Truckers knew of problems with the Sanwa Seiki type of handbrakes since at least 2004. File Image. Photo: 123RF
Authorities knew for years that some trucks had a handbrake so sensitive it could be dislodged simply by shutting the cab door - in fact, since just after a man was crushed to death in 2010.
But they allowed the trucks to stay on the roads for another decade.
During this time, a second person was killed and there were multiple near-misses when handbrakes failed.
An expert's report, released to RNZ, said the dangers were widely known but not enough was done about them.
Read the full report (PDF: 7MB)
It said Waka Kotahi NZ Transport Agency should have banned them early on, but did not until 2021.
Stan Turner, 62, was crushed between two trucks in 2010, and roadworker Joji Bilo, 25, was hit by a runaway truck in Ngauranga Gorge in 2019.
"Luisa and I are just saddened by the report," said Bilo's mother-in-law, Una Kama, on behalf of her daughter Luisa.
Joji and Luisa Bilo with their children. Photo: Supplied by the family
"We are, however, grateful that this report has come out to highlight some of the lack of responses."
The case was revealing of how long it can take for official regulators to take effective action.
Waka Kotahi said it had never been shown the report until now. It was completed in October 2021 for Worksafe.
Truckers knew of problems with the Sanwa Seiki type of handbrakes since at least 2004. They were fitted to about 1100 mostly Nissan trucks.
An official hazard bulletin about the 2010 death said:
"The driver exited the truck with the park brake engaged but not correctly locked.
"Factors such as engine vibration, the bump of the closing door, and the return spring pressure on the operating lever would have been enough to release the brake, with fatal consequences."
This was echoed in a police report into the 2019 fatality: "The most likely scenario was that the vibrations caused by closing the truck's door caused the [handbrake] lever to release."
The truck rolled 400 metres down the motorway and over the top of Bilo.
Fulton Hogan pleaded guilty to one health and safety charge, but questioned why Waka Kotahi and others were not charged.
Kama has been asking the same thing since 2019.
"When will they get it right?" she said to RNZ.
"Emi and Koli's dad, Joji, went to work and never returned. No-one should go through that, ever."
The independent expert report has been released under the Official Information Act to RNZ.
It was especially critical of Waka Kotahi, vehicle inspection service VTNZ and the vehicle distributor UD Trucks.
It said that from "about 2012":
- UD Trucks should have investigated the "fundamental flaws" in the handbrake design, and "this should have led to a recall"
- Waka Kotahi should have banned the handbrake - or at least ordered truck inspection companies to make sure handbrake maintenance was being done
- VTNZ should have had a system to ensure any recalls, urgent advisories and safety alerts were acted on by inspectors
When UD Trucks did not do a recall, "NZTA had the authority to ensure that this occurred for the safety of all New Zealanders", said report author, Dr Justin Ludcke in Australia.
The transportaAgency told RNZ: "Waka Kotahi has not previously been provided with a copy of this report.
"Needless to say, Waka Kotahi takes these issues very seriously. We will co-operate fully with the ongoing inquiries."
It extended its sincere condolences to the Bilo family, but had no comment when asked by RNZ if it had ever acknowledged it played a role in Bilo's death, and if it had ever apologised to the family.
Instead of a recall, Waka Kotahi and the industry relied for seven years on safety alerts and advisories - and distributing orange warning stickers to go on trucks.
Fulton Hogan went further, getting rid of all such handbrakes in its fleet in 2012 - but it did not make sure its subcontractors followed suit, and not all did, which proved deadly at Ngauranga.
The alerts told truck owners to carefully check and maintain the handbrakes.
However, OIA documents show officials knew the handbrake checks at vehicle testing stations were "cursory" and hard to improve.
Fulton Hogan told Waka Kotahi in mid-2019 that "we are conscious many of these trucks are now in ownership that are given minimum servicing levels".
The expert report noted that UD Trucks did a recall over another type of truck handbrake in 2014.
VTNZ inspected the truck that killed Bilo days before his death.
"However, VTNZ also noted that they did not specifically inspect the park brake to see if it had been maintained or observed the presence of the sticker, as it was not a directive from NZTA," the expert report said.
In mid-2019, Waka Kotahi told Fulton Hogan it was meeting UD Trucks "to work through encouraging a recall".
The following year, Waka Kotahi said it was reviewing all the evidence.
Since September 2021, trucks with an unmodified handbrake have been unable to get a Certificate of Fitness at their six-monthly check.
Internal police documents released earlier to RNZ, showed police pushed for stronger, quicker action but said NZTA was not prepared to impose a ban "as it could impact truck operators".
Police later apologised to Waka Kotahi] for saying this.
On Wednesday, the agency said: "All 1200 registered vehicles have either had the brake mechanism removed or have been taken off the road - eliminating the safety risk these brakes presented."
VTNZ declined to comment for this report, including on whether it had improved its truck inspection processes as the expert reviewer suggested was needed.
Previously, VTNZ said that the 2019 WorkSafe inquiry found the company "conducted the inspection in line with the requirements at the time".
UD Trucks did not respond to requests for comment.