A driver was allowed to continue frontline duties despite a catalogue of errors on the region's railway lines, which culminated in him crashing into a stationary train at Norwich station.
Eight passengers were taken to hospital after the low-speed collision in July, which may have been caused by the driver nodding off, an accident report revealed yesterday.
Officials from the Railway Accident Investigation Board (RAIB) urged Greater Anglia to review and improve its fatigue management and competence management after it emerged that the driver was responsible for 14 incidents during his 24-year career, including speeding, station overruns, stopping short at stations, and unscheduled stops, which was described as 'not typical of even an average driver'.
An investigation was launched after a train coming from Great Yarmouth, carrying 35 passengers, collided at 8mph with a train at Norwich station at 12.11am on July 21.
A report from the RAIB said that during the last 20 seconds of the driver's approach to the station, he 'either had a lapse in concentration or a microsleep'.
Officials from the rail operator yesterday said that they had already taken actions to improve its procedures and a spokesman said the train driver, who has not been named, was still employed with the firm, but not in a train driving role.
Investigators said that a number of factors may have been responsible to explain the driver's possible lapse in concentration, including the noise made by passengers coming back from a stag party immediately behind his cab. The RAIB added that the driver was tired through a lack of sleep, and his performance might also have been affected by the prescribed medication that he was taking.
The report said the driver was prone to lapses in concentration, and it had not been identified by Greater Anglia's competence management system.
'Opportunities to formally review the driver's operational history were missed,' the report said.
As a result of the collision, eight passengers with minor injuries were taken to hospital. Another three passengers attended hospital the following day and a further ten people were treated at the scene for cuts and bruises.
The report said the driver could not recall all of the events between passing a signal outside the station and the time of the collision. On the evening of the accident, the driver was on his second consecutive late shift and he had problems sleeping the night before because of a medical condition.
The driver had been on a development plan for most of the three years before the accident at Norwich, the report said.
Between June 2010 and July 2012, the driver had been involved in six incidents, including an overrun at Stratford station, a 'door incident' at Diss, acceptance of a wrong route at Trowse junction, speeding at London Liverpool Street station, and he stopped short and released doors at Stratford station.
The RAIB issued four recommendations to Greater Anglia and one to Network Rail following the incident.
A Greater Anglia spokesman yesterday said: 'We have studied and note the contents of the RAIB report and have already implemented the majority of the recommendations that have been made, in addition to the specific actions that we have taken since July 2013 to improve our management systems.
'From the commencement of Greater Anglia taking over the franchise just over two years ago we have ensured that the safety of our passengers and employees is at the heart of our operation and the key priority for us at all times.'
A Network Rail spokesperson added: 'Network Rail will take note of any recommendations raised in the RAIB report. These will be considered carefully and we will take action as appropriate.'
John Woods, of the Norwich and Norfolk Transport Action Group, said: 'A train coming into contact with another is not something that should be allowed to happen and we need to ensure that they tighten up procedures.'
Were you a passenger on the train and would like to have your say? Email newsdesk@archant.co.uk
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