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Report 07-105: Push/Pull Passenger Train Sets Overrunning Platforms

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Report 07-105: Push/Pull Passenger Train Sets Overrunning Platforms Report 07-105: push/pull passenger train sets overrunning platforms, various stations within the Auckland suburban rail network, between 9 June 2006 and 10 April 2007 The Transport Accident Investigation Commission is an independent Crown entity established to determine the circumstances and causes of accidents and incidents with a view to avoiding similar occurrences in the future. Accordingly it is inappropriate that reports should be used to assign fault or blame or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose. The Commission may make recommendations to improve transport safety. The cost of implementing any recommendation must always be balanced against its benefits. Such analysis is a matter for the regulator and the industry. These reports may be reprinted in whole or in part without charge, providing acknowledgement is made to the Transport Accident Investigation Commission. Report 07-105 (incorporating reports 06-105 and 06-107) push/pull passenger train sets overrunning platforms various stations within the Auckland suburban rail network between 9 June 2006 and 10 April 2007 Auckland Figure 1 Location of incidents Report 07-105 | Page i Contents Data Summary ............................................................................................................................................... v 1 Factual Information ........................................................................................................................ 1 1.1 Background information ................................................................................................. 1 Concept and development of the push/pull sets ............................................................. 3 1.2 Occurrence 06-105, Train 3114, Homai, 9 June 2006 .................................................... 5 1.3 Occurrence 06-105, Train 3321, Manurewa, 13 June 2006 ........................................... 6 1.4 Occurrence 06-107, Train 3169, Ellerslie, 11 August 2006 ........................................... 8 1.5 Occurrence 07-105, Train 2216, Te Mahia and Meadowbank, 10 April 2007 ............. 10 Post-incident mechanical examination of Train 2216 .................................................. 12 1.6 Subsequent reported platform overrun incidents .......................................................... 13 1.7 National Rail System Standard ..................................................................................... 13 1.8 Licensing and monitoring of the rail industry participants ........................................... 15 1.9 Safety system standard and practices ........................................................................... 16 Minimum train braking/stopping distances .................................................................. 16 Signalling system design parameters ............................................................................ 16 Comment on regulatory oversight from a previous report ........................................... 17 Toll Rail/KiwiRail interpretation of the NRSS/stopping distances .............................. 18 Mechanical engineering design manual ....................................................................... 18 Brake testing ................................................................................................................. 19 Single-carriage test results ............................................................................................ 20 Complete-train test results ............................................................................................ 20 SD driving trailer control volume reservoirs ................................................................ 22 Maintenance of a locomotive‟s air brake system ......................................................... 23 Maintenance of a carriage‟s air brake system .............................................................. 23 1.10 Personal accounts of the incidents ................................................................................ 24 Locomotive engineer trainee, Trains 3114 and 3321 ................................................... 24 Minder driver Train 3314 ............................................................................................. 24 Locomotive engineer, Trains 3169 and 2216 ............................................................... 24 Other locomotive engineers .......................................................................................... 26 Comparison of train timekeeping to timetable ............................................................. 27 Professional services group comment .......................................................................... 28 1.11 Training ........................................................................................................................ 29 Internationally sourced locomotive engineers .............................................................. 29 Conversion to driving the push/pull sets ...................................................................... 29 Minder driver selection ................................................................................................. 30 1.12 Train handling .............................................................................................................. 30 2 Analysis ....................................................................................................................................... 32 2.1 The overrun incidents ................................................................................................... 32 2.2 Locomotive engineer training ....................................................................................... 33 2.3 Push/pull set braking performance and the National Rail System Standard ................ 35 2.4 Regulatory oversight .................................................................................................... 40 3 Findings ....................................................................................................................................... 41 4 Safety Actions .............................................................................................................................. 43 5 Recommendations ........................................................................................................................ 43 Previous recommendation ............................................................................................ 43 New recommendations ................................................................................................. 44 Page ii | Report 07-105 6 Appendices ................................................................................................................................... 46 6.1 Push/pull train vehicles and equipment ........................................................................ 46 DC locomotives ............................................................................................................ 46 Westinghouse air brake system .................................................................................... 47 Sanding system ............................................................................................................. 48 SD driving trailer speedometer system ......................................................................... 49 6.2 Post-incident internal inspection and comment ............................................................ 49 6.3 Operating rules ............................................................................................................. 52 6.4 Comparative overseas practices.................................................................................... 53 Brake distance testing parameters in the United Kingdom .......................................... 53 Operating push/pull passenger train sets in Toronto, Canada ...................................... 54 6.5 Train performance detail .............................................................................................. 54 6.6 Event recorder detail ..................................................................................................... 55 Figures Figure 1 ........... Location of incidents ........................................................................................................... i Figure 2 ........... Push/pull train sets .............................................................................................................. 1 Figure 3 ........... The Auckland suburban rail (southern lines) network (not to scale) .................................. 2 Figure 4 ........... Homai station track alignment/gradient detail (left) and (right) event recorder data from SD5761 (neither graph is to scale) (refer appendix section 6.6 for a larger scale of the event recorder data) ............................................................................................................ 5 Figure 5 ........... Manurewa station track alignment/gradient detail (left) and (right) event recorder data from SD3197 (neither graph is to scale) (refer appendix section 6.6 for a larger scale of the event recorder data) ...................................................................................................... 7 Figure 6 ........... Ellerslie station track alignment/gradient detail (left) and (right) event recorder data from SD5648 (neither graph
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