I commend to anyone interested in safety on the railway the
RAIB▸ Report into the fatality at Stoats Nest Junction on the Brighton line.
https://assets.publishing.service.gov.uk/media/5d261143e5274a592254abbf/R072019_190711_Stoats_Nest_Junction.pdfThe causal factors include safety management processes, workplace culture and the personal circumstances of those involved.
The Report, as you would expect from the RAIB, is detailed and thorough and takes a while to assimilate. I had to read it several times to understand the full picture. It is thought provoking and left me at least feeling a bit sad.