The Rail Accident Investigation Board (RAIB) has published the above report on the 12th May 2020 - available through this link. Some 55 pages long it is rather complex to try and make a summary of it here. I quote part of the RAIB's own Summary:
The investigation examined five categories of incident:
The investigation identified several common factors influencing the actions of
- user worked crossing irregularities
- line blockage irregularities
- users trapped at CCTV level crossings
- irregularities involving level crossings on local control
- other operational irregularities.
signallers across these scenarios, associated with:
The report also observes that Network Rail’s incident investigations do not always fully
- signaller workload
- user-centred design
- competence management
- experiential knowledge
- organisational structure.
exploit the opportunities to learn from these incidents.
As a result, RAIB has made six recommendations to Network Rail, addressing each
of the five areas listed above as well as the observation on learning from incident
investigations. There is also a learning point for incident investigators relating to the
identification of systemic causal factors.