An error of judgement, and not methamphetamines in a worker’s system, were to blame for a 2015 near-miss, according to a new report.
The Transport Accident Investigation Commission (TAIC) has released a report detailing the near-collision of a passenger train and rail workers on North Island Main Trunk line in December 2015.
The incident occurred while track maintenance workers were replacing sleepers on Bridge 197 between Manunui and Taumarunui, at a worksite protected by stop boards requiring trains to stop before receiving authority from a rail protection officer (who was also the maintenance team leader) to continue.
Four freight trains had passed through the worksite in this manner in earlier in the morning without incident.
When a fifth train – a passenger service – stopped at the boards, the officer let the train pass through, and proceeded to engage in conversation with the train controller, leaving his work vehicle and then “locked on” – a KiwiRail safety process which signals to maintenance workers that tracks are clear and safe to occupy.
According the report, while some of the workers knew a train was due to pass through the site at that time, all the workers proceeded to “lock on” and occupy the bridge.
The driver of the approaching passenger train was able to sight the workers in time and stop 72 metres short of the bridge, averting any collision or injuries.
The Commission concluded that the rail protection officer made the error of both allowing the train to pass and the workers to occupy the tracks due to a “lapse in memory influenced by the pressures he was under in his role as team leader”.
After the incident, the rail protection officer tested positive for methamphetamine. However, the report found that it was “unlikely that the rail protection officer was impaired at the time of the incident”.
TAIC’s report states that the officer’s error should have been identified by other staff, who might have been able to intervene to prevent the near-collision incident.
The Commission found that having one individual take on both the rail protection officer and the maintenance team leader roles was a safety risk which contributed to the incident.
“The responsibility for overseeing the sleeper replacement project and ensuring the safety of the workers should never have been placed on one person,” the report states.
“In this case the team leader did have other members of the work group who were qualified to take on the rail protection officer role. However, because of personal and professional issues within the team, he felt more comfortable taking on the role himself.”
The rail protection officer was considered by TAIC to have been placed under significant pressure by his responsibilities, especially as the project was running late due to scaffolding problems.
“The rail protection officer was clearly distracted by stressors associated with his other roles. This incident is a good example of why staff assigned to the safety-critical role of rail protection officer should be able to dedicate their full attention to fulfilling that role,” the report states.
KiwiRail has since introduced a plan to separate the rail protection officer and work supervisor (team leader) roles.
TAIC also recommended that non-technical skills, such as encouraging teamwork, improving communication skills, and improving situational and safety awareness, ought to be provided in training by KiwiRail to track workers.
“The rail protection officer’s error could have been picked up and nullified by any of the other staff on site if they had been trained in and working to a good standard of non-technical skills,” the report concluded.
The Commission has recommended that KiwiRail expand its random drug and alcohol tests for its employees working in its safety-critical infrastructure maintenance and train operations areas. In response, KiwiRail has increased the testing to cover 20% of its workforce per year, up from 10%, with the change coming into force this month.