AN UNINTENDED remote-control movement caused a locomotive to end up at the bottom of Picton Harbour in 2021, a new report has found.
New Zealand’s Transport Accident Investigation Commission (TAIC) this past week released its final report on the Picton freight-yard incident.
A shunt locomotive was relocating a wagon at the freight yard in September 2021 when the loco and wagon travelled over the rail linkspan and into the harbour at the Picton ferry terminal.
Port Marlborough owns the ferry terminal assets including the linkspan and infrastructure at Picton.
TAIC noted the shunt loco was being operated by remote control; the operator had the remote-control pack attached to their chest with a harness.
There was no ferry berthed at the wharf at the time of the incident, and the rail linkspan was not in use. Nobody was injured.
TAIC’s investigation found there was no single factor that caused the incident, but there was likely a combination of factors that led to the unintended movement.
“The remote-control operator was working independently when the incident occurred, when usually they worked as one of a team,” TAIC said.
The report noted disruptions in the rail ferry operating schedule meant shunting staff’s workloads increased throughout the day, leaving a “reasonably inexperienced” remote-control operator to act on their own during a busy period.
It also found the rail linkspan was not protected from rail movements when not in use, and the rail operator’s rules were silent on when a remote-control pack should be deactivated to prevent unintended movements.
“Shunting rail vehicles is a safety-critical task,” TAIC said.
“The post-certification support process is a vital component for newly trained staff to receive regular feedback and support on their performance.
“Those in a two-person shunt team should, where possible, maintain visual contact to help mitigate shunting risks.”
The commission said periods of busy activity can also present challenges, even if they are not cognitively demanding.
“Organisations should be mindful of such challenges and ensure workers are well equipped with strategies to manage workflow, and have measures in place to ensure workers are able to remain focused on safety-critical tasks.”
TAIC also found there was no common understanding between the rail operator and Port Marlborough on how to mitigate risks of unexpected rail movements.
At the time of the incident there was no interoperability agreement between the rail operator and the port, but the two parties signed a joint operating plan in April 2022, which TAIC said addresses that safety issue.
The rail operator accepted TAIC’s recommendations around safe working procedures and installing a more effective engineering solution to prevent rail movements entering the Picton rail linkspan unauthorised.
