Tranz Rail inaction contributed to poor communications that led to a fatal train collision, say accident investigators.
Freight train driver Graham White died at Waipahi, South Otago, on October 20 last year when another train, driven by David McKie, ran into it head-on at a crossing point on the main trunk line.
In its report released today, the Transport Accident Investigation Commission found that by choosing not to adopt recommendations made in 1996 about its track warrant control system (TWC), Tranz Rail missed an opportunity to protect against such accidents.
The company's reactive response to suggestions about the TWC system may have contributed to that lost opportunity.
Decisions affecting day-to-day use of the TWC had been made at senior management level but there was no evidence of referral to those carrying out and supervising such operations, said the report.
Track warrants are issued as an alternative to a signalling system and are a method for ensuring that only one train occupies a section of the main line at any time.
They are issued by a train control officer, who dictates details to the driver, who writes them down, then reads them back as a check.
The TWC system was criticised in the report, which found that both drivers had valid warrants for their intended crossing, which was supposed to take place at Clinton.
Southbound train 919, driven by Mr White, had authority to be on the main line at Waipahi and had stopped there. The reason was unknown.
Northbound train 938, driven by Mr McKie, did not have authority to be on the main line. Mr McKie believed his track warrant was for a crossing at Clinton, not Waipahi.
Factors that may have contributed to this belief were that there was no formal requirement for him to read his warrant; he relied on a crew changeover procedure to determine his right to be on the main line; the procedure for accepting conditional track warrants at crew changeovers did not require him to read or check back the warrant with anyone; and a suggestion to drivers to check their warrants at stations was not acted on.
The report also found that if Mr White had contacted Mr McKie when he entered the main line at Waipahi, Mr McKie would have noticed his warrant was incorrect.
The TWC regulations had inconsistencies on reading warrants and communicating at crossings, the report found.
After the accident, Tranz Rail set up a working party to look at the TWC system and this year introduced more communications requirements for drivers using the system and a new procedure for crossing points.
The report made safety recommendations, some of which were taken up by Tranz Rail, including one that feedback from staff be used to improve safety. It did not accept a recommendation that TWC rules be revised to protect against human error.
Mr McKie was cleared by a jury last month of a charge of manslaughter over Mr White's death.