Wano's hearing was described by his flatmate as "not that good", which may have contributed – along with the hood and beanie he was wearing - to why he didn't notice the train until it was too late.
Coroner Windley said the controlled level crossing Wano should have used would have required a deviation of a few hundred metres.
"That, of course, is no justification for trespass, but simply reflects human nature."
An NZTA rail safety investigator who later visited the site where Wano was struck reported being "horrified" at the extent of trespassing, and found a passing train, with the muffling effect of the trees, a "pretty incredible and actually quite scary" experience.
Coroner Windley said the train was just metres away when Wano stepped on to the
tracks wearing a beanie with the hood of his sweatshirt over top, and he didn't look up until it was too late.
She said his death was unintentional, and avoidable.
"At the end of Rail Safety Week it couldn't be more important to highlight that railways are, simply put, extremely dangerous places for members of the public to be. Trains are quiet, fast, and cannot stop in a hurry or swerve to avoid people. People must only cross at formed pedestrian crossings or an overpass or underpass," she said.
Coroner Windley commended KiwiRail for its commitment to put up substantial fencing on the perimeters of the rail yard and to trim vegetation close to the tracks.
KiwiRail's decision follows consultation on recommendations proposed by Coroner Windley; that KiwiRail identify means by which members of the public can be physically excluded or discouraged from accessing the railway yard at the specific Levin location, by erecting fences, increasing planting to discourage access, and increasing warning signage.
"I commend KiwiRail for its undertakings to act swiftly to address a real and ongoing risk of unintentional pedestrian-train incidents. At best these incidents will be near misses, and at worst result in avoidable loss of a life like Mr Wano's," Coroner Windley said.
"KiwiRail's engagement with the safety issues raised in my inquiry, and planned practical
improvements in response to my recommendations, demonstrate a recognition and
commitment to improving rail safety.
"It is not lost on me, or any of the organisations I have engaged with in relation to this
inquiry, that Rail Safety Week 2019 has focused its public campaign on near miss incidents between people and trains, and vehicles and trains, of which there were in excess of 400 last year.
"Implementing these planned improvements are practical means by which rail safety will be immediately enhanced and the chances of serious injury or death markedly reduced at this location."
The Coroner has also recommended NZTA monitor the progress and pace of KiwiRail
implementing the safety improvements.
"Unfortunately, in New Zealand, there is no mandatory requirement under the Coroners Act 2006 for organisations to report on the action that has been, or will be taken, in response to a Coroner's recommendation.
"Notwithstanding this, I invite KiwiRail and NZTA to provide the Chief Coroner an update as to progress with safety improvements at this location within three months of the finding."
