KiwiRail has been told to make changes in its Picton freight yard and to its safety procedures, after a locomotive engine fell into the sea.
A 50-tonne locomotive and a wagon were submerged in the Picton Harbour in September 2021 after they fell off a wharf.
The Transport Accident Investigation Commission (TAIC) found the remote control operator controlling the locomotive, who had three months qualified experience in the job, was working alone with a workload normally done by a two-person team.
While attending to one of a number of extra tasks, the operator was unaware the control pack was driving the locomotive and wagon onto the linkspan, which joins the wharf to vessels.
When the operator saw what was happening, it was too late to stop the locomotive travelling into the sea.
TAIC found a combination of factors contributed to the unintended shunt movement and it identified safety issues concerning safe working practices, engineering protections, and safety guidelines.
It found KiwiRail's process for supporting recently qualified staff in safety-critical roles was not managed effectively and the Picton rail linkspan lacked protection from rail movements when a ferry was not connected.
An investigation by KiwiRail last year found the employee thought he had applied the brakes on a remote-controlled shunt locomotive and went to make a call on his phone, before the engine fell into the sea.
The brakes were not applied before the operator walked away from the shunt locomotive and wagon, looking for his cellphone to call the container terminal. The operator then remembered that the use of mobile phones was prohibited, and placed their phone back in their pocket, with no call made.
The commission recommended KiwiRail install a solution to prevent unauthorised rail movements on the linkspan and implement safe working procedures to manage the risks associated with shunting activities.
KiwiRail has accepted the recommendations and said it's working to implement them.