Byrne was a member of a four-person group of track workers, undertaking inspections at the location while trains were running in both directions.

There was no protection and an inadequate warning system in place, which exposed all members of the working party to the risk of being struck by a train in the course of their work.

ORR’s investigation identified failings with the planning, monitoring and supervision to ensure the workers were adequately protected while carrying out their maintenance activities on the track.

The regulator had previously served Network Rail two Improvement Notices in July 2019, requiring it to implement, preventive and protective measures necessary to safeguard workers on or near the line.

One of the notices concerned planning, and the other concerned the use of technology.

While Network Rail had made some improvements to track worker safety arrangements at the time of Byrne’s accident, its implementation across the organisation lacked urgency and pace, said the ORR.

In recent years and subsequent to the incident, there has been a vast reduction in red-zone working, when lines remain live during track work, while new technologies have been introduced to reduce the risk of harm.