Morningside Report and Summary Here - KiwiRail

Summary of KiwiRail’s Report into Morningside Accident 

KiwiRail has conducted an investigation into the collision of Train 126 with an occupied 

power wheelchair at Auckland’s Morningside pedestrian crossing on Monday, February 25, 

2013. An independent external review of this Report has also been undertaken by Brian 

McIntosh, a Senior Associate of Australasian Transport Risk Solutions Pty Ltd. 

KiwRail Actions 

The Investigation Report notes that immediately following the accident the following safety 

actions have been progressively undertaken by KiwiRail. 

1. The Morningside pedestrian crossing involved was temporarily resealed during the 

evening following the accident and was completely renewed the following weekend. 

2. An advisory was issued to all KiwiRail Infrastructure & Engineering Regional Managers 

advising them to inspect all pedestrian crossings nationally for similar damage and to 

initiate repairs if required. 

3. A same day inspection of Auckland metro crossings identified none with similar levels of 

deficiency, but with the heightened awareness as a consequence of the accident, eight 

of the approximately 60 crossings in total were regarded as not providing an appropriate 

level of service for crossing by a similar wheelchair. Work on these crossings was 

completed over three days following the accident. 

4. 350 formed pedestrian level crossing surfaces have been inspected nationally. While no 

other examples of surface deterioration seen at Morningside have been found, initial 

repairs to evenness, which could potentially present a significant hazard to disabled 

users, have been completed on some 20 crossings. Minor work has been completed on 

a further 60 crossings and, where necessary, work to reduce the gaps against the rail 

head is being scheduled. 

5. Progress and issues arising from inspections of level crossings are discussed at weekly 

Infrastructure and Engineering management meetings and it has been confirmed that all 

such inspections are to be undertaken on foot. 

6. The Infrastructure & Engineering team were instructed to investigate the establishment 

of a standing procedure which maintains gap depth at 50 mm or less and maintains an 

evenly trafficable pedestrian surface for formed pedestrian crossings. 

7. The Auckland Area office and CCS Disability Action together visited a number of 

Auckland Metro pedestrian crossings to gain a greater awareness of issues faced by 

people with mobility impairments. 

Longer term associated actions to further reduce residual risk 

KiwiRail is also taking the following longer term actions to reduce the residual risk of 

accidents of this nature.

1. Work with other agencies in the development of their long-term (5-10 year) transport 

infrastructure plans to ensure that, over time, busy crossings are taken off grade with 

over and under passes. 

2. Ensure those over and under passes are effective alternatives for mobility users. 

3. Liaise with manufactures of mobility vehicles to try and establish improvements to wheel 

design to minimize risk at flange gaps. This could include wider wheels and or double 

wheels. 

Investigation Findings 

The findings of the Investigation Report are as follows: 

1. The combination of the uneven surface of the crossing on the day of the accident, the 

width and depth of the flange gap, and the angle of the crossing (which was at 67 

degrees to the railway line and runners) were major contributing factors to the accident. 

2. A number of factors contributed to this situation existing at the time of the accident and 

our findings in that regard are: 

• At the highest level, the fact that at-grade pedestrian crossings (as opposed to the 

use of under and overpasses) continue to be utilised in New Zealand on busy metro 

networks meant that this accident was possible. 

• No specific consideration was given to the appropriateness of the design of the 

pedestrian crossing used at Morningside for special needs users such as wheelchair 

bound pedestrians, push chair users and cyclists. Had such consideration been 

made, it may have resulted in a choice of design which may have been less 

susceptible to damage and/or once damaged, would have posed less of a potential 

hazard to wheelchair users. However, had the Morningside crossing been 

maintained as constructed, the crossing surface would likely not have posed a 

potential hazard to wheelchair users. 

• There was no specific recognition of potential hazards to special needs users such 

as wheelchair bound pedestrians, push chair users and cyclists in the maintenance 

inspection procedures for level crossings and when granting an exemption to the 

inspection regime to permit inspections to be undertaken from the cabs of 

locomotives, no specific consideration was given to level crossings. 

• Once the Morningside crossing suffered the water damage, the track inspection 

regime did not identify the deteriorated condition of the crossing, it was identified by a 

Track Inspector while performing other duties who reported it as requiring work. 

• Due to a number of failings within KiwiRail’s systems, the remedial work required to 

repair the surface of the Morningside Crossing was recorded with a lower priority 

than intended, the required remedial work was then not undertaken and it was also 

then incorrectly recorded as having been completed. 

Recommendations 

The recommendations of the Investigation Report are as follows: 

1. A review be undertaken of international practice in respect of the design, 

construction, inspection and maintenance of rail pedestrian crossings. The review 

should also include:

a. Consideration of whether (and if so in what situations) at-grade crossings 

should be used; 

b. Consideration of raising the public awareness of the residual risk of at-grade 

crossings. 

This review should involve representatives of all stakeholders including those 

representing special needs users such as wheelchair bound pedestrians, push chair 

users and cyclists as well as roading authorities and other agencies with an interest 

in and/or responsibility for safety at road/rail crossings. 

2. Based on the review, KiwiRail’s end to end work processes be reviewed and revised 

as necessary (including interim measures based on learnings as the review takes 

place). 

3. A review be undertaken of the code exemption process to ensure it is aligned to the 

relevant NRSS risk management approach to changes. 

4. A review be undertaken of KiwiRail’s processes to ensure work identified as being 

required from Inspection reports is properly prioritised, reviewed, logged, 

programmed and completed.

Rail Level Crossings & Pedestrian Crossings: Further Background 

Improving pedestrian safety and access for those who are mobility impaired across the 

entire national rail network is an on-going process. Specific initiatives when improving or 

building new infrastructure that incorporates pedestrian access have included ensuring 

pedestrian mazes and ramps are wheelchair access compliant, the installation of bells and 

signs for those who are hearing and visually impaired at higher risk crossings, and the 

installation of tactile ground surface indicators. 

PUBLIC LEVEL CROSSING COLLISIONS 

CALENDAR YEARS 2004 – 2013 (To 18 April ) 

Vehicle 

Pedestrian 

33 

36 

31 

23 

20 

22 

16 16 16 

4 

3 

6 

7 

5 5 

2 2 2 

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 

Number includes self-harm incidents at designated rail crossings. 

Motor Vehicle Collisions 

In 2012 there were 16 collisions and 139 reported near collisions with motor vehicles 

Over the past ten years, there were: 

• 244 public road level crossing collisions between road vehicles and rail vehicles at 

203 different locations – an average of 24 collisions a year. 

• Compare this with over 4,000 injury collisions at other road intersections in a typical 

year. 

Pedestrian Collisions 

Over the past 10 years there were:

• 35 collisions between pedestrians and rail vehicles at 32 different locations – an 

average of 3 – 4 per year. This figure compares with around 300 pedestrian collisions 

at road intersections in a typical year. 

Where these occurred: 

• About 60 per cent of pedestrian level crossing collisions occur at paths alongside 

public road level crossings 

• About 75 per cent of pedestrian collisions occur where automatic alarms are installed 

• About 40 per cent of fatal pedestrian collisions are suicides. 

Auckland 

Significant improvements to the rail network have been made in Auckland over the past six 

years as part of the $600 million DART project work carried out. This included the New Lynn 

trench which completely removed crossings through a very busy set of road, footpath and 

rail intersections. 

All Auckland pedestrian crossings are now fitted with flashing lights and bells and mazes, 

and there are automatic gates at at five busy double track stand-alone pedestrian level 

crossings around the network. 

Since September 2006, KiwiRail has completed upgrades to 25 level crossings throughout 

Auckland. This work has seen: 

• Automatic half-arm barriers added to 11 public road level crossings on the Western 

Line and Onehunga Line. 

• Automatic pedestrian gates and flashing light and bell alarm systems installed at five 

busy double track stand-alone pedestrian level crossings on the Western Line. 

• Flashing light and bell alarm systems installed at four stand-alone pedestrian level 

crossings on the Western Line and five pedestrian level crossings on the Southern 

Line. 

Number of crossings: 

• In the Auckland suburban passenger train area i.e. Pukekohe to Waitakere there are 

37 road crossings and 22 public pedestrian level crossings (59 total). 

• In the wider Auckland Council region which includes Mission Bush and north to Te 

Hana then there are 96 crossings in total, consisting of 24 stand-alone pedestrian 

plus 72 road crossings. 

Infrastructure Spend 

The issues identified in this incident are not as a result of any perceived capital shortfall as is 

often raised when New Zealand’s rail network is discussed. 

The capital expenditure on improving the rail network has been over $2.8 billion since 2006, 

not including the major rail upgrade projects in Auckland ($600 million) and Wellington ($550 

million) that have been completed on time and on budget. 

As the major renewal projects in Auckland and Wellington are finishing we are reverting to a 

more normal agreed plan for annual maintenance and renewal for rail infrastructure. This

funding will be split according to the use of the infrastructure between metropolitan 

Government agencies and KiwiRail. 

On top of this work every year $1 million is spent on major upgrades to level crossings. This 

work is prioritised according to the individual risk rating of the 1400 level crossings 

nationally. Funds are also spent upgrading level crossings as part of overall infrastructure 

improvements, particularly in Wellington and Auckland. 

Approximately $200,000 is also spent annually on improving rail safety awareness in the 

community. 

ENDS

COLLISION TRAIN 126 WITH POWER WHEELCHAIR 

MORNINGSIDE NORTH 

AUCKLAND LINE 

MONDAY 25 FEBRUARY 2013 

Date of Report: 20 April 2013 

Investigation Team: 

Dennis Bevin 

Audit & Investigations Advisor 

Standards & Risk 

Safety and People 

KiwiRail 

Ian Cotton 

National Manager 

Standards & Risk 

Safety and People 


KiwiRail Review: 

Matt Ballard 

GM Safety and People 


Andrew Brown 

General Counsel 


Independent External 

Reviewer: 

Brian McIntosh 

Senior Associate 

Australasian Transport Risk Solutions Pty Ltd 

Iris Incident Reference: 130944 

Report on Collision Train 126 with Power Wheelchair, Morningside, 25 February 2013 Page 1

Table of Contents 

Investigation Team:................................................................................................................................. 1 

Iris Incident Reference: ........................................................................................................................... 1 

Table of Contents .................................................................................................................................... 2 

Glossary................................................................................................................................................... 3 

Introduction ............................................................................................................................................ 4 

What happened? .................................................................................................................................... 4 

Train Operation ....................................................................................................................................... 6 

Morningside Drive Pedestrian Crossing .................................................................................................. 6 

What caused the wheelchair to become stuck? ..................................................................................... 7 

Design and Construction of Crossing .................................................................................................... 10 

Inspection of the Crossing..................................................................................................................... 12 

Responses of Inspectors ....................................................................................................................... 14 

Undertaking the Work .......................................................................................................................... 15 

Safety Actions Arising............................................................................................................................ 16 

Findings ................................................................................................................................................. 16 

Recommendations ................................................................................................................................ 17 

Ongoing Investigations ......................................................................................................................... 18 


Glossary 

Asset Data Base (ADB) 

At-grade rail pedestrian crossing 

Auckland Electrification Project 

Block of Line (BOL) 

Codes and Standards 

Down Main Line 

Flange gap 

Field gap 

High Rail Vehicles 

Loop 

Pedestrian maze 

Runners (sleepers) 

T:200 Network Engineering Track 

Handbook 

Turnout 

Up Main line 

The computerised data base containing work records of 

track and trackside infrastructure. 

A crossing of the railway at ground level (as compared to 

grade separated crossings which go over or under 

the railway) 

Electrification of the suburban rail network within the 

Auckland Metropolitan area. 

Procedure for blocking a section of railway against the 

passage of trains to permit planned work to be 

undertaken. 

Together with Rules and associated documents these 

contain KiwiRail’s approved processes for the operation 

of various related aspects of the railway 

network. 

The Down Main Line at Morningside which carries 

trains bound for downtown Auckland. 

The gap between the inside of the rail line and the 

runner of the pedestrian crossing which allows the 

passage of wheel flanges. 

The gap between the outside of the rail line and the 

runner of the pedestrian crossing. 

A road vehicle fitted with retractable Hi rail wheels such 

that it can be driven along the track and can also 

be on / off tracked at level crossings or other suitable 

sites. 

The loop line directly connected to a main line provided 

for the passing or storage of trains. 

A structure consisting of fences which funnel pedestrians 

between station platforms and over railway tracks. 

Wooden sleepers laid parallel to the railway across 

asphalt level crossings to deflect vehicle wheels over 

the rail head. 

A hand book for track and other staff to have a handy 

reference point and guide when carrying out track 

inspections and maintenance work. 

Found where railway tracks diverge to control the 

direction of trains. 

The Up Main Line at Morningside which carries trains 

travelling from downtown Auckland. 


Introduction 

This Report records the findings of our investigation into the collision of Train 126 with an 

occupied power wheelchair at the Morningside pedestrian crossing on Monday 25 February 

2013. 

The investigation has been undertaken by the incident investigation team within KiwiRail’s 

Safety and People group. This team investigates significant incidents for the purpose of 

understanding what happened and to determine whether there are changes that need to be 

made in the way KiwiRail undertakes its rail activities to better ensure safety. 

In carrying out this investigation the investigators reviewed relevant documentation and 

interviewed relevant KiwiRail staff and members of the public including the two individuals 

who went to help. The investigators also spoke with the police officer in charge of the scene. 

The investigators’ initial findings were discussed with relevant KiwiRail staff and 

management. This Report was reviewed by the KiwiRail GM Safety and People and KiwiRail 

General Counsel. 

An independent external review of this Report has been undertaken by Brian McIntosh, a 

Senior Associate of Australasian Transport Risk Solutions Pty Ltd. 

What happened? 

At about 0906 hours on Monday 25 February 2013, Train 126, a Westfield to Whangarei 

express freight service consisting of locomotive DFT7064 and 25 wagons with a gross 

tonnage of 401 tonnes and length of 329 m, collided with an occupied power wheelchair on 

the pedestrian crossing over the Up Main Line to Swanson at Morningside Drive on the 

North Auckland Line. 

The operator of the wheelchair, a physically disabled female, had entered the crossing 

travelling in an easterly direction. After successfully negotiating the pedestrian crossing over 

the loop, she moved on to cross the Up Main Line which ran parallel to the loop. 

While doing so, the front caster wheels of the wheelchair became lodged in the flange gap 

between the runner (sleeper) and the right hand rail. 

A member of the public went from the platform and attempted to free the wheelchair, but 

being unable to so, requested assistance from a female passerby who was approaching 

from the eastern side of the crossing. 

About this time the level crossing alarms activated as Train 126 approached. It appears 

that the helpers were eventually able to free the wheelchair’s caster wheels and jump clear 

themselves, seconds before Train 126, which was under full emergency braking, passed. 

As the locomotive passed, the cow catcher struck the wheelchair which was still occupied by 

the operator, and dragged it about five metres from the point of impact until it was released 

just short of the southern abutment of the Morningside Up Main Line platform. 

The operator of the wheelchair sustained life threatening injuries. 


Figure 1 shows the layout of Morningside Drive Level Crossing when viewed from the ramp 

leading to the island platform and looking towards Kingsland. 

Approach of Train 126 

Down Main 

line 

Pedestrian 

maze to island 

platform 

Up Main line 

Direction of travel 

of wheelchair 

Loop 

Figure 1 

Morningside Drive level crossing looking towards Kingsland 

Figure 2 shows the layout of Morningside Drive level crossing and island platform viewed 

from the direction of travel of Train 126 and shows the position of the wheelchair. 

Position where 

wheelchair became 

stuck 

Direction of travel 

of wheelchair 

Figure 2 

Morningside Drive level crossing and island platform 


Train Operation 

The locomotive event recorder verification for locomotive DFT7064 confirmed that Train 126 

was being driven in accordance with KiwiRail’s Codes and Standards as the train 

approached the pedestrian crossing. 

Following the accident the Locomotive Engineer submitted to a drug and alcohol test in 

accordance with KiwiRail’s post incident procedures. The outcome was a “Negative - 

Passed Test” result. 

Morningside Drive Pedestrian Crossing 

The Morningside Drive pedestrian crossing is located on the North Auckland Line in 

Sandringham, Auckland. 

There are two pedestrian crossings at Morningside, one on each side of, but separated from, 

the vehicle level crossing. 

The crossing traversed three separate tracks as shown in Figure 1, the Down and Up Main 

Lines and the Loop. It also provided access to the island platform between the Down and 

Up Main Lines. 


What caused the wheelchair to become stuck? 

Wheelchair Design 

The wheelchair involved in the accident was a TDX SP Wheelchair. These wheelchairs are 

imported from the United States of America and are distributed in New Zealand by Invacare 

(See Figure 3). 

TDX SP Wheelchairs weigh 120kg empty and are 890mm long and 647mm wide. The 

wheel arrangement is front and rear casters of 147mm diameter with a central drive wheel of 

255mm diameter. Suspension is designed to allow for the front casters to travel 36mm up 

and 36mm down. The caster wheels have a diameter of 147mm and a tyre width of 47mm 

which extend to 89mm at the axle (See Figure 4). The front caster wheels swivelled 

independently as well as moving up and down given the suspension of these wheels. 

147m 

89mm 

47mm 

74mm 

Figure 3 

A TDX SP Wheelchair 

Figure 4 

Caster Wheel Measurements 


The Crossing Surface 

The relevant section of the Morningside crossing surface consisted of asphalt, wooden 

runners (sleepers) positioned parallel to each railway line, field and flange gaps and rail 

tracks. 

The width of both the flange gaps was 75mm. The width of the field gaps ranged from 

83mm to 98mm (See Figure 5). 

At the time of the accident, the surface of the Morningside crossing over the Main Lines was 

uneven due to the fact that it had suffered premature degradation of the asphalt surface and 

the loss of asphalt from between the rails and the runners on either side of the rails. The 

surface of the crossing over the Loop had not deteriorated to any extent since the 

reconstruction in June 2011, although the gap, runner and asphalt construction was the 

same as the other crossings. This is in contrast to the deterioration at the Up and Down 

Main Lines. 

Major drainage issues had been reported at the Morningside level crossing during heavy 

rain. At such times large volumes of water ran downhill from New North Road to fill the only 

drain and overflow onto the crossing. 

In addition, while undertaking excavation work as part of the repair/upgrade work of the 

pedestrian crossing following the accident, a break in an Auckland Council water pipe was 

discovered almost directly beneath the pedestrian crossing over the Up Main Line. 

Extensive amounts of water were found to be lying beneath the crossing and also in the 

signal cable pits. 

The investigation confirmed that the pedestrian crossing on the Up Main Line had been used 

as an on / off tracking facility for high rail vehicles during the Auckland Electrification Project 

as a normal construction procedure given its proximity to Morningside Drive. This would 

account for the torn and twisted tactile strips shown in Figure 5. Although the seal was built 

to vehicle level crossing standards, it is possible that the weight of these vehicles may have 

further contributed to or aggravated the condition of the pedestrian crossing given the 

deterioration of the formation beneath the crossing because of the burst water main. 

The investigation has concluded that the probable reason for the deterioration of the asphalt 

around the Main Lines was water issues. By comparison, the asphalt around the Loop was 

not deteriorated to any significant extent because: 

1. the break in the water pipe was immediately under the Up Main; 

2. the Main Lines are much more heavily used by trains than the loop. 

This is significant because the continual passage of trains over the Up and Down Main line 

crossings would likely have aggravated the conditions occurring beneath and would have 

further contributed to their deterioration in contrast to the loop which was very seldom used, 

and then usually only for the storage of train sets during events at Eden Park. 

An expert in asphalt engineering has been engaged by the investigation team to give an 

opinion on the effect of these factors on the asphalt. 


83mm 

75mm 

72mm 

92mm 

Field gap 

Direction of Travel of 

Wheelchair 

Flange gap 

Flange 

gap in 

which the 

wheels 

became 

lodged 

90mm 

75mm 

75mm 

98mm 

Figure 5 

Up Main Line pedestrian crossing at the time of the collision 

The wheelchair’s wheels becoming lodged in the gap 

The operator of the wheelchair had entered the crossing travelling in an easterly direction 

and had negotiated the pedestrian crossing over the Loop. As explained above, that section 

of the crossing was not in the degraded condition of those over the Up Main Line and, to a 

lesser extent, the Down Main Line. The surface of the crossing at the Loop was relatively 

smooth and likely posed no problem to the wheelchair dynamics. The operator of the 

wheelchair then moved to cross the Up Main Line crossing. 

Interviews with the two helpers stated that the front caster wheels of the wheelchair were 

lodged in the flange gap of the right hand rail of the Up Main Line. The caster wheels of the 

wheelchair were of such a diameter that they could not have fallen into the gap as long as 

they faced in the direction of travel. The front caster wheels have a diameter of 147 mm and 

the flange gap was 75mm wide. However, the front caster wheels are 47mm wide and to 

become lodged, therefore, the wheels must have turned at right angles to the direction of 

travel, and parallel to the rail, or at angle which was sufficiently acute to cause the wheels to 

slide into that position. However, we cannot know for certain the reason why the wheels 

became lodged in the gap. 

In our view, the width and depth of the flange gap, the uneven surface of the crossing and 

the angle of the crossing (which was at 67 degrees to the railway line and runners) were 

probably major contributing factors. The uneven surface would likely have given rise to 

juddering and a redistribution of weight, which could have caused the caster wheels to 

swivel as the wheelchair moved across that section of the crossing. 

Despite the best efforts of the helpers who went to the occupant’s aid, in our view, it is likely 

that the weight of the occupied wheelchair would have made it extremely difficult to dislodge 

the wheels from the gap. However, the helpers were eventually able to move the wheelchair 

from the centre of the track such that the impact of the train deflected the wheelchair to the 

right hand side of the track. How they achieved this could not be determined. 


Design and Construction of Crossing 

What do the codes and standards require in terms of design and 

construction of pedestrian crossings? 

There are a number of designs used by KiwiRail for level crossings which involve different 

construction techniques. These include rubber level crossing systems, prefabricated 

concrete slabs, asphalt without runners and asphalt with runners. 

In some cases specific pedestrian design plans were available, but for asphalt crossings, 

road crossing designs were used. For asphalt crossings two design plans were available, 

one for asphalt road crossings without wooden runners and one with wooden runners. 

For level crossings constructed using asphalt with wooden runners, the wooden runners 

were inserted parallel to the outer edge of each rail. The purpose of this was to deflect road 

vehicles from impacting on the head of the rail as they passed over. 

In crossings of this type, the field gap between the runner and the rail in the design was 

75mm wide and was required to be completely filled with asphalt. The design also included a 

75mm flange gap between the inside of each rail and the adjacent runner. The flange gap 

was necessary so that the wheel flanges of rail vehicles could pass without striking the 

crossing surface. The depth of the flange gaps for the type of crossing used at Morningside 

Drive varied from 30mm to 37mm, depending on the size of the rail so that even with wear, 

the depth could not exceed 50mm if the crossing was built to plan. The floor of the gaps 

required 120mm of asphalt fill down to the supporting sleeper and fastenings. 

Designs existed for level crossings using the rubber level crossing systems. Where these 

were to be used, the Track Engineering Office in Wellington was required to be involved and 

arranged for specifications of the level crossing to be sent to the manufacturer who designed 

and submitted a drawing specification for the crossing for approval prior to supply of the 

rubber panels. In these cases the design drawing was specific to the particular level 

crossing they were being designed for. The rubber panels came in lengths of 600mm up to a 

maximum of 1800mm. The design flange gap for rubber level crossings was 70mm wide 

and 50mm deep. 

Examples of these crossings had been installed in the Wellington Metro area. 

A prefabricated concrete panel design was also available and there were several examples 

of these in the Auckland Metro area. These designs did not make provision for the filling of 

the flange gaps which are consequently full depth. 

Construction of the Morningside Crossing 

The Morningside Drive pedestrian crossing had originally been part of the vehicle level 

crossing. 

In 2011 prior to the Rugby World Cup and during the Auckland Rail Network preparation 

stage leading up to the Cup, the existing Morningside pedestrian crossing layout was 

considered to be inadequate for large crowd access / egress. It was decided that it be 

upgraded, including the maze layout, to provide more flexibility. Part of that upgrading 

included the separation of the pedestrian crossings from the vehicle level crossing. The 

crossings were installed over the weekend of 5, 6 and 7 June 2011. 

The Morningside pedestrian crossing was constructed using the asphalt and runner road 

crossing design. 

Alternatives of using either rubber panels or concrete slab inserts were considered. 

Concrete slabs were considered unsuitable because of the angle of this pedestrian crossing 

to the track (67 degrees) which meant that the three panels required for each of the six 


individual crossings would be staggered which would result in a restricted width pathway in 

parts. Continuous pour concrete was not considered as a suitable construction method 

because of its tendency to crumble with movement from passing trains and the longer 

installation period required, over 24 hours. 

A rubber panel crossing was considered for the Morningside level crossing, however, the 

time to procure including design (4 months) was too long to meet the construction timeframe. 

The crossing at Morningside was therefore built to the specifications applicable to the 

construction of an asphalt road crossing as per Track and Structures Engineering Group 

Wellington Asphalt Road Crossing Drawing CE No 100 405. 

The project team had selected this standard because of its use in other existing pedestrian 

crossings in Auckland. 

Figure 6 

Morningside Drive pedestrian crossing after completion of upgrading 

June 2011 


Inspection of the Crossing 

What do the Codes and Standards require in terms of inspections? 

Track inspections of the North Auckland Line through Morningside were required to be 

undertaken by the Track Inspector twice a week and, until around 2006, practice was that 

they were normally undertaken by Hi Rail Vehicle. These inspections included inspections of 

level crossings in accordance with Infrastructure Code Supplement Section 21 Clause 3.2. 

This clause stated that Track Inspectors were responsible for off track infrastructure 

inspections including: 

Level Crossings: 

 

 

 

Check road surface condition; 

Check flangeway clearances are adequate; 

Check signs are correct. 

There was no specific mention of pedestrian crossings, as they are encompassed by the 

level crossing regime. 

Exemptions to this Code could be granted by the Technical Manager responsible for the 

Code / Standard where it was proposed that a particular requirement of the Code or 

Standard be changed. 

A Code Exemption had been issued in May 2009 which permitted track inspections within the 

Auckland Metro area to be undertaken from the cab of a locomotive. The Exemption, with 

conditions, was granted because traffic density meant that there was insufficient time 

between trains to get hi rail vehicles on track for inspection purposes. As a result, 

inspections were done from locomotive cabs. Regular extensions to this Exemption had 

been issued and it was still in place at the time of the accident. The Exemption contained 

conditions, including requiring all Turnouts to be inspected on foot on a weekly basis and for 

any other issues observed during the inspection to be followed up with a ground inspection if 

necessary. The Exemption did not contain a condition that level crossings be inspected by 

foot. 

What inspections occurred? 

The condition of the Morningside pedestrian crossing had deteriorated at a fast rate since 

construction of the crossing in June 2011. The deterioration had not been noticed during the 

regular locomotive cab inspections. 

However, on 5 September 2012 a Track Inspector while walking within the Morningside rail 

corridor for the purpose of inspecting the Turnout identified low spots in the surface of the 

pedestrian crossings over both Main Lines. He reported his findings on the M125/6 Track 

Inspection Form together with the comment “This is a major trip hazard” and a 

recommendation “Resurface with new hot mix. Both mains”. He also attached a photograph 

of the site at that time (see Figure 7, noting that the arrows and words were subsequently 

added to the photo by the Inspector at the time he submitted his M125/6). 


Figure 7 

Condition of Morningside Drive pedestrian crossing as reported by Track 

Inspector 5 September 2012 

The Track Inspector had reported the condition of the asphalt seal between the rails on both 

the Down and Up Main Lines during a foot inspection, but had not at that time raised either 

the lack of fill nor the overall deteriorated condition of the remaining fill in the field and flange 

gaps on either side of the rails as an issue. 

As noted later in this Report, no remedial work was undertaken to address the issues raised 

by the Track Inspector prior to the accident. 

At the end of November or early December 2012 the same Track Inspector had revisited the 

site (as part of his Turnout inspections). He was concerned that nothing had been done in 

the way of repairs to the crossing so he applied fluorescent paint to mark danger spots for 

members of the public using the crossing. Those markings are shown in Figure 5. 


Responses of Inspectors 

What do the Codes and Standards require in terms of Inspectors’ 

responses? 

Track Inspectors were required to report inspection findings in accordance with Railnet Code 

Clause P 26(a) which stated that: 

“Track inspections shall be carried out in accordance with Clause P21 & P24 and reported on 

an approved form to the Line Manager." 

In the same way as any other deterioration found during inspection, if the surface of a 

crossing had deteriorated, the Inspector would identify what work was required and allocate 

a priority to that work. 

Prioritisation was made based on a T200 Standard which had the following regime: P1=work 

required within 2 days, P2= work required within 1 week, P3=work required within 1 month, 

P4= work required within 6 months. 

Track Code Supplement CSP 22 Issue 2 dated July 2012 contained pictorial guidelines to 

help inspectors appropriately prioritise work. It also changed the regime to - P1= work 

required within 24 hours, P2= work required within 7 days, P3= work required within 30 days, 

P4= work required within 90 days. 

CSP 22 was prepared because T200 did not specifically provide a prioritisation regime for 

remedial work at level crossings. 

CSP 22 only contained guidelines relating to condition assessment of the roadway and was 

silent on the appropriateness of assessment to walkway surfaces at pedestrian crossings. 

CSP 22 was available on the intranet and was being progressively introduced at training 

updates. 

How did the work get prioritised? 

The Track Inspector who noticed the condition of the Morningside crossing assessed the 

priority of the work required as Priority 4 (working under the T200 regime), however, he 

believed this equated to repair required in 90 days, where in fact P4 in T200 required the 

repair within 6 months. 

He was not aware of the existence of CSP 22 Issue 2 because he had not at the time of 

reporting attended the Track Inspectors’ Refresher Course at which copies of CSP22 Issue 2 

were provided to attendees. 

. 


Undertaking the Work 

What do the Codes and Standards require in terms of undertaking works? 

The information from M125/6 Track Inspection report prepared by Track Inspectors which 

identifies work required is sighted by the Area Manager, then assessed by the Field 

Engineer and is then logged into the Asset Data Base (ADB). A summary report (which lists 

the work required) is then created from ADB for review by line management (Field Engineer 

and/or Area Manager) who then schedule the work for the appropriate ganger (being the 

person responsible for the team carrying out the work). 

Once work is completed, the completed job list is then returned to the Field Engineer who 

reviews the list, which is then entered as complete, with the completed date in the relevant 

record. 

This process is set out in a training document and is customary practice but is not codified. 

What happened in relation to the works on the Crossing? 

The information from the relevant M125/6 Inspection Report was entered into the ADB, but 

without review by the Field Engineer. When entered into the ADB system, the P4 

prioritisation was accorded a six month repair timeframe, not the 90 days as it would have 

been in accordance with the initial intention of the Track Inspector or if it had been assessed 

as P4 in accordance with CSP22. 

A Block of Line was in place during the Christmas 2012 – New Year 2013 period for the 

entire Auckland Metropolitan Area for the purposes of continuing major project work in the 

absence of trains. The outstanding work listed on the M125/6 Track Inspection Summary 

Report dated 21 December 2012 which included the work required at the Morningside 

crossing was to be accommodated within the project-related Block of Line program. 

The summary report still showed the work at Morningside crossing as a P4 with a 6 month 

maximum completion date from initial inspection date of 5 September 2012. 

Over the Christmas period the Track Inspector in charge of the maintenance gang (not the 

Inspector who had identified the uneven surface) had concentrated his efforts on repairing 

EM80 (Track Recording Car) track geometry exceedances recorded on the M125/6 Track 

Inspection Summary Report dated 21 December 2012 and, although he had rectified a fault 

at the first pedestrian crossing at Morningside, he was not equipped or resourced to respond 

to the issues raised in the 5 September 2012 M125/6 Inspection Report in relation to the 

second pedestrian crossing and the original 6 months for completion had not yet expired. 

The copy of the M125/6 Track Inspection Summary Report was subsequently endorsed with 

the date “29/12/12” signifying that the work had been completed. It was possible that the 

Track Inspector had signed off the work on both pedestrian crossings as having been 

completed, even though the work had only been completed on one, by mistake. The close 

physical proximity of the pedestrian crossings, separated only by the vehicle level crossing, 

and their proximity on the Summary Report would tend to support this. 

That information was entered into the ADB on 4 January 2013. At that time the TID 

reference was transferred as completed from the M125/6 Track Inspection Summary Report 

to the ADB Archive (Complete). 


Safety Actions Arising 

Following the accident the following safety actions have been undertaken by KiwiRail. 

1. The Morningside pedestrian crossing involved was temporarily resealed during the 

evening following the accident and was completely renewed the following weekend. 

2. An advisory was issued to all I&E Regional Managers advising them to inspect all 

pedestrian crossings in their areas for similar damage and to initiate repairs if 

required. 

3. A same day inspection of Auckland metro crossings identified none with similar level 

deficiency, but with the heightened awareness as a consequence of the accident 

eight of some 60 metro crossings in total were regarded as not providing an 

appropriate level of service for crossing by a similar wheelchair. Initial work on these 

crossings was scheduled and completed over three days. 

4. 350 formed pedestrian level crossing surfaces have been inspected nationally. While 

no other examples of surface deterioration seen at Morningside have been found, 

initial repairs to evenness which could potentially present a significant hazard to 

disabled users have been completed on some 20 crossings. Minor work has been 

completed on a further 60 crossings and where necessary, work to reduce the gaps 

against the rail head is being scheduled. 

5. Progress and issues arising from inspections of level crossings are discussed at 

weekly Infrastructure and Engineering management meetings and it has been 

confirmed that all such inspections are to be undertaken on foot. 

6. The Infrastructure & Engineering team were instructed to investigate the 

establishment of a standing procedure which maintains gap depth at 50 mm or less 

and maintains an evenly trafficable pedestrian surface for formed pedestrian 

crossings. 

7. The Auckland Area office connected with CCS Disability Action and together visited a 

number of Auckland Metro pedestrian crossings to gain a greater awareness of 

issues faced by people with disabilities. 

Findings 

Our findings as to what happened in relation to the accident at Morningside crossing on 25 

February 2013 are set out in the sections of this Report entitled “What happened?” and 

“What caused the wheelchair to become stuck?” In our view, the width and depth of the 

flange gap, the uneven surface of the crossing on the day of the accident and the angle of 

the crossing (which was at 67 degrees to the railway line and runners) were major 

contributing factors. 

Based on our investigation, a number of factors contributed to this situation existing at the 

time of the accident and our findings in that regard are set out below. 

At the highest level, the fact that at-grade pedestrian crossings (as opposed to the use of 

under and overpasses) continue to be utilised in New Zealand on busy metro networks 

meant that this accident was possible. 


No specific consideration was given to the appropriateness of the design of the pedestrian 

crossing used at Morningside for special needs users such as wheelchair bound 

pedestrians, push chair users and cyclists. Had such consideration been made, it may have 

resulted in a choice of design which may have been less susceptible to damage and/ or 

once damaged, would have posed less of a potential hazard to wheelchair users. However, 

had the Morningside crossing been maintained as constructed, the crossing surface would 

likely not have posed a potential hazard to wheelchair users. 

There was no specific recognition of potential hazards to special needs users such as 

wheelchair bound pedestrians, push chair users and cyclists in the maintenance inspection 

procedures for level crossings and when granting an exemption to the inspection regime to 

permit inspections to be undertaken from the cabs of locomotives, no specific consideration 

was given to level crossings. 

Once the Morningside crossing suffered the water damage, the track inspection regime did 

not identify the deteriorated condition of the crossing, it was identified by a Track Inspector 

while performing other duties who reported it as requiring work. 

Due to a number of failings within KiwiRail’s systems, the remedial work required to repair 

the surface of the Morningside Crossing was recorded with a lower priority than intended, 

the required remedial work was then not undertaken and it was also then incorrectly 

recorded as having been completed. 

Recommendations 

It is recommended that: 

1. A review be undertaken of international practice in respect of the design, 

construction, inspection and maintenance of rail pedestrian crossings. The review 

should also include: 

a. consideration of whether (and if so in what situations) at-grade crossings 

should be used; 

b. consideration of raising the public awareness of the residual risk of at-grade 

crossings. 

This review should involve representatives of all stakeholders- including those 

representing special needs users such as wheelchair bound pedestrians, push chair 

users and cyclists as well as roading authorities and other agencies with an interest 

in and/or responsibility for safety at road/rail crossings. 

2. Based on the review, KiwiRail’s end to end work processes be reviewed and revised 

as necessary (including interim measures based on learnings as the review takes 

place). 

3. A review be undertaken of the Code exemption process to ensure it is aligned to the 

relevant NRSS risk management approach to changes. 

4. A review be undertaken of KiwiRail’s processes to ensure work identified as being 

required from Inspection reports is properly prioritised, reviewed, logged, 

programmed and completed. 


Ongoing Investigations 

This Report records the investigation to date. Aspects remaining the subject of ongoing 

investigation include: 

• The external study of the asphalt deterioration issues. 

• If there are any wider ramifications of the inspection regime.

Morningside Report and Summary Here - KiwiRail

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