastructure, and the risk of serious harm to people (industry and the general public). The results of the risk assessment should then be used to set appropriate remedial measures to reduce the likelihood of bogie side frame failures, and could also be used to set appropriate measures to reduce main-line derailments from other causes.
Implementation Status:
Open
Reply:
We intend to work closely with KiwiRail with an aim to implementing and closing this recommendation as soon as practicable.
Discussions on it will commence on publication of the report and will be ongoing. Any outstanding Transport Accident Investigation Commission (TAIC) recommendations also form and integral part of our annual safety assessments of the rail industry. Discussions on the bogie component issues this report highlights have already commenced.
When these discussions are concluded and the appropriate evidence has been gathered, we will be liaising with TAIC with a view to closing this safety recommendation.
Safety Recommendation
039/10
Issued To
NZTA
on 23 Sep 10
The present severe weather warning system described by Rail Operating Rules and Procedures Section 1, Rule 6(b) does not require feedback from area managers to the network control manager on receipt of severe weather alerts, which creates an open loop information flow and prevents the network control manager from maintaining an overview of severe weather actions being taken across the entire network. Network control managers spoken to did not see maintaining an overview of actions during severe weather as their responsibility. In this case the network control manager did not monitor the severe weather alerts as they were being updated by MetService, with the result that neither the area manager nor his staff nor the locomotive engineers of trains in that area were aware of the current severe weather alert. Current contact details for recipients of severe weather warnings from network control were also allowed to lapse.
The Commission recommends that the New Zealand Transport Agency oversee a review of KiwiRail?s severe weather warning system and underlying processes for effective communication of warnings to ensure that it results in an appropriate level of awareness, actions and responses to severe weather events across the entire rail system.
Implementation Status:
Open
Reply:
We intend to work closely with KiwiRail to oversee the internal reviews of documentation and procedures and implementation of a risk management system for slip hazards on the rail corridor with and aim to implementing and closing these recommendations as soon as practicable.
Discussions on them will commence on publication of the report and will be ongoing. Any outstanding Transport Accident Investigations Commission (TAIC) recommendations also form an integral part of our annual safety assessments of the rail industry.
When these reviews and implementation are concluded and the appropriate evidence has been gathered, we will be liaising with TAIC with a view to closing these safety recommendations.
Safety Recommendation
040/10
Issued To
NZTA
on 23 Sep 10
KiwiRail provided a draft document that demonstrated its proposed risk-ranking system for assessing the slip hazard risk along the rail corridor. It included a method for assessing potential groundwater conditions, slope stability, soil type, surface cover, slope alterations and rail traffic and outlined a framework to come up with a risk rating. The proposed rollout of this system was over the next 2 financial years but this had not been confirmed at the time of writing. Analysis of available data such as rainfall, river flows and slip activity can be a useful activity to complement the proposed risk-ranking system for determining slip hazard risk, but this data is not currently used by the rail industry. Until the risk-ranking system has been completed, the risk to the rail network from unpredicted slips is likely to be higher than is reasonably acceptable.
The Commission recommends that the NZ Transport Agency work with the rail industry to implement a risk-management system for the slip hazards along the rail corridor.
Implementation Status:
Open
Reply:
We intend to work closely with KiwiRail to oversee the internal reviews of documentation and procedures and implementation of a risk management system for slip hazards on the rail corridor with and aim to implementing and closing these recommendations as soon as practicable.
Discussions on them will commence on publication of the report and will be ongoing. Any outstanding Transport Accident Investigations Commission (TAIC) recommendations also form an integral part of our annual safety assessments of the rail industry.
When these reviews and implementation are concluded and the appropriate evidence has been gathered, we will be liaising with TAIC with a view to closing these safety recommendations.
Safety Recommendation
041/10
Issued To
NZTA
on 23 Sep 10
The existing track and structures inspection codes were prescriptive and did not embrace the risk assessment principles documented in the more recent Structures Inspection Manual W200 or required for rail systems under National Rail System Standard (NRSS) 4.
The Commission recommends that the NZ Transport Agency oversee KiwiRail Network?s internal review of its track and structures inspection regimes defined in the codes T003 and W004 to ensure that the outcome is a combined track inspection process that covers all aspects of the track risk assessment using a methodology guided by that defined in NRSS 4: Risk Management.
Implementation Status:
Open
Reply:
We intend to work closely with KiwiRail to oversee the internal reviews of documentation and procedures and implementation of a risk management system for slip hazards on the rail corridor with and aim to implementing and closing these recommendations as soon as practicable.
Discussions on them will commence on publication of the report and will be ongoing. Any outstanding Transport Accident Investigations Commission (TAIC) recommendations also form an integral part of our annual safety assessments of the rail industry.
When these reviews and implementation are concluded and the appropriate evidence has been gathered, we will be liaising with TAIC with a view to closing these safety recommendations.
Safety Recommendation
042/10
Issued To
NZTA
on 23 Sep 10
NRSS 5 (Occurrence Management) refers to the Coordinated Incident Management System (CIMS) as if it only applies to a specific incident site and does not take into account that, for a larger or more complex emergency response, the incident command centre could be somewhere
Page 32 | Report 09-103
else. NRSS 10 (Crisis Management), which is designed to work in parallel with NRSS 5, does not refer to the CIMS but refers to the civil defence model as being separate from the CIMS model, when instead it forms part of it.
The Commission recommends that the NZ Transport Agency oversee a review of NRSS 5 and NRSS 10 to ensure they are consistent and integrate efficiently with the CIMS used by emergency response agencies.
Implementation Status:
Open
Reply:
We intend to work closely with KiwiRail to oversee the internal reviews of documentation and procedures and implementation of a risk management system for slip hazards on the rail corridor with and aim to implementing and closing these recommendations as soon as practicable.
Discussions on them will commence on publication of the report and will be ongoing. Any outstanding Transport Accident Investigations Commission (TAIC) recommendations also form an integral part of our annual safety assessments of the rail industry.
When these reviews and implementation are concluded and the appropriate evidence has been gathered, we will be liaising with TAIC with a view to closing these safety recommendations.
Safety Recommendation
033/10
Issued To
MoT
on 19 Aug 10
the status of the National Rail System Standard and the relationship between these standards and rail participants' safety cases and underlying safety systems is not clear. For example, it is not clear whether KiwiRail's safety case and its underpinning safety system can be required to comply with the NRSS as a minimum, or whether the NRSS is subservient to KiwiRail's safety system. An approved (by the regulator) change to KiwiRail's safety system could then by default become an approved change to the NRSS. If the latter, then it is also unclear what the relationship between the NRSS and other rail participants' safety cases and underpinning safety systems would be.
Implementation Status:
Open
Reply:
Safety Recommendation
031/10
Issued To
NZTA
on 19 Aug 10
The push/pull train sets were signed off as fit for purpose and commissioned to the Auckland passenger train network when they did not comply with the National Rail System Standard with regard to maximum allowable stopping distance as a complete train, and it has not yet been proven that they do so under all conditions of loading and track condition.
Implementation Status:
Closed acceptable
Reply:
Safety Recommendation
032/10
Issued To
NZTA
on 19 Aug 10
The training system for drivers of the push/pull sets on the Auckland rail network did not use standard training techniques, did not teach standard best practice methods for train operations, and did not include appropriate standards for minder drivers to achieve before being certified to teach trainee drivers.
Implementation Status:
Closed acceptable
Reply:
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