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Report 07-113, Express Freight Train 239, Wagons Left in Section at 514.9Km, Between Te Awamutu and Te Kawa, 22 September 2007

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Report 07-113, Express Freight Train 239, Wagons Left in Section at 514.9Km, Between Te Awamutu and Te Kawa, 22 September 2007 Report 07-113, express freight Train 239, wagons left in section at 514.9km, between Te Awamutu and Te Kawa, 22 September 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 07-113 express freight Train 239 wagons left in section at 514.9km between Te Awamutu and Te Kawa 22 September 2007 Abstract At about 1915 on Saturday 22 September 2007, southbound express freight Train 239 parted between the 22nd and 23rd wagons while the train was travelling on the North Island Main Trunk line between Te Awamutu and Te Kawa. The emergency brakes applied automatically as the air pressure in the brake pipe reduced and both portions of the train rolled to a stop, some distance apart. The locomotive engineer went back to examine the train and saw that there was no train end monitor attached to the last wagon. Thinking this was the last wagon on the train and that the loss of the train end monitor was responsible for the loss of air in the brake pipe, he advised train control and continued, leaving behind the rear 10 wagons. These wagons were found some time later by the locomotive engineer of a following train who was following at caution on instruction from train control, because the section of track was showing as occupied on the train control centralised traffic control panel. There were no injuries and no damage to the train or infrastructure. The safety issues identified included: • the manual overriding of a correctly operating signalling system • failure to establish beyond reasonable doubt the cause of the brake pipe air loss • failure to ensure beyond reasonable doubt that the Te Awamutu – Te Kawa block section was unoccupied before a train was authorised to enter the block section • the poor level of training in and application of crew resource management within the rail industry • the response of train controllers to operating incidents. One safety recommendation covering these issues has been made to the Chief Executive of the New Zealand Transport Agency. Contents Abbreviations ............................................................................................................................................... ii Data Summary .............................................................................................................................................. ii 1 Factual Information ........................................................................................................................ 1 1.1 Narrative ......................................................................................................................... 1 1.2 Site and signalling information....................................................................................... 2 1.3 Track and signal indication data ..................................................................................... 3 1.4 Mis 59 Authority to Pass Departure Signal at Stop ........................................................ 9 1.5 Train end monitor ........................................................................................................... 9 1.6 Head end display unit ................................................................................................... 10 1.7 Locomotive event recorder ........................................................................................... 11 1.8 Personnel ...................................................................................................................... 11 Locomotive engineer Train 239 ................................................................................... 11 Locomotive engineer Train 243 ................................................................................... 11 Train controller ............................................................................................................. 11 1.9 Train control audio recorder ......................................................................................... 12 1.10 ZL and ZH class wagons .............................................................................................. 12 1.11 Crew resource management.......................................................................................... 14 Toll Rail ........................................................................................................................ 14 Ontrack – train controllers ............................................................................................ 14 Ontrack – track workers ............................................................................................... 15 Extracts from Rail Crew Resource Management (CRM): the Business Case for CRM Training in the Railroad Industry, published by US Department of Transportation Federal Railroad Administration, September 2007 ...................................................... 15 Introduction .................................................................................................................. 15 Initial awareness training .............................................................................................. 15 Practice and feedback ................................................................................................... 16 Continuing reinforcement ............................................................................................. 16 Conclusions .................................................................................................................. 17 1.12 Crew resource management occurrences investigated by the Commission ................. 17 Introduction .................................................................................................................. 17 Rail occurrence report 05-102, track warrant control irregularities, Woodville and Otane, 18 January 2005 ................................................................................................ 18 Rail occurrence report 07-108, express freight Train 720 track warrant overrun, Seddon – Vernon, 12 May 2007 ................................................................................... 18 Rail occurrence report 07-110, collision express freight Train MP2 and Work Train 22 at Ohinewai, 19 June 2007 ...................................................................................... 19 1.13 A crew resource management occurrence brought to the Commission’s attention ...... 19 1.14 Tonnage left in section incident, Camden Road Tunnel, Camden Town, London, 19 July 2007 .................................................................................................................. 20 1.15 Maritime CRM case study in New Zealand ................................................................. 21 2 Analysis ....................................................................................................................................... 21 Introduction .................................................................................................................. 21 Prior to departure from Te Rapa ................................................................................... 22 Train parting at 514.9 km ............................................................................................. 22 After departing 514.9 km ............................................................................................. 23 Train control ................................................................................................................. 24 The signalling system ................................................................................................... 24 Issue of the Mis 59 ....................................................................................................... 25 Track warrant control ................................................................................................... 26 Human factors .............................................................................................................. 26 Crew resource management.......................................................................................... 27 3 Findings ....................................................................................................................................... 28 4 Safety Recommendations ............................................................................................................. 29 Report 07-113, Page i Figures Figure 1 Site diagram (not to scale) ......................................................................................... 2 Figure 2 Track indications prior to departure of Train 239 from Te Awamutu ....................... 2 Figure 3 Track indications as Train 239 departed Te Awamutu .............................................. 2 Figure 4 Track indications as Train 239 occupied
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