None of KiwiRail's staff involved with loading and securing the wagon body was sufficiently familiar with the KiwiRail Freight Handling Code to realise that the securing arrangement was not compliant with the Code.
KiwiRail had a responsibility to ensure that staff was trained and competent in all tasks being undertaken. It had to ensure that the loading and stowage of goods on railway wagons were carried out by people with the appropriate training and certification.
The Commission recommends that the Chief Executive of KiwiRail take steps to ensure that appropriate training is given to all staff involved in load security and that staff responsible for checking load security at the various stages of a train journey are discharging their duties in a manner consistent with the KiwiRail Freight Handling Code.