025/13

Status
Closed
Recommendation Date
Recipient Name
KiwiRail
Date Closed
Text
The train controller in this case made an assumption that the passenger train had passed a particular location based on information from the person-in-charge. Rather than verifying the train's location, the train controller acted on his assumption and authorised the person-in-charge to occupy a section of track that the passenger train was approaching.

Train controllers must not make assumptions about the locations of trains without first verifying their locations. Unless KiwiRail and train controllers remain alert to this risk and take all appropriate steps to minimise the likelihood of train controllers making assumptions, further incidents could occur, perhaps with more serious consequences.

The Commission recommends that the Chief Executive of KiwiRail ensure that appropriate mechanisms are in place, and are being applied, to minimise the likelihood of train controllers making assumptions about the locations of trains and other rail vehicles.
Reply Text
Following on from the Commission's investigation report 11-102, KiwiRail has made significant changes in respect to mitigating the risk of Train Controllers making assumptions by introducing enhanced "Block to be clear" verification process, implemented on 1 August 2013 by Bulletin 449 [refer below].

Where track safety rules require train control to verify the position of a train to ensure that it is passed the on-tracking location, this must be performed by:
- Observing all track circuits are clear within the on-tracking location when within station limits of an interlocked station, or
- Observing all track circuits are clear between adjacent stations for any continuously detected block sercion, or
- Obtaining verbal advice and confirmation of a trains position form the Locomotive Engineer that it is clear of the next station (incl Metro Platforms & Intermediate Boards) when the on-tracking location is in dark territory or non-continuously detected (DLAS, TWC, SLAS, ASR)

This new procedure has been reinforced by the Manager Network Operations by way of a Safety Briefing and a personal letter to all Train Control Personnel, outlining the change in procedure.

Compliance with the new process is monitored through our safety observation process.
Related Investigation(s)