RAIB additionally discovered the rule ebook didn’t cowl the particular circumstances of the “wrong-direction” motion in the incident, that means that the signallers had been ignoring the principles unintentionally.
It requested the RSSB to think about if the modules in the rule ebook ought to account for such situations.
Investigators additionally discovered the incident highlighted how staff ought to have a greater understanding of how their private points may have an effect on their work.
They learnt the signalling shift supervisor had been coping with “significant personal issues” that had been affecting their focus.
After reviewing the witness proof, the RAIB stated that if this member of staff had declared these points to their supervisor they’d have been taken off responsibility on compassionate grounds.
The RAIB prompt staff ought to “ask a competent person” and problem colleagues in the event that they had been uncertain about work being finished.
Responding to the report, a Network Rail spokesperson stated it had taken the suggestions “very seriously”.
They stated Network Rail was implementing the suggestions, together with adjustments in coaching for signallers.
