A train driver died after climbing out of his cab onto the rail tracks - probably to urinate or smoke a cigarette, an investigation has found. The man was found dead after searches when his train failed to leave the sidings on time.
The crew of the train which hit him was initally unaware they had hit someone as it was dark at the time of the accident. However a report into the incident by the Rail Accident Investigation Branch said the driver suffered injuries which were "immediately fatal."
Now a string of recommendations have been made after investigators found the driver would have had no opportunity to use the toilet for hours - with no facilities on the train he was on and too little turnaround time at the station to go there.
These include ensuring staff have access to toilets on their routes. They are also calling for forward-facing CCTV cameras fitted to both new and existing trains.
The report said the driver died when he was hit by a passenger train travelling at approximately 33mph on February 1 last year at around 8.30pm. The man had left the cab of his train which was stationary in West Worthing Middle Siding.
It said: "When the stationary train in the middle siding did not leave at its scheduled departure time, the signaller attempted to contact the driver. When the signaller could not get a response, he instructed the next train on an adjacent line to stop alongside the stationary train and to contact the driver. The driver of this third train found the driver who had been struck.
"RAIB determined that, before leaving the stationary train in the middle siding, the driver did not tell the train’s guard or the signaller that he intended to do so. He also did not request that trains on the adjacent lines be stopped.
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"RAIB has not been able to establish why the driver left the cab of his train. However, in considering only those factors relating to railway safety, RAIB has concluded that the driver was unlikely to have accidentally fallen out of the cab or left it intentionally for a work- related reason and that he most probably exited the train for a personal reason. This may have been to urinate or to smoke a cigarette, possibly in the belief that it was safe for him to be outside of his train.
"The driver then entered the path of the approaching train. He may have done this inadvertently after a loss of balance or while trying to regain his feet following a fall from the cab access steps or a loss of footing on ballast. He may also have slipped or tripped on a wooden board that had been left detached on the track for many years."
The report said the Class 313 train on which the driver had been travelling had no onboard toilets. It had been more than two hours since his last opportunity to use a toilet at Brighton station. And while there was a staff toilet available there the amount of turn-around time given to workers would have been insufficient to use it.
The report said there was a history of drivers needing to urinate at this location with Govia Thameslink Railway publishing a number of notices to drivers between 2015 and the date of the accident requesting that they stop throwing bottles of urine from their train cabs at the location.
It said this meant if the driver did need to urinate at this time, he may have not wanted to do so in an empty two-litre water bottle found in the driving cab because he knew he could be disciplined for it
The RAIB made three recommendations. The first, made to GTR, requires that on-train staff have adequate access to toilets across all of their routes.
The second recommendation is made to the Department for Transport, in conjunction with the Rail Safety and Standards Board, and relates to reviewing standards to ensure the mandatory fitment of forward-facing CCTV equipment to new trains. The third recommendation is made to the Rail Safety and Standards Board, in conjunction with operators of trains, and encourages consideration of fitment of forward-facing CCTV equipment to existing trains.
In addition it identified four learning points. It said: "The first reminds traincrew to arrange appropriate protection before leaving their cabs. The second highlights the importance of wearing suitable personal protective equipment. The third learning point prompts infrastructure managers to take timely action to remove tripping hazards. The final learning point reminds employers of train drivers to assure themselves that the correct protective equipment is being worn by their staff."
