KiwiRail. Another NZ Safety Fail?


Good safety practices can minimise human error

The NZ press has been full of various versions of a story about two disabled passengers (a woman in a wheelchair and her partially sighted husband).

The couple almost came to grief when their train started to pull away whilst they were still on a disabled ramp suspended between the train and the station platform.

According to one report by

A rail commuter watched in horror as the Capital Connection pulled out from Waikanae station with a woman in a wheelchair and her partially blind husband still on a disability ramp extended on to the platform.

Former health and safety officer Warren Doughty said he was standing on the platform waiting for a train about 7.20am yesterday when he saw the woman being helped off the train.

Her husband, who Mr Doughty said was partially blind, was holding the wheelchair on part of the ramp resting on the platform when the train started to move off, and the ramp was scraped along the platform for about a metre.

She was still on the ramp . . . the train was creeping along.

“I thought: what the f… is going on. I was screaming out and the train stopped. The man and woman got off the ramp. The conductor apologised and the woman said it was not his fault and left…” read the full report here

Another report said that the train doors were still open and that KiwiRail‘s general manager for passenger services Deborah Hume said an investigation had been launched into the incident. We also learn that

“The couple were in the last carriage on the train, and as they were leaving the train began its journey with the doors open and the ramp still on the platform…”

and an employee who was helping them off the train pressed the emergency stop button.

The eagle eyed safety sleuths out there who have read the news reports will be immediately asking the following questions.

1. Is the procedure for allowing the train to depart far too vulnerable to human error? Presumably if the train manager  can’t see all the doors at this station the visibility down the side of the train must be improved, or a second person used. Was this not picked up during safety audits? Who does the safety audits?

2. Why is there no central locking system for the carriages and a fail safe that will prevent the train from moving off if the doors are open?

3. Why does it appear that only KiwiRail is investigating this and not the NZ Transport Agency reporting it to the Transport Accident Investigation Commission (TAIC) ? This was a near miss which could have had fatal consequences. There are lessons to be learned. KiwiRail’s record for internal investigations isn’t exactly exemplary, read “Ministry criticises KiwiRail probe of gas incident”(May 2003) and you’ll see why.

4. How often do New Zealand’s trains pull away with the doors still open – are figures collected for this?

5. How often do the regulators make inspections of KiwiRail and what are they doing about open carriage doors?

The body responsible for investigating accidents and incidents in the transport sector is the Transport and Accident Investigation Commission (TAIC).

You may remember the TAIC investigated the Fox Glacier Skydiving disaster. Investigator Ian McClelland criticised the modifications made to the plane but also said regulation of the aviation adventure industry by the CAA was not what it should be. Under-regulation of safety in New Zealand  – how many times have we heard that phrase in recent years, usually in relation to safety in the tourism industry. It’s now being used to describe other sectors too.

The TAIC also called for an alcohol and drug testing regime to be implemented for people performing activities critical to flight safety.

That is a very familiar theme. In May 2003 KiwiRail said it had introduced random drug and alcohol testing for its employees after a worker failed to check his co-workers were off the track before a passenger train passed by and nearly hit them. He was later found to be a regular cannabis user.

KiwiRail also said it was “developing a new learning management system and safety initiatives as recommended by a report into the incident north of Wellington.”

“NZ Transport Agency rail safety manager John Freeman said an annual safety assessment of KiwiRail was under way and staff competency records were being reviewed as part of a drive to meet the commission’s recommendations…” source.  **2011’s report may be found here

Surely this wheelchair incident warrants another check of those staff competency records, not just for the people at the sharp end of the service but for the people managing safety at Kiwirail. This is the second wheelchair incident involving KiwiRail this year.

Kiwirail, a state owned enterprise, is currently looking for a new chief executive. The outgoing incumbent, Jim Quinn, will not have his contract renewed when it expires next January, nor will he be receiving a golden handshake. He has been quoted as saying he is happy with what he’s achieved whilst he’s been in charge.

** some excerpts from the 2011 report

Several areas of non-compliance were noted. Firstly, some 40% of South Island mainlines and branches had gone between two, and three years, between their previous and last annual engineering inspection. This included most of the Main North and the Stillwater Westport Line. The Hokitika and Rapahoe Branches have not been inspected since June 2009! Condition 11/06 C 10 refers. Further, one of the recent inspections identified some rail that was beyond the maximum wear limits set in the Track Handbook

no internal audits took place between mid 2010 and July 2011 (refer 11/06 C 32) and that the process of internal audit has not been managed in accordance with your Safety Case and the Railways Act. 11/06 C 2 refers…

…As indicated above earlier under occurrence management, current event and non-conformancedata is not collated and analysed in relation to the risks identified on the Risk Register. Without this information a Risk Register is, or becomes, a simply a static record of the initial risks…”

One thought on “KiwiRail. Another NZ Safety Fail?

  1. The attitude in New Zealand is that “because cannabis slows you down and enhances attention to detail, that therefore cannabis enhances your driving skills” Unfortunately, nothing could be closer to the truth. It slows your reaction time and noticing things in your environment. Those tour buses that go careering off of the narrow curving roads often turn out to have impaired stoner drivers. see see see

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