My first reaction on reading the report is that, as with the recent near miss with track workers at Bookham that was the subject of the last RAIB report (discussion
here), there has been an absolutely huge amount of Swiss cheese aligning here to create this dreadful incident.
The report seems to be unusually explicit that the error of the driver of 1J25 in not operating the emergency sander was a factor in the incident, but equally they do, in a more typical and subtle RAIB way, hint that the driver was set up to fail to an extent.
I think it's telling that the RAIB were explicit about the sander, but somewhat glossed over the fact that 1J25 was being controlled in a way typical of a train passing along the main line rather than through the loop, because of the confusing way in which speed limits were presented on the ERTMS, and the driving style which had been adopted on the line. Compare, for instance, the tone of paragraph 239 of the report, and the tone of paragraph 204. In particular, I found it surprising that drivers reported getting interventions from the system at least once a week (paragraph 368). That suggests to me that this was an accident waiting to happen. Also, if that kind of culture existed on the line with regard to driving style, with a huge amount of trust placed on the ERTMS system, I can completely understand how the unfortunate driver of 1J25 forgot about a manual system which they never had cause to use and didn't seem to have been adequately trained on anyway, particularly given they had no reason to believe that the automatic system wasn't working. I suppose, though, that there is no obvious solution to the fact that the Cambrian is worked entirely by drivers who only sign about three minutes'-worth of conventionally-signalled track, given the length of the line. But it can't have helped matters that the Cambrian is so thoroughly separate to any other railway environment.
I am slightly disappointed that the RAIB gave mention to seatbelts in paragraph 329 without explicitly saying that if the poor driver of 1S71 had been wearing a seatbelt (as was mooted after Carmont) the consequences may well have been even worse for them given the state of their cab.
A final word on the severity of the collision; given the excellent safety record of railways in the UK I think it's a stark reminder that a 30mph head-on collision carries a huge amount of energy, and thankfully we haven't had such an incident in years. Hopefully, the various small lessons learned from this incident, which combined in such a terrible way, won't need to be learnt in blood again.
RAIB report references:
Para 239
Para 204
Para 368
Para 329