A number of recommendations have been put forward by the Rail Accident Investigation Branch (RAIB) following a fatal injury near Ashtead, Surrey, in 2022.

A pedestrian was traversing the tracks at Lady Howarth footpath and bridleway when she was struck by an out-of-service passenger train.

She was walking on the crossing, accompanied by a dog and pushing a wheeled trolley bag. She had paused to let one train pass but was struck by a second train travelling in the opposite direction. The incident took place at about 14:49 on Thursday 21 April 2022.

The driver of the second train saw the woman on the crossing and sounded the train’s horn. Instead of stepping back, she hurried forward to the exit and was struck by the train.

An initial report was published on 14 February 2023 following RAIB’s original investigation. However, the inquiry was re-opened on 15 August 2023 after new evidence became available.

It was found that the woman had been unaware that a second train was approaching and therefore made the decision to cross. She had looked twice in the direction from which the second train came but was unable to see it approaching.

The second train was hidden by the first train which has passed by and was moving away from the crossing on the line which was closer to the pedestrian.

The report concluded that it was possible that the women did not perceive any risk associated with the possibility that the first train might be obscuring another train travelling in the opposite direction.

Prior to the accident, Network Rail decided that the level of risk to people crossing the line at the point where the incident took place was unacceptable. The re-opened investigation heard that Network Rail had planned, and budgeted for, the installation of miniature stop lights at the crossing to reduce the risk to users.

Shortage of resources meant that the delivery of the system was delayed and that Network Rail has, therefore, not provided any effective mitigation of risk at the crossing.

Similarly, effective options to reduce risk to users on an interim basis pending the installation of the new system were not considered. The organisation had also not considered applying for a derogation to an internal standard, which would have allowed a simpler system of a miniature stop light system to be installed at the crossing.

However RAIB found that, even if a derogation had been obtained and the simpler system installed, it would have been unlikely to have been in operation before the accident befell the pedestrian.

In the original report, two recommendations were made to Network Rail and these remain unchanged in the updated report.

The first asked that Network Rail should address the risks associated with pedestrians using crossings where the sight of a second train on approach may be obscured by another train.

Secondly, consideration should be given to the implementation of appropriate risk mitigations for those level crossings that are awaiting long-term solutions.

One of the conclusions of the second report is that lessons need to be learnt regarding checking whether derogations from standards exist or may be applied for, since this could, in some cases, provide an opportunity to reduce risk in a more timely and cost-effective manner.

A Network Rail spokesperson said: “Our thoughts remain with the family and friends of the woman who sadly lost her life on this foot crossing. Since the accident we’ve co-operated fully with the Rail Accident Investigation Branch (RAIB) and we both recognise and accept the recommendations of their report.

“We’ve already made changes at this location including installing new miniature stop lights, and designing, developing and fitting new industry-standard signage which became law last year, alerting people to the possibility that an oncoming train may be hidden by another train.”