New Zealand’s Transport Accident Investigation Commission (TAIC) has published its report on a cargo shunting incident that resulted in serious injury on the rail ferry Aratere on April 9, 2021.
On the evening (local time) of the said date, a crewmember operating a remotely controlled shunt locomotive was injured during discharging operations on board Aratere, which was then at berth at the Interislander ferry terminal in Wellington.
The individual was caught between the foot step of the head wagon and the runner wagon while attempting to couple to the wagons. The head wagon was the first of a set of coupled wagons (a rake) located on the starboard outer track of the ferry’s rail deck.
The remote-control operator had made multiple unsuccessful attempts to couple the two wagons. The position of the two wagons on a curved section of the outer starboard track had caused a misalignment of the two couplers.
During the final attempt, the operator moved between the two wagons to physically open the knuckle of the couplers, but did not relocate to a safe area before operating the shunt locomotive remotely.
Why it happened
The TAIC found that the remote-control operator entered the danger zone (an area in which individuals are exposed to physical risk) to realign an off-centre coupler, but did not reposition clear of the danger zone before they operated the shunt locomotive remotely.
The commission found that the degree of track curvature on the starboard outer track on Aratere made it difficult to couple wagons positioned on parts of the curve.
The commission also found that the risk assessment undertaken to determine the maximum rake length on the outer rails had not adequately mitigated the difficulty involved with coupling wagons positioned on the curved part of a track.
What can be learned
Shunting rail vehicles is a safety-critical task. Safety-critical tasks should be designed in such a way so as not to cause additional or unnecessary risks for employees.
Experiencing difficulties with a procedure can lead to task fixation. This can create an environment conducive to risk-taking activity and error-producing conditions.
Who may benefit
Rail operators and operational staff involved in shunting activities may benefit from this report.
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