A train was just two seconds away from hitting a tanker in Shropshire after a signaller used controls that circumvented safeguards, an investigation found.
The near miss at Craven Arms level crossing in July sparked a probe by the Rail Accident Investigation Branch (RAIB) to find out how it occurred.
It found that the train was able to be signalled over the crossing while the barriers to road traffic were raised.
“This was possible because the controls the signaller used to operate the crossing circumvented the engineered safeguards intended to prevent such an occurrence,” an RAIB report into the incident said.
It said the train was travelling at about 15mph and had to make an emergency stop when its driver saw the HGV, but nobody was injured and no damage was caused.
The RAIB said the signaller had used a local control unit (LCU) situated outside to operate the crossing, which can override the commands from a control panel.
The signaller told investigators they did this because they were experiencing problems with a barrier locking lever and also felt they had to rush.
They were also conscious of traffic building up on the road.
Instructions for the LCU give a signaller permission to use it only during a failure, but investigators discovered a key to access the unit was in an unlocked and unsealed glass box and had been accessed 359 times in under three years.
“Although a small number of such events could be expected due to maintenance and out-of-course operations, this number of recorded events supports witness evidence that the LCU was routinely used by signallers at this location to control the crossing for some time before this incident occurred,” the report said.
The RAIB issued a series of safety messages, including that signallers only undertake tasks that they are assessed as competent to undertake and arrangements introduced to prevent systems intended for emergency events becoming routinely used during normal operations.