A train driver is believed to have been urinating or having a cigarette when he was struck and killed by a passing train.

Michal Olesiak was instantly killed when he was hit by a passenger train travelling at 33mph on February 1, 2022, at West Worthing Station.

It is believed Mr Olesiak may have been out of his cabin to use the toilet or smoke a cigarette, a report from the Rail Accident Investigation Branch (RAIB) said.

Due to it being dark, train crew in the moving train were “initially unaware” that they had hit a person, the report said.

But, when the stationary train in the middle siding did not leave at its scheduled departure time, the signaller attempted to contact Mr Olesiak.

When the signaller could not get a response, he instructed the next train on an adjacent line to stop alongside the stationary train and to contact Mr Olesiak.

The driver of this third train found Mr Olesiak.

RAIB said he had "suffered injuries that were immediately fatal".

RAIB determined that, before leaving the stationary train in the middle siding, Mr Olesiak did not tell the train’s guard or the signaller that he intended to do so.

He also did not request that trains on the adjacent lines be stopped.

RAIB said it had not been able to establish why he left the cab of his train.

However, in considering only those factors relating to railway safety, RAIB concluded that he was unlikely to have accidentally fallen out of the cab or left it intentionally for a work- related reason and that he "most probably" exited the train for a personal reason.

RAIB said this may have been to urinate or to smoke a cigarette, possibly in the belief that it was safe for him to be outside of his train.

The report said Mr Olesiak then entered the path of the approaching train.

“He may have done this inadvertently after a loss of balance or while trying to regain his feet following a fall from the cab access steps or a loss of footing on ballast,” it said.

“He may also have slipped or tripped on a wooden board that had been left detached on the track for many years.”

RAIB has now made three recommendations to try and prevent a similar tragedy.

The first recommendation, made to Govia Thameslink Railway, requires that on-train staff have adequate access to toilets across all of their routes.

The second recommendation is made to the Department for Transport, in conjunction with the Rail Safety and Standards Board, and relates to reviewing standards to ensure the mandatory fitment of forward-facing CCTV equipment to new trains.

The third recommendation is made to the Rail Safety and Standards Board, in conjunction with operators of trains, and encourages consideration of fitment of forward-facing CCTV equipment to existing trains.

RAIB has also identified four learning points.

The first reminds traincrew to arrange appropriate protection before leaving their cabs.

The second highlights the importance of wearing suitable personal protective equipment.

The third learning point prompts infrastructure managers to take timely action to remove tripping hazards.

The final learning point reminds employers of train drivers to assure themselves that the correct protective equipment is being worn by their staff.

A spokesman for Govia said it has implemented improvements following the incident, including publishing more detailed information on where toilets are at stations in drivers’ route packs and improved station signposting to help if they need to make an unscheduled stop.

They said drivers have breaks built into their schedules but can also stop their service to use the toilet at a station if ever needed, and there are “no repercussions” for a driver who needs a break.

“Safety and welfare will always come first.,” they said.

Angie Doll, chief operating officer for GTR, said: “A year on from such a devastating event at West Worthing, I continue to offer my heartfelt condolences to Michal’s family, friends and colleagues.

“We have worked with both the Rail Accident Investigation Branch and Office for Road and Rail to fully support their investigations into this tragic incident.”