The Rail Accident Investigation Branch made a total of nine recommendations
The Rail Accident Investigation Branch (RAIB) made a total of nine recommendations(Image: PA)
An investigation into the first fatal head-on train collision to cause a person’s death in the UK in 25 years has criticised Transport for Wales’ processes and training. The report found that the Welsh Government owned transport authority TfW did not effectively prepare its train drivers to deal with emergency situations like the fatal collision in Mid Wales on October 21, 2024.
The driver did not deploy an emergency sanding system that could have prevented the crash or weakened the impact.
It also found that an automatic system to deploy sand did not function as it had blocked pipes and an electrical fault, and said that TfW did not have sufficiently effective processes to ensure it would work. For the biggest stories in Wales first sign up to our daily newsletter here
The Rail Accident Investigation Branch (RAIB) made a total of nine recommendations directed at Transport for Wales, Network Rail, the Rail Safety and Standards Board, and Angel Trains – the company that owns and leases out the trains.
Passenger David Tudor Evans, 66, died in the collision between two trains in Talerddig, Powys, while a further four people received serious injuries and 23 suffered minor injuries.
Among the report’s recommendations was to look at train cabin design. It found that Mr Evans died after colliding with a table. Other passengers found one of their exit routes blocked by a jammed door. And emergency services found it difficult to gain access because of open cupboard doors.
The incident happened on a rural section of the Cambrian line, which is predominantly single track with loops to allow trains travelling in opposite directions to pass each other.
Despite braking, a westbound TfW train failed to stop as intended inside a loop and rejoined the single line too soon, crashing into an oncoming train run by the same operator.
The RAIB report said this happened because the westbound train’s wheels were sliding, which can be a particular issue in autumn when fallen leaves make tracks slippery.
The class 158 trains involved in the crash have two systems – one automatic and one manual – to dispense sand between wheels and rails when extra grip is needed.
The RAIB revealed in an interim report in April last year that the westbound train’s automatic system did not work in the moments before the crash because of several failures, including blocked hoses, electrical faults and incorrectly installed plates measuring the flow rate of sand.
In its full report published on Thursday the RAIB states that the driver did not deploy the manual emergency sanding system, which is done by pressing a yellow plunger in the cab. The system discharged sand as expected when tested after the crash.
If the driver operated emergency sander was deployed early enough, a collision could have been avoided, the report says.
However, the driver did not recall any training on the use of emergency sanders, even though records showed his training was up to date. He had not previously needed to use them while driving.
The driver stated that it had not occurred to them to use the emergency sanders on the day of the accident. They recalled thinking that the adhesion conditions would improve – an expectation based on previous experience which had resulted in successful outcomes.
The report found that TfW’s training and competency management did not effectively prepare the westbound driver to take the correct actions.
Following the incident the RAIB conducted a survey of other train drivers employed by TfW to understand how well they understood the use of the emergency sanding system. The results of this survey revealed a “lack of clarity by drivers about the circumstances that required its use”.
A further “possible underlying factor” relating to the severity of the crash was Network Rail’s “lack of a detailed understanding of the effectiveness of wheel-rail adhesion modifiers”.
While another “probable underlying factor” was that TfW had an “incomplete understanding” of the signalling system used on the Cambrian lines and its drivers’ interactions with it.
The westbound train travelled approximately 1,080m (0.7 miles) beyond its intended stopping position before the collision.
It was moving at about 24mph when the crash happened, while the other train was travelling at about 6mph. Mr Tudor Evans was a passenger on the westbound train.
Three other people on the train – including the guard – were seriously injured, while at least 18 suffered minor injuries. Damage to the cab of the eastbound train trapped the driver, who was also seriously injured. The other five people on board that train reported minor injuries.
The recommendations aim to reduce the likelihood of similar events, and include urging TfW to review how drivers are trained.
A joint statement for TfW and Network Rail reads: “Safety remains our highest priority for both our customers and colleagues.
“Our thoughts continue to be with the family and loved ones of David Tudor Evans and those passengers injured in the incident, and we continue to support our colleagues who were injured or affected.
“Network Rail and Transport for Wales welcome the publication of the Rail Accident Investigation Branch’s final report into this incident and have cooperated fully with the investigation throughout.
“While incidents of this nature are extremely rare on our rail network, we remain committed to working together as an industry to carefully consider the report’s recommendations to help prevent a similar incident in the future.”
Andrew Hall, the RAIB’s chief inspector of rail accidents, described the Talerddig crash as “a tragedy”.
He said: “Widely varying levels of grip between steel wheels and steel rails is an inherent issue for railways and a lot of effort goes into managing this and its possible consequences.
“That can involve the way track and the surrounding area is maintained, the way trains and signalling systems are designed, and the way trains are operated and maintained.
“The Talerddig investigation found factors associated with several of these areas, and related to the way different parts of the overall railway system interacted.”
He added: “I sincerely hope the lessons of this accident deliver lasting safety improvements.”
Dave Calfe, general secretary at train drivers’ union Aslef, said: “Our thoughts are with the family of David Tudor Evans, who tragically lost his life that day, and with those who were injured, including our member.
“We welcome the recommendations in the report and will assist their implementation to ensure incidents like this become even rarer on Wales’s railway.”
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