The findings came to light after the Transport Accident Investigation Commission (TAIC) produced a report, released today, into an incident at the freight transfer depot at the Port Otago rail storage facility in January last year.
In the incident, nine wagons rolled towards a locomotive where two KiwiRail staff members were working in the dark.
After investigating the incident, TAIC called on KiwiRail to improve its safety culture at Port Otago, its training for shunt staff and its remote-control equipment.
On January 23, 2025, at 1.25am, two KiwiRail employees were moving 25 wagons from Dunedin to the Port Otago site for freight transfer.
Nine of those wagons were parked in the marshalling yard on a slight gradient, then the locomotive was moved to collect the remaining wagons.
While the employees were between the locomotive and the other wagons, one of the employees noticed a ‘‘moving shadow’’.
They yelled ‘‘get out of the way’’, and both employees managed to jump moments before the wagons struck the locomotive, pushing it backwards and uncoupling it from the wagons already attached to it.
One employee applied the locomotive’s emergency brake using a remote-control pack.
No-one was injured, but the locomotive and wagons sustained moderate damage.
The TAIC investigation found the wagons were not secured correctly, the crew did not clearly confirm the securing task was complete and training did not give staff enough understanding of the air-brake system, equalisation timing, or the risk of trapping air in the system.
The only step taken to stable and secure the nine wagons was by applying the full service train brake.
TAIC chief investigator of accidents Louise Cook said the accident showed how quickly a job could turn from routine to dangerous.
‘‘This event was low-speed, but not low-risk — a 472-tonne rake of wagons moving at only a walking pace carries enough force to cause serious injury or death.’’
She said local operating culture mattered because it could make unsafe actions feel ordinary.
‘‘Once that happens, non-compliance stops looking like an exception and starts looking like ‘the way we do things around here’.’’
TAIC found that unsafe work practices and rule violations had become normalised at the Port Otago site, and incidents were not being correctly or reliably reported.
As part of the investigation, TAIC obtained and reviewed 10 days’ CCTV footage from before the incident.
During that time, the footage captured 88 individual rail-vehicle stabling movements, similar to what the two employees were doing the night of the wagon crash.
TAIC found every one of those 88 movements involved non-compliance with the rules, and 11 of those involved staff moving into unsafe positions, placing them at risk of harm or injury.
None of the incidents over those 10 days had been reported.
They also found that over the past 10 years there were 78 roll-aways involving the incorrect stabling of rail vehicles.
KiwiRail chief operations officer Duncan Roy said the incident was serious, and KiwiRail treated it as such.
‘‘We have accepted the commission’s recommendation to take immediate steps to further improve the safety culture at the Port of Otago rail yard.
‘‘KiwiRail has already taken significant steps in response to TAIC’s recommendations — we have updated our joint operating procedures to ensure every process meets required standards.’’
