The approval process authorised one person to carry out the rail protection duties for two separate worksites within a protected work area throughout a 52.5-hour track occupation period without appointing a relief rail protection officer. The rail protection officer had worked relatively long hours during the week leading up to the incident and had had no days completely free of work. His working hours had provided limited opportunity for recovery from any fatigue or sleep loss that may have built up, and particularly sleep loss that he experienced on the first night of the planned work.
On 28 June 2017 the Commission recommended that the Chief Executive of KiwiRail review the company's Fitness for Work Policy to ensure that the workloads of personnel undertaking safety-critical work, including staff not on a roster, are managed effectively and that the risk of their suffering from the effects of fatigue is mitigated.