Saved by ‘a moving shadow’: Rail workers in near miss at Port Otago 

Safety investigators are urging KiwiRail to overhaul practices at Port Otago after runaway wagons narrowly avoided seriously injuring two crew members during a routine shunting operation last year.

The Transport Accident Investigation Commission has released its final report into the incident, which occurred at the Port Otago rail storage facility in Port Chalmers.

At about 1.25am on January 23, 2025, two crew members were moving 25 wagons at the Port Otago rail storage facility. After parking nine wagons on a slight gradient in the marshalling yard, they moved the locomotive to collect the remaining wagons.

As they were coupling the locomotive to the next set of wagons, the nine parked wagons rolled back down the gradient toward them.

One crew member spotted a moving shadow, realised the wagons were rolling, and yelled a warning, allowing both workers to move clear seconds before the wagons struck the locomotive, pushing it backwards and uncoupling it from the wagons already attached.

No one was injured, but the locomotive and wagons suffered moderate damage.

The investigation commission's report found the wagons had not been secured correctly, the crew did not clearly confirm that the securing task was complete, and training did not give staff a sufficient understanding of the air brake system, equalisation timing, or the risks of trapping air within the braking system.

It also identified signs of a poor local safety culture at Port Otago, where rule violations and unsafe practices had become normalised and safety incidents were not being reported reliably.

Transport Accident Investigation Commission chief investigator of accidents Louise Cook said the incident illustrated how quickly routine work could become dangerous.

"This event was low speed, but not low risk. A 472 tonne rake of wagons moving at only a walking pace carries enough force to cause serious injury or death," she said.

Cook said the risk was greatest when workers were close to or between vehicles, as was the case during this incident.

"The quiet, slow moving wagons were only detected at the last minute due to the shadow they cast."

She said communication failures played a key role, with the crew moving on to a new task without fully closing out the previous one.

"Communication discipline matters in all safety-critical work. The crew had moved from the task of securing wagons in one location to the task of coupling wagons in another location without ensuring the first task was fully closed out."

Cook said task changes were a known risk point in high hazard environments.

"In higher risk work, any change in task should trigger a deliberate safety reset, so crews reassess the risk and apply the right controls before moving on."

The report also emphasised the importance of deeper training, saying workers were more likely to follow procedures when they understood the reasoning behind them.

"The mechanism behind the rule matters, not just the sequence they must follow," Cook said.

The Transport Accident Investigation Commission recommended KiwiRail address safety culture issues at Port Otago, improve shunt staff training, and review the design of remote control equipment so the emergency stop button can alert train control even when a locomotive is already stationary.

KiwiRail chief operations officer Duncan Roy told 1News in a statement this was a serious incident and KiwiRail treated it as such even though there were no injuries.

He said the rail company had has already taken significant steps in response to the Transport Accident Investigation Commission’s recommendations.

"We have updated our Joint Operating Procedures to ensure every process meets required standards and is clearly understood by our operators.

"We have accepted the commission’s recommendation to take immediate steps to further improve the safety culture at the Port of Otago rail yard.

"KiwiRail is working hard to improve safety throughout the organisation, and, with guidance from global experts, has developed an ongoing company-wide programme to build a safety culture where everyone chooses to be responsible for protecting themselves and everyone around them. This is reflected in sustained improvements in key safety indicators.

Roy said a recommendation to add automatic alerts when an emergency stop button was used on remote control packs was "under consideration". "We are exploring options to enhance emergency alert notifications."

He added KiwiRail remained committed to working collaboratively with the commission, the Port of Otago and its teams on safety practices for the benefit of all staff, stakeholders and the public.