A truck driver was distracted by his phone and had been driving for 13 hours straight when he was struck by a speeding freight train in Northland.
In its final report released on Thursday, the Transport Accident Investigation Commission said both drivers were at fault for a December 2022 crash at Whangārei's Fertiliser Road level crossing.
It said the train was travelling at almost three times the speed limit as it approached the crossing.
Although the Rail Operating Code dictates a 5km/hr speed limit at crossings, "the train was approaching the level crossing at about 14 km per hour," the report said.
"The train was almost on the level crossing when the [rail operator] realised the truck was not going to stop. They called to the [locomotive engineer], 'stop, stop, stop!' over the radio."
When they realised the train wouldn't stop in time, the operator jumped away from the wagon and broke their collar bone.
The operator was only person injured in the collision.
Investigators also found that the truck driver was severely fatigued after a 13-hour work day without breaks, and was talking on the phone.
"The truck driver was engaged in a phone conversation as they manoeuvred a complex intersection," the report said.
"Given the length of time they had been on duty without taking the required scheduled rest breaks, it is likely that their ability to scan and perceive critical information effectively from the road environment was [reduced]."
The commission also found KiwiRail had not conducted a proper risk assessment for the route, which might have identified safety issues.
It recommended KiwiRail complete an assessment of the crossing and others like it "without delay," and that it increase the speed at which it performs safety-critical work.