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A rail accident investigation into the death of a Gwynedd pensioner at a crossing in 2009 says miniature warning lights could reduce the risk of a future accident.
The car being driven by Sally Hudson, 83, was hit by a train close to her Penrhyndeudraeth home.
Following the accident, the risk level to crossing users at the site has been increased.
Network Rail says it will now review the findings of the report.
The Rail Accident Investigation Branch (RAIB) launched its review of safety at the level crossing in the days following the death of Mrs Hudson.
She died when her Fiat Punto car was struck and shunted down the track by a 105-tonne single locomotive, which was being used to familiarise train drivers on the Cambrian Coast Line.
A later inquest heard that there was a telephone stationed at the crossing, which was supposed to be used before anyone ventured onto the line.
However, the RAIB investigation found that the phone had not been used since August 17 that year, and had not been used by Mrs Hudson on the day she died.
An inquest into her death found that she may have been "too familiar" with using the crossing for almost every day for 40 years.
The RAIB report echoed this, adding: "It therefore appears that Mrs Hudson decided to cross the line on the basis of visual sighting alone, perhaps supported by her prior knowledge of the train timetable, which may have led her to believe there would not be another train approaching until about 1210.
"It is unlikely that she would have been aware of the driver route familiarisation runs by single locomotives."
The report said that because of the layout of the rail line and signalling operators, anyone using the telephone line to discover if it was safe to cross could be told to wait up to 20 minutes.
The investigators warned that this could "encourage the user to cross without using the telephone", as happened in Mrs Hudson's case.
Another option to reduce dangers at the crossing could be the use of miniature warning stop lights (MWLs), said the report.
It stated: "While there are costs and some disadvantages of MWLs compared to telephones at a crossing such as Penrhyndeudraeth, the advantages from the users point of view are:
- They provide a visual warning to a crossing user of an approaching train;
- They make it unnecessary for a crossing user to make a telephone call to the signaller; and
- Because the red light is triggered by the train itself, the period during which a user is warned against using the crossing is relatively short.
"For these reasons, it might be expected that the provision of MWLs would reduce the risk at Penrhyndeudraeth user worked crossing."
However, Network Rail rejected putting the warning system in place following the crash after running a risk assessment based on a generic computer model.
But the RAIB said the result of that assessment was "counter-intuitive and apparently incorrect".
It added: "Network Rail's post-accident assessment did not take into account the circumstances of the accident on 2 September 2009, nor did it take into account the other factors at the crossing which might have increased the risk above the average for all such crossings."
Responding to the report, a spokesperson for Network Rail said: "Our thoughts remain with the family and friends of Mrs Sally Hudson. We have been working very closely with the police and RAIB since the tragic incident to support their investigation and have also taken extra steps, including improving signs at the crossing. We welcome the report from RAIB today and will review the recommendations put forward."