A railway worker in charge of a locomotive that plunged into Picton Harbor had failed to apply the brakes before pulling away to use his mobile phone, an investigation has heard.
The remote control operator was using the unmanned shunting locomotive to move a car through the marshalling yards when he went to make a phone call, around 3.30pm on September 1.
Security camera footage showed the operator walking away from the locomotive and shunting car, looking for a phone number on his cell phone, according to KiwiRail’s internal report, which was published for Thing under the Official Information Act.
Security camera footage shows the moment a train and carriage of remote-controlled shunters leave a crossover in the Port of Picton.
As it pulled away, the locomotive and wagon traveled 139.2 meters across the yard, reaching 13 km/h in 64 seconds, and on a crossover. With no ferry waiting, the linkspan dropped and the locomotive and the wagon rolled in the water.
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The wagon floated, due to its load of two empty dangerous goods containers, one of soda and the other of liquid nitrogen. The cart was pulled out of the water that evening.
However, the 50-ton locomotive remained on the seabed for two more days while a complex recovery plan was devised.
The Transportation Accident Board, investigating the incident, sent the remote control pack for testing, and it was found to work fine.
The locomotive’s event recorder was sent to the builder and its data extracted, when the locomotive was too expensive to repair, and instead stripped for parts.
KiwiRail’s internal investigations included an interview with the operator, who said he believed he had set the brakes correctly before driving off to look for a telephone number for the container terminal at the rail yard, although he did not actually make the call, as verified by his phone records.
“Phone use provided a distraction from the task,” the report said.
There was no engineering protection in place to protect the link, nor any Port Marlborough personnel in the area, the report said.
A the derailment block had since been installedbut a more appropriate solution was needed and would be incorporated into the design of the iReX projectupgrading the terminal to accommodate larger ferries due to arrive in 2025.
Investigations also revealed that the operator was certified to use the remote control pack four months before the incident, i.e. 37 teams.
The training included setting the brakes, stopping the locomotive, applying the air brakes and hand brakes, then turning off the control block.
However, he had received no safety observations in his new role.
He was supposed to have one a month for the first three months, and every two months for the next nine months.
Picton’s operations manager had incorrectly entered the operator’s certification into the KiwiRail Learning Exchange software, which meant that the required observations were never booked.
In fact, the operations manager had not been trained in the use of the software for this, according to the report.
A previous incident in May 2019 had already led to requests for processes to be reviewed, but this had not happened.
Following the Picton incident in May, the report lists 10 actions to be taken, including revisions to relevant codes, protocols and processes to prevent such incidents from happening again.
A KiwiRail spokesperson said Thing the incident was taken very seriously.
“We have already put in place mitigation measures to prevent it from happening again.
“Reviews are also underway to rectify the identified need for better oversight of newly certified remote control operators, to ensure the requirement for monthly safety observations is carried out.”
There would also be a review of any areas of similar risk and an action plan put in place to deal with any hazards, the spokesperson said.
KiwiRail said it was unable to release personal details of the staff members involved, including any disciplinary or corrective action.
Waka Kotahi NZTA and the Transport Accident Investigation Board were also still investigating.