RO-2020-104 Safe Working Irregularity, East Coast Main Trunk Line, Hamilton Eureka, 21 September 2020

What happened

1. At 0747 on 21 September 2020, a freight train on the East Coast Main Trunk line entered a section of track that the rail protection officer believed was part of a protected work area and which was already occupied by a contractor operating a hi-rail vehicle.
2. The hi-rail vehicle was working under the protection of a rail protection officer who was responsible for organising the safety of the work area.
3. It was intended that the protected work area extend for a distance of about 15 kilometres between Hamilton and Eureka. However, due to a number of miscommunications, Train Control only protected the track between Hamilton and Ruakura for a distance of about 7 kilometres.
4. It resulted in the hi-rail vehicle operator unknowingly working on the track in a section that had not been protected from rail traffic.
5. A collision between the train and the hi-rail vehicle was only avoided because the hi-rail vehicle had voluntarily cleared the track about five minutes earlier.

Why it happened

1. While establishing the protected work area, neither the rail protection officer nor the train controller noticed a discrepancy recording the limits of the protected area that they were referencing.
2. The rail protection officer was unfamiliar with the area of operation.
3. The ineffective use of communication skills with erroneous read-backs (hear-back error) while trying to implement an administrative control measure resulted in a designated procedure not being followed correctly and protection arrangements not being put into place.

What we can learn

1. The key lessons arising from this inquiry are:

• Workers on the national rail network are at risk of serious harm if a rail vehicle enters the section of track while they are working.
• All personnel involved in safety-critical operations should recognise non-technical, and particularly communication, skills as an important risk mitigation measure.
• The use of engineering control measures may enhance the safety of track workers.

Who may benefit?

1. Rail operators (including train controllers), rail protection officers and track maintenance personnel may benefit from the findings in this report.

Background

1. A hi-rail vehicle (HRV) operator was scheduled to carry out ballast profiling work between Ruakura and Hemopo on the East Coast Main Trunk (ECMT) line between 21 and 24 September 2020 inclusive. The work was to be carried out between 0700 and 1700 daily under the protection of a rail protection officer (RPO).
2. Due to a planned network maintenance shutdown, there was only one train scheduled to pass through the area during the Monday shutdown period, which was on the morning of 21 September.

Narrative

1. On Sunday 20 September 2020, the RPO travelled to Hamilton in preparation for work on the ECMT. That evening the RPO checked the local Signalling & Interlocking Diagrams (diagrams indicating the location of signals and motor points), and the related paperwork (documentation that includes the Daily Information Bulletin and Signalling & Interlocking Diagrams), in preparation for commencing work the next day.
2. At about 0630 on Monday 21 September 2020, the HRV operator arrived at Percival Road (see Figure 2) and unloaded the vehicle.
3. At about 0700 the RPO arrived at Percival Road and conducted a pre-start meeting with the HRV operator. It included the information contained on the Daily Information Bulletin (the Daily Information Bulletin was issued by KiwiRail and applied for on the day of the operation only, and included information on general daily instructions, running of extra trains and maintenance work) and was followed with a safety briefing.
4. At 0705 the RPO contacted Train Control (TC) using the radio fitted inside the KiwiRail vehicle. Protection in the form of signal blocking was requested, which allowed the HRV operator to work on the track between Hamilton and Eureka (see Figure 2).
5. The RPO was using a track occupancy cross check sheet known as an Mis (Miscellaneous) 71. The RPO had already part-completed the form and described the work area as ‘work between Hamilton and Eureka’.
6. Track occupancy protection was in place by 0706, the RPO and HRV operator locked onto (before leaving the safe place, all personnel on-site must attach a padlock for themselves and a padlock for any vehicle under their control that will foul the track to the lock-on frame) the RPO’s frame (the lock-on frame showing people and vehicles within the worksite at any given time), and the vehicle on-tracked. The vehicle made its way towards Eureka, carrying out ballast work at pre-designated places (see Figure 2).
7. When the vehicle was safely on track, the RPO drove his road vehicle to the agreed off-tracking point, located about 3 kilometres (km) to the east (see Figure 2).

1. At about 0745 the RPO contacted the HRV operator to inform them that the blocking protection expired at 0800, as per the clearance provided by TC to allow the passing of the train.
2. After they received the call, the HRV operator made their way to the agreed off-tracking safe place.
3. At about 0747 a train entered the Eureka to Ruakura section while it was still occupied by the HRV operator. The train and the vehicle were separated by a distance of about 5 km (see Figure 3).
4. At about 0750 the HRV was safely removed from the track.
5. Both the RPO and the HRV operator remained at the designated safe location, clear of the track.
6. At about 0755 both the HRV operator and RPO noticed the headlights of a train approaching from the direction of Eureka. The RPO immediately contacted TC to advise them a train was operating in their protected work area (PWA).
7. The train passed the designated safe location about 5 minutes after the vehicle had off-tracked.
8. There was no collision and the train continued to Hamilton without further incident.
9. The train controller reported that there had been a potential safe-working incident to the Network Control Manager and an investigation was initiated.

Personnel information

1. At the time of the incident, the RPO had 14 years’ experience in this role, initially as an HRV operator and then for the last few years with KiwiRail. He held current certification for his role. The RPO underwent a post-incident drug and alcohol test that returned a negative (clear) result.
2. The HRV operator worked for a subcontractor to KiwiRail and had 25 years’ rail experience, the last 14 years operating an HRV for their current employer.
3. The train controller completed training at the TC school in December 2015. They were certified on the Auckland Zone desk in July 2016 and then on the ECMT desk in March 2020. The train controller underwent a post-incident drugs and alcohol test that returned a negative (clear) result.

Meteorological information

1. On the day of the incident the weather was fine with clear visibility.

Recorded data

1. The locomotive was fitted with a data recording system known as Tranzlog. The data was obtained by the Commission.

Train/Vehicle information

1. The train involved in the incident was a DC class locomotive travelling without any wagons attached.
2. The Commission found no evidence that either the condition or the operation of the train contributed to the incident.

Previous occurrences

1. The Commission has received statistical data from KiwiRail about track occupancy irregularities where miscommunication was identified as a contributing factor.

   Table 1 shows that from 1 June 2019 until 31 May 2021, KiwiRail recorded 61 track occupancy irregularities. Twenty-one of the irregularities were due to a discrepancy between the authority and the actual location, whereby miscommunication was considered to be a contributing factor to the incident.