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The driver of a train fell asleep in the control room at London Bridge station before it crashed into a buffer, an investigation has revealed.
The low-speed incident occurred at 3.45 pm on December 13 last year.
The Rail Accident Investigation Branch (RAIB) found that the Southern Railway driver experienced “light drowsiness due to fatigue”.
The unnamed driver slept less than usual due to caring for children and frequently worked rest days, increasing his risk of fatigue.
The train was traveling at just 2.3 miles per hour when it hit the buffers as it approached platform 12.
Minor damage was caused to trains and railway infrastructure, but no injuries were reported.
Analysis of the onboard data recorder shows that the train was traveling at 13.3 mph when it entered the platform and gradually decreased its speed.
The driver applied the emergency brakes when the train was three and a half meters away from the buffers, but it was too late to prevent a collision.
He was usually in bed by 9am before going to work in the afternoon, the RAIB said, but due to an “unexpected change in childcare arrangements at home” he had to get up at 7.30am on the morning of the accident.
Investigators reported that the driver recalled that when the train stopped at Crystal Palace station 26 minutes before the incident, he “began to feel distressed” and recognized “the need to concentrate and remain alert”.
The report said: “Although aware that they were feeling fatigued, the driver felt able to continue the journey.”
He was scheduled to have 12 days of rest in the 22 days before the accident, but he worked nine of these.
Many train operators rely on volunteer drivers for additional paid shifts to run timetabled services.
The investigation also found that none of the safety mechanisms fitted to the train prevented it from hitting the buffers, as it was traveling below the minimum speed at which they intervened.
The report found that other safety systems could not detect “the driver’s reduction in alertness”.
The RAIB recommended that Southern Railway’s parent company Govia Thameslink Railway (GTR) improve its fatigue management process.
Samantha Facey, GTR’s Director of Safety, Health and Security, said: “Safety is always our number one priority and we are determined to learn from every incident to improve our safety standard for our people and customers.
“We are committed to ensuring that our employees remain fit and alert when they are at work.
“In August, we updated and improved our fatigue risk management standard, which includes employee reports of fatigue, to help manage fatigue more effectively.
“We have also established strong working groups with staff representatives, and we are now using robust scientific modeling to plan staff shifts so we can detect and prevent fatigue before it becomes a risk.
“This is all part of our ongoing efforts to meet the recommendations in the RAIB report and keep our passengers and staff safe.”