Safety investigators are calling for a comprehensive overhaul of practices at Port Otago after a near-miss incident involving runaway wagons. The Transport Accident Investigation Commission (TAIC) issued a final report after two crew members narrowly avoided serious injury during a routine shunting operation last year.
The Midnight Near-Miss
The incident took place at approximately 1.25am on January 23, 2025, at the Port Otago rail storage facility in Port Chalmers. Two crew members were in the process of moving 25 wagons.
After parking nine wagons on a slight gradient in the marshalling yard, the crew moved their locomotive to collect the remaining wagons. As they began coupling the locomotive to the next set, the nine parked wagons rolled back down the gradient toward them.
The workers were saved when one member spotted a moving shadow and yelled a warning. This allowed both employees to move clear seconds before the wagons struck the locomotive, pushing it backward and uncoupling it from the attached wagons.
Although no injuries were reported, the wagons and the locomotive sustained moderate damage.
Systemic Failures and Safety Culture
The TAIC report identified several critical failures, noting that the wagons had not been secured correctly. The crew failed to clearly confirm that the securing task had been completed.
Investigators found that staff training was insufficient regarding equalisation timing, the air brake system, and the risks associated with trapping air within the braking system.
The commission likewise highlighted a “poor local safety culture” at Port Otago. The report stated that unsafe practices and rule violations had become normalised, and safety incidents were not being reported reliably.
The Risk of Routine Work
Louise Cook, the TAIC chief investigator of accidents, emphasized that the event was “low speed, but not low risk.” She noted that the danger is highest when workers are positioned between or close to vehicles.
Cook pointed out that communication discipline is vital in safety-critical work. She argued that workers are more likely to follow procedures when they understand the reasoning behind the rules rather than just the sequence of steps.
KiwiRail’s Response and Future Steps
KiwiRail chief operations officer Duncan Roy described the event as a serious incident. He stated that the company has already updated its Joint Operating Procedures to ensure processes meet required standards.
KiwiRail has accepted the recommendation to improve the safety culture at the Port Otago rail yard. The company is currently implementing a company-wide programme, developed with global experts, to foster personal responsibility for safety.
A recommendation to add automatic alerts to remote control packs when an emergency stop button is used is currently under consideration. KiwiRail is exploring options to enhance these notifications.
Frequently Asked Questions
When and where did the incident occur?
The incident occurred at about 1.25am on January 23, 2025, at the Port Otago rail storage facility in Port Chalmers.
What caused the wagons to roll back?
The wagons were not secured correctly, and there was a failure by the crew to confirm the securing task was complete. Training gaps regarding the air brake system also contributed to the risk.
What changes is KiwiRail making?
KiwiRail has updated its Joint Operating Procedures and is working on a company-wide safety culture programme. They are also considering adding automatic alerts to remote control emergency stop buttons.
How can heavy industry better ensure that safety rules are followed rather than becoming “normalised” over time?
