KEY POINTS:
Ontrack has been heavily criticised by a report into the death of a railway worker who was knocked under a freight train last year.
Hamilton man Sean Smith, 25, was killed on June 19 at Ohinewai, north of Huntly, after a swinging crane boom struck him under the wheels of a passing freight train.
The crane, which had been lifting unused rails onto a stationary work train, had been hit by the freight train.
The Transport Accident Investigation Commission (TAIC) report said poor communication, training, written procedures and supervision, as well as a lack of safety procedures were among the factors that contributed to the accident.
It found the freight train was operating in an appropriate manner, but the work train had been fouling up the track without authority.
It said the workers were unfamiliar with working in double line territory and had not been not given a safety briefing at the start of the day.
The worksite boss had wrongly assumed both lines of the track would be clear after the train controller told him he had a two-hour window to work, with no trains passing on the down line.
The man in charge had operated in single line areas for many years and Ontrack should have given him induction training, before allowing him to work unsupervised on his first rail recovery operation in a double line area, TAIC said.
"In the context of normal human behaviour, when individuals have worked for a long time in one work environment doing the same tasks...they tend to become rigid in their way of thinking and reacting to situations that arise."
The man in charge also should have been able to warn Mr Smith that the train was approaching using hand signals, the use of which a safety briefing would have stressed, the report said.
The work gang was not sufficiently manned, which would have impacted on the ability of the man in charge to carry out his prime responsibilities of protection and communication.
It was also significant the man in charge did not know the freight train was passing and the freight train did not know the exact location of the work train, the report said.
However, the engineers had seen each other and there should have been ample time for the train to stop, or the track to be cleared.
"There is little doubt once the system failed and allowed two trains to occupy or foul the same section of track, all the workers attached to (the work train) and the locomotive engineer of (the freight train) were put at extreme risk."
The report recommended the chief executive of New Zealand Transport Agency address several issues including:
* the use of hand signals in noisy worksite and the lack of standard system for them;
* the inadequate level of compliance monitoring of Ontrack;
* trains being allowed to pass work trains at speeds up to 100kmph;
* the over-complex rules-based system the rail industry uses, which relies heavily on employees knowledge of it;
* unclear work site protection rules.
- NZPA
