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02-129. Train Control Incidents, Trains Authorised To

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02-129. Train Control Incidents, Trains Authorised To RAILWAY OCCURRENCE REPORT 02-129 train control incidents, trains authorised to enter sections of track 29 August 2002 – already occupied by hi-rail vehicles and work groups, various 4 December 2002 locations TRANSPORT ACCIDENT INVESTIGATION COMMISSION NEW ZEALAND 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 02-129 train control incidents trains authorised to enter sections of track already occupied by hi-rail vehicles and work groups various locations 29 August 2002 - 4 December 2002 Abstract On 29 August 2002, an incident occurred at Maimai when a locomotive engineer was authorised by train control to enter a section of track already occupied by a rail contractor. The locomotive engineer saw the contractor and stopped the train short of the work site. On 21 November 2002, train control cleared a signal at Ashburton that authorised a train to enter a section of track that was already occupied by a hi-rail vehicle. Fortunately the driver of the hi-rail vehicle overheard the conversation between the train controller and the locomotive engineer and interrupted to advise that he was still in the section. The train did not enter the occupied section. On 4 December 2002, an incident occurred near Lepperton when a locomotive engineer was issued with a track warrant by train control and given a signal to proceed into a section already occupied by a track gang replacing a broken rail. A collision was averted only because the track gang had cleared the track minutes before the train arrived. Given the potential for each incident to have resulted in a collision and the similar issues arising from each incident, all 3 were combined into one report. The safety issues identified included: • the train controllers not following correct procedures for handling track user inquiries • the lack of forward planning on the train control diagrams • the train controllers’ lack of attention in ensuring the train control diagram was accurate and complete • the issuing of a track warrant into a section of track that at the time was known to be occupied • the hand-over process when the outgoing train controller completed his shift • train controllers not using, nor being required to use, signal “blocking commands” to protect maintenance gangs and hi-rail vehicles • the absence of an area familiarisation visit for the train controller prior to certification. The Commission’s previous Occurrence Reports 00-101, 00-116 and 02-118 identified similar safety issues, and safety recommendations were made to the Managing Director of Tranz Rail to address the issues. Tranz Rail has now taken appropriate safety actions and no further safety recommendations have been made. Contents Abbreviations .............................................................................................................................................. iii Data Summary..............................................................................................................................................iv 1 Introduction....................................................................................................................................1 2 02-129, Train 575, Midhirst, 4 December 2002 ............................................................................1 2.1 Factual information ........................................................................................................1 Narrative.........................................................................................................................1 2.2 Signalling information and operating system.................................................................3 2.3 Radio communication.....................................................................................................3 2.4 Train control procedures.................................................................................................4 Train control diagram.....................................................................................................4 Track user inquiries ........................................................................................................4 Reporting of track irregularities .....................................................................................5 Hand-over process..........................................................................................................6 2.5 Personnel ........................................................................................................................6 Locomotive engineer of Train 575 .................................................................................6 The ganger......................................................................................................................6 The track inspector .........................................................................................................6 Train controller (TC1) ....................................................................................................6 Train controller (TC2) ....................................................................................................7 2.6 Train control voice log ...................................................................................................7 3 Analysis .........................................................................................................................................7 4 02-119, 84 shunt, Maimai, 29 August 2002 9 4.1 Factual information ........................................................................................................9 Narrative.........................................................................................................................9 4.2 Site information............................................................................................................11 4.3 Operating system..........................................................................................................11 4.4 Train control procedures...............................................................................................11 4.5 Personnel ......................................................................................................................12 The rail contractor ........................................................................................................12 The train controller.......................................................................................................12 5 Analysis 12 6 02-128, Train 937, Ashburton, 21 November 2002.....................................................................13 6.1 Factual information ......................................................................................................13 Narrative.......................................................................................................................13 6.2 Site and signalling information.....................................................................................14 Train control procedures...............................................................................................15 6.3 Personnel ......................................................................................................................15 Locomotive engineer of Train 937 ...............................................................................15 Track inspector .............................................................................................................15 Trainee train controller (TC1) ......................................................................................15 Tutor train controller (TC2)..........................................................................................15 7 Analysis .......................................................................................................................................16 8 Other relevant occurrences investigated by the Commission ......................................................16 Occurrence report 00-101, train control incidents, hi-rail vehicles and trains occupying the same section of track and a collision, various locations .......................16 Occurrence report 00-116, Train 225 and hi-rail vehicle occupying the same section of track, near Te Kauwhata.....................................................................17 Occurrence report 02-118, near collision between Train 484 and hi-rail vehicle at Tauranga ...................................................................................................................17 9 Summary......................................................................................................................................17 Report 02-129 Page i 10 Findings .......................................................................................................................................18
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