Rail workers in tunnel outrun Wellington train with seconds to spare

Two rail maintenance workers in a tunnel outran a Wellington passenger train with only seconds to spare last year after a hand-drawn diagram was misinterpreted, among several causes identified in a new report.

As a result of the near miss, the national commission for transport safety has called for improvements to KiwiRail worker safety practices.

The Transport Accident Investigation Commission (TAIC) released the findings of an investigation into the May 2023 incident this morning.

TAIC chief accidents investigator Naveen Kozhuppakalam said the near miss showed the "exact opposites" of what were good safety practices.

"A passenger train entered the tunnel behind them and the track workers had to break into a run to make it to safety," he said.

"Miscommunication, assumptions, not listening and incorrect procedures led to this train being authorised to drive through a work site."

TAIC wrote that short-staffing led to issues with worker technical skills and knowledge, and inadequate use of non-technical skills led to incorrect protection procedures.

The incident took place on May 4, around midday, on the Johnsonville line - a single-track route that winds through steep terrain with multiple narrow tunnels throughout.

A slip detection alarm was activated at around 5.30am, meaning speed restrictions for trains. In noting the alarm, the train controller on duty accidentally marked the incorrect spot on a line diagram, near an unrelated alarm raised overnight.

Investigators believed a green highlighted line associated with the overnight alarm had confused the controller and created a "false association" between the events.

Two maintenance workers went to reset the alarm around seven hours later, but arrived on foot at a tunnel nearby without the required permission to enter it.

The erroneous diagram markings and subsequent miscommunication between a train controller and two rail workers meant the wrong section of the line was marked blocked.

Despite being read back the incorrect block, the track worker wasn't able to identify the location discrepancy while listening to the controller give authorisation to enter.

Workers were given four minutes of track time to make their way through the 127-metre curved tunnel, which they elected to do by jogging.

While the pair made their way into the tunnel, one worker used their phone as a flashlight because neither had brought torches and the tunnel wasn't lit.

As they continued jogging, the other worker saw light coming from behind them and also noticed the apparent sound of train wheels. They called out to the other worker and both began running faster towards the end of the tunnel.

The pair exited the tunnel and moved out of the way of the track, with a CCTV freeze frame from the train showing the workers mere metres from the tunnel opening.

The passenger train left the tunnel about five seconds after the track workers reached safety. Shortly afterwards, the near miss was reported by the train driver.

One track worker failed an immediate post-incident drug and alcohol test, according to the TAIC. They tested positive for THC, an organic chemical commonly found in cannabis.

"The pattern of THC consumption and recency of use, and therefore the level of THC impairment, was not determined by a secondary test as the track worker left KiwiRail’s employment immediately," the report authors wrote.

All others involved in the incident tested negative.

A spokesperson for TAIC said the commission "is calling for KiwiRail to improve safety procedures, to train workers to follow procedures and communicate clearly, and to ensure workers are well rested and in a fit state to work.

"Everyone in a safety-critical role should be able to communicate clearly; make good decisions; work well in teams; and be fully aware of what's happening. The exact opposites of those characteristics were in play in May 2023."

In a statement, KiwiRail zero harm executive manager Sacha Montgomery said the organisation "treats safety as central to everything it does."

"We are committed to making sure everybody gets to go home safely every day, and we took both these incidents very seriously," she said in a statement.

"We accept TAIC’s findings, and have already moved to change our practices and procedures around both issues.

"As the report into the Johnsonville incident details, KiwiRail has taken a series of steps to ensure the incident is not repeated, including ensuring radios rather than cell phones are used. TAIC recognised this in its report, and made no further recommendations."