NB: The below is a brief plain English summary of key points in the Report issued today by the Transport Accident Investigation Commission. The report is available here RO-2024-102.
TAIC report on rail near miss reinforces importance of effective supervision of trainees undertaking safety-critical tasks and robust engineering risk controls for complex systems.
Lessons for all industries where the supervision of safety-critical tasks performed by inexperienced or unqualified staff is necessary to maintain safety.
What happened
A trainee rail protection officer (RPO) authorized Fulton Hogan workers to start work on the main south line in Hornby before a scheduled train had passed through. The workers realized a train was approaching when level crossing bells started ringing and were able to get off the track in time.
Why it happened
The trainee was carrying out tasks that required a high level of proficiency unsupervised and with limited experience and became distracted. This led to an important step in the process of track protection being missed.
The supervising RPO was absent while the trainee RPO was performing the safety-critical tasks associated with track protection and was not available to provide the guidance necessary to rectify the situation.
The supervising RPO had not been provided with any additional training in coaching and mentoring personnel undertaking safety-critical roles, and the level of supervision required had not been clearly articulated or documented.
Safety Issues
Safety issue 1: KiwiRail, as the rail licence holder, did not take all reasonable steps to ensure that Fulton Hogan carried out track work protection in accordance with KiwiRail’s safety case and safety system. KiwiRail’s RPO training, provided to Fulton Hogan RPOs, did not describe the level or purpose of supervision of a trainee RPO.
Safety issue 2: The Fulton Hogan procedures and guidelines for the supervision of trainee RPOs were inadequate. They had not provided the supervisor RPO with additional training to perform this function. This increased the risk of the trainee RPO being left unsupervised or without the required level of supervision, while performing safety-critical activities that they were not yet qualified to do.
Safety issue 3: The track work protection in place largely relied on administrative controls, which were subject to human error. KiwiRail did not consider utilising available engineering controls to mitigate the risk of human error resulting in a rail movement entering the worksite while it was occupied by track workers.
Recommendations
TAIC is recommending improvements to training and supervision, and use of engineering controls.