Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Ensure that procedures for dealing with stalled trains are understood and adhered to by all operating staff.

Establish a policy that all staff undergoing training are properly supervised.

Investigate the need for and the feasibility of, introducing a suitable maintenance procedure to detect internal wear of winch cables before the cable's strength was reduced to an unacceptable stage.

Safety-critical rail workers are not required to declare prescribed medications they are taking when presenting for triggered health assessments. The driver had been prescribed a combination of medication that was known to cause performance impairment and behavioural changes, anxiety, agitated delirium and disorientation in more severe cases. The medicines also came with a warning to patients to not drive or operate heavy machinery until the effects became known.

The system for recording faults on Tranz Metro trains was not user-friendly, was not being followed all of the time and did not achieve its purpose of reporting faults and informing drivers.

The train controller had been identified by KiwiRail management as having concentration and focus issues in relation to tasks required for the safe execution of track occupation authorities following a track occupation irregularity during February 2012. This was 16 months before the track occupation irregularity covered in this report, and during that period the train controller went on to have two further operating irregularities while he remained in the role.

The Commission further recommends that KiwiRail assess all other terminating stations on the controlled network throughout New Zealand and similarly apply permanent speed restrictions as necessary to the approaches at those stations.

On 28 May 2025, the Commission recommended that KiwiRail review and improve its process for authorising rail movements within worksites to ensure the safe movement of all rail traffic and personnel within protected work areas, including the verification of track integrity and the sharing of and access to safety-critical information.

decide what role check calls have during controlled on track time for HRVs, track maintenance gangs and other track users and issue clear instructions covering any permitted use

Issue a Safety Notice warning pilots of the potential damage resulting from such an occurrence and requiring an engineer's inspection if an attempt is made to start with the clutch engaged.

[the LTSA, MSA and OSH] Immediately bring the potential of substandard connections between stacked bases to the attention of appropriate Australian transport safety agencies.

Amend Police Standard Operating Procedures to include early engagement of the Police dive squad in maritime responses, when appropriate, to take advantage of their expertise and knowledge in water rescue.