Rail contractors in Christchurch were given the all clear to work on the tracks, but realised a train was approaching when level crossing bells started ringing. Photo: daboost/123RF
Contractors working on a rail line in Christchurch managed to avoid being struck by an oncoming train after they were given the all clear to work on the track, the Transport Accident Investigation Commission says.
In a report released on Thursday, the Transport Accident Investigation Commission found a trainee rail protection officer had authorised Fulton Hogan workers to start work on the main south line in Hornby on 7 March 2024, before a scheduled train had passed through.
The workers realised a train was approaching when level crossing bells started ringing and were able to get off the track in time.
The investigation found the trainee was carrying out tasks unsupervised that required a high level of proficiency.
They had limited experience and became distracted, which led to an important step in the process of track protection being missed.
The supervising officer was absent while the trainee was performing the safety-critical tasks associated with track protection and was not available to provide the guidance necessary to rectify the situation.
They also did not have any training in coaching and mentoring personnel undertaking safety-critical roles, and the level of supervision required had not been clearly articulated or documented.
It identified three safety issues; that KiwiRail did not take all steps to ensure that Fulton Hogan staff carried out work in accordance with its safety systems, that Fulton Hogan's procedures for supervision of trainee rail protection officers were inadequate and that the track work protection largely relied on administrative controls, which were subject to human error.
The commission said there were lessons for all industries where the supervision of safety-critical tasks performed by inexperienced or unqualified staff was necessary to maintain safety.
It recommended improvements to training and supervision and use of engineering controls.
The TAIC report said the level-crossing alarm system was not a method of protection for the work being conducted.
"The proximity of the incident to these crossings provided early warning to the track workers and trainee RPO, and very likely reduced the consequences of the incident by giving them time to clear the worksite before the arrival of Train 882," it said.
"Had this incident occurred in a location without a level-crossing alarm system, the track workers would not have received a warning of the train approaching the worksite at line speed."
The report outlined three key lessons:
- On-the-Job Training can introduce risks to an operation. Effective supervision of trainees undertaking safety-critical tasks is an important defence against unsafe acts.
- Complex systems require robust engineering risk controls to guard against human performance limitations within the systems.
- Administrative controls, which are vulnerable to human error and non-compliance, should not solely be relied upon to keep a system safe.
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