Thousand tonne freight train and passenger trip nearly collide at stop sign

A KiwiRail freight train (file photo).

Photo: Katy Gosset/RNZ

The Transport Accident Investigation Commission (TAIC) says it is concerned at the numbers of trains driving past stop signs, as it releases a report into a near miss between a thousand tonne freight train and a passenger train in February 2025.

Chief accident investigator Louise Cook said the Signal Passed at Danger (SPAD) incidents - where stop signals were not obeyed - should not be happening.

"The commission is certainly concerned at the level of SPADs that are occurring. In each investigation we're looking at, there might be a slightly different circumstance that led to that driver passing a signal at stop, but regardless of the reason why they've done that ... people will make mistakes.

"The commission is focusing on what about the system needs to be changed and improved so the system captures those mistakes and prevents an error turning into an accident."

The TAIC report into last year's incident at Westfield, Auckland, identified three systemic safety issues that led to the near miss - insufficient route knowledge, a lack of visual cues and the failure to use a system called risk-triggered commentary driving.

The freight train hauling 25 wagons was travelling on the North Island Main Trunk when it drove past a stop signal. The locomotive engineer realised before passing the signal, applying the emergency brake, and the train came to a halt about 50 metres beyond the stop signal.

A diagram of the near-miss.

Photo: Supplied / TAIC

The stop signal was to allow a passenger train to cross over onto the same track about 250 metres ahead, which it did without incident.

There were no injuries and no damage.

Cook said while that could sound like a fair distance, when it came to stopping something like a train, 250 metres was close.

TAIC chief accident investigator Louise Cook.

Photo: Supplied / TAIC

"Trains take a significant period of time to stop, they're very heavy and any distance past a signal at stop is concerning.

"That signal was at stop to allow a passenger train to cross over in front of it on the same track, so it's a real concern that signal wasn't read correctly and the train continued."

The report found the crew's route training was insufficient given the complexity of the area, and pointed to the lack of visual cues such as marker posts - identified by KiwiRail's own research into SPADs a decade ago to improve safety.

Risk-triggered commentary driving - which involved crews speaking out loud, reporting the signals they saw and the action they would take in response - had been shown to improve safety, catching small human errors before they become accidents, Cook said.

TAIC found the crew were not sufficiently trained in risk-triggered commentary, nor was it part of their training, increasing the likehood of passing a signal at danger.

In April, following an investigation into another near miss, the commission urged KiwiRail to implement automatic stopping mechanisms to its trains, calling signal overruns "a nationwde rail safety issue".

The freight train did not have any form of automatic stopping mechanism.

The other train, an Auckland One Rail commuter train, was fitted with European Train Control System (ETCS), a safety system that monitored speeds, relayed information and could automatically stop or slow trains.

KiwiRail informed the commission late last year it had created a training tool to improve route familiarity, which the commission believed addressed that issue.

TAIC recommended KiwiRail put trackside information in place, and included risk-triggered commentary driving in its training.

Chief operations officer Duncan Roy said KiwiRail accepted the findings of the report, and recognised how serious the risk was.

KiwiRail chief operations officer Duncan Roy.

Photo: RNZ / Marika Khabazi

Roy said KiwiRail had embarked on a wide range of initiatives since the incident, including changes to driver training, improving communication and information sharing between drivers and the Train Control team, a new in-cab signal alert system and improvements to signal visibility where needed.

KiwiRail would roll out the European Train Control System on the Auckland metro network by the end of August, which would prevent a collision if a train passed a signal, he said.

KiwiRail did not plan to implement trackside markers, as it believed introducing markers could create complexity and potential confusion in some areas.

The rate of Signal Passed At Danger (SPAD) incidents across KiwiRail's network had risen to 3.2 SPADs per million kilometres in 2025, compared to KiwiRail's own benchmark of 1 SPAD per million kilometres, a previous TAIC report said.

Records showed the rate had nearly tripled from 1.2 per million in 2020.

In April, the commission called for stronger action from KiwiRail, the New Zealand Transport Agency (NZTA) and the Ministry of Transport to address the high rate of SPADs.

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