KiwiRail has accepted responsibility for an accident in which a train hit a young woman in a wheelchair at a level crossing in Auckland in February.
The state-owned company has finally released a report, originally due before Easter, on its investigation into the accident at Morningside Drive on February 25, accepting that the crossing was in a "degraded condition".
"We take our responsibility for meeting our own safety standards seriously and are very disappointed and apologetic for our failure in this instance," said KiwiRail chairman John Spencer.
A 22-year-old woman suffered horrific injuries in the accident when her wheelchair got stuck in the level crossing.
Two bystanders rushed to help her when they saw a freight train approaching, but could not get her wheelchair unstuck in time and had to throw it roughly out of the train's path.
The train still hit the edge of the chair and dragged the young woman along the track until it could stop. She was in intensive care for a week and almost died. Her mother said that when she asked what she could do, the intensivist replied: "Pray."
She suffered a fractured pelvis, fractured right humerus (upper arm bone), fractured left elbow, had part of left foot amputated, and had plates inserted in her right femur (hip bone) and in her left hand.
Her mother said today that her daughter had "made an amazing recovery" since the accident and recently moved to a rehabilitation unit.
"She is communicating with family and friends through signing, texting and using a computer (she is deaf). The multiple fractures she sustained along with the partial amputation of a foot, are all healing. She is experiencing some difficulty in weight-bearing, but is receiving daily physio," the mother said.
The report found that the width and depth of the flange gap, the uneven surface of the crossing and the angle of the crossing at Morningside Drive were contributing factors to the accident.
"Despite the crossing being fully rebuilt in mid-2011, its condition had deteriorated rapidly mostly due to the combined impact of stormwater flooding and a broken water pipe beneath it," Mr Spencer said.
"We have shared the findings of this report with the young woman's family, and we will continue to remain in contact with them providing any appropriate levels of support for as long as is needed."
He said work has already begun to mitigate the risk of any accidents like this occurring again.
"We took immediate steps after the accident to re-seal Morningside crossing and inspect other similar pedestrian rail crossings nationally. There were no crossings identified with the same level of deficiency as that at Morningside, but over the three days following the accident work was done on eight of the 60 crossings in Auckland to improve their underfoot evenness.
"KiwiRail staff immediately acted on the issues this incident made obvious and have already implemented some improvements.
"With the completion of this report we will act on its recommendations to review both pedestrian level crossing design and construction, and make further improvements to our inspection process."
He said KiwiRail would be looking internationally to identify other methods that may help better manage the design, construction, inspection and maintenance needs specific to rail pedestrian level crossings.
"Our intention is to also continue to involve groups representing mobility impaired users and cyclists in this work. We have already taken the first steps with key staff taking part in field trips with wheel chair users in Auckland to understand the issues they face when crossing the tracks.
"Level crossings are the interface between road/footpath and rail and it is critical that KiwiRail, relevant roading authorities and other agencies with an interest in, or responsibility for, safety at level crossings continue to work closely together to ensure appropriate solutions and processes are in place to best manage the public risks around New Zealand's 4,000km long national rail network."
The young woman's mother said the family wished to acknowledge "outstanding care" from Auckland City Hospital's critical care unit and Ward 76, and the courage of the bystanders "who saved her life that day on the train tracks".
She said her daughter "looks forward to eventually resuming normal life, and getting back to the part-time admin work she was previously employed in".
"The family have seen the report and are happy with the findings, and have no further comment, other than to say that the staff of KiwiRail have been in regular contact, and have been very supportive," the mother said.
"Her family wish to make a heartfelt thank you to everyone involved in helping or caring for their daughter. They wish to remain anonymous and continue to move on with their lives, and will not be giving any interviews."
The union for rail workers says greater use of over bridges or underpasses is needed to properly protect pedestrians from rail accidents.
Rail and Maritime Transport Union general secretary Wayne Butson said level crossings of all types were high stress points for rail staff operating trains and vehicles.
"Nobody comes to work wanting to kill or seriously injure another human being. We need to learn from this incident and make sure it doesn't happen again.''
To avoid any danger at crossings, KiwiRail needed to ensure there were over bridges or underpasses that forced pedestrians away from trains, which had no ability to stop at short notice, Mr Butson said.
"Morningside has no grade separation and remains a poor design.''
He said staff cuts at KiwiRail's Infrastructure and Engineering division last year were "terribly short-sighted'', with the Wellington and Auckland metro areas suffering severe job cuts.
"We were deeply concerned then, and still are, about the impact on safety and performance from the budget and staffing cuts to Infrastructure and Engineering.
"KiwiRail's own internal business plan stated it would lead to a decline in track standard,'' Mr Butson said.