A train blew past two stop signals and entered a section of track it was not supposed to be on, where a hi-rail truck was operating.
The truck, which was operating on a section of track near Kereone in Waikato, was never hit, but a report into the incident has highlighted how the "system is not providing a reliable safety backstop".
On the morning of August 2 last year, shortly after 11am, a freight train left Ruakura in Hamilton heading north towards Tauranga.
Ten minutes later, the operator of a hi-rail vehicle – a truck equipped to operate both on the road and on train tracks - was granted protection authority from train control, and moved onto the tracks. It was heading from Waharoa, north of Matamata, to Kereone station, in the direction of the approaching freight train.
Because of the protection authority, the vehicle was safe, as long as the oncoming train stopped when signalled.
The hi-rail arrived at the Kereone station and entered the crossing, a move arranged with train control. The vehicle's operator then contacted control to start the process of cancelling the track protection authority.
Before this process was finished, the train passed through a stop signal, and then another, entering the truck's section of track.
The train only stopped when its engineer was contacted by train control via radio. No one was injured, and there was no damage.
According to the Transport Accident Investigation Commission report into the incident, the engineer had expected the track to be clear, was using his mobile phone, and missed "critical" radio calls about track protection.
He also misread signs as ‘proceed’ instead of ‘caution to stop’ and ‘stop’.
TAIC’s chief investigator of accidents, Louise Cook, said the incident was a "preventable chain of events".
"Signals misread, calls missed, rules not followed. The first mistake mattered, and the next and the next, and the system had no automatic backstop.”
She said it was not an isolated failure and raised concerns about a nationwide safety issue involving signal passed at danger (SPAD) incidents.
Cook said the system was not providing a reliable safety backstop.
“Rail safety in New Zealand depends on people following rules and procedures, making and receiving radio calls, and correctly interpreting signals. It’s okay to depend on administrative controls like this if you can guarantee everyone will perform perfectly all the time.
“But we all know nobody’s perfect. When imperfections add up in our rail network, too often there’s nothing automatic to stop the train.
“Had an engineering control been in place, it’s likely the train would have stopped before the first signal, and it’s virtually certain that had European Train Control System been fitted and operational, the train would have stopped before the next signal, well before entering the HRV’s section of track.”
The report found the rate of SPAD incidents had been increasing for both freight and passenger services.
KiwiRail's benchmark for these incidents was one per million kilometres travelled.
"The records show the rate has risen from 1.2 per million in 2020 to 3.2 per million in 2025."
It said that in 2024 and 2025, there were four serious incidents involving passenger trains, with "risk of head-on collision, side-on collision with merging rail traffic, or collision with a motor vehicle at a protected level crossing".
TAIC has now called for "stronger action" by KiwiRail, the New Zealand Transport Agency, and the Ministry of Transport to address "the decline in safety performance, including nationwide rollout of engineering controls to backstop variability in human performance".
Since the incident, KiwiRail had started work on SPAD risk.
This included signal alert tools and changes to operating practices.
"TAIC recommends expanding this work across the network."
It also recommended NZTA to ensure KiwiRail’s "high SPAD rate" was being "well managed and controlled".
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