A tractor which was hit by a train travelling at nearly 90mph in Roudham was given permission to cross the tracks by a possibly fatigued signaller.
The driver of the tractor was seriously injured in the incident at the level crossing at Hockham Road in April 2016.
With the train a minute away from the crossing, the tractor driver had been granted permission to cross by a signaller at the Network Rail signal box in Cambridge.
At about 12.30pm, the Norwich to Cambridge service struck the tractor at 87mph. The train driver had sounded the vehicle’s horn and applied the emergency brake but was unable to stop.
The train driver and four passengers were also hurt.
In a report released by the Rail Accident Investigation Branch (RAIB) today, it is claimed the signaller had “lost his awareness of the position of the train” because his levels of concentration “may have lapsed”.
Since the incident at Hockham level crossing in April 2016, we have already made a number of changes to improve safetyHelen Warnock, senior incident officer for Anglia, Network Rail
Network Rail says a number of improvements have been made at the crossing since the accident.
These include an electronic warning system, new ways of working being implemented at the signal box and the installation of screens to better track trains on the network, and the appointment of a new operations manager.
The report read: “An underlying factor was that the arrangements in Cambridge signal box for managing fatigue among signalling staff were inadequate.”
Simon French, Chief Inspector of Rail Accidents, said: “In recent years, the RAIB has become concerned about signaller error as a cause of accidents at level crossings where it is always necessary for vehicle drivers to telephone the signaller for permission to cross
“Giving permission for users to cross the railway will often require signallers to carefully check the location of trains and estimate the time available for users to cross in safety.
“Although the reliability of such decisions is likely to be improved if signallers are provided with better information, it would be preferable to see, over the longer term, the progressive removal of crossings where the only form of protection is the telephone.
“We are recommending that Network Rail should undertake a review of its measures for the protection of such crossings with the objective of reducing the risk of signaller error.”
The report has made three recommendations to Network Rail, including changing their approach on how they manage user worked level crossings, processes when introducing new signalling equipment, and the management of the competence of signalling shift managers.
Helen Warnock, Network Rail’s senior incident officer for Anglia, said: “We take on board the recommendations outlined in the report. Since the incident at Hockham level crossing in April 2016, we have already made a number of changes to improve safety. Reducing the risk at level crossings remains a top priority and we are committed to make level crossings as safe as possible for everyone. Our thoughts remain with the injured tractor driver and those affected.”