Safety failures were partly responsible for the death of a train driver at a rail depot, a report has found.
The man, who has not been named, died after he became trapped between two trains at Tyseley maintenance depot in Birmingham on 14 December.
The Rail Accident Investigation Branch (RAIB) said West Midlands Trains, which runs the depot did not properly consider the risks faced by drivers.
The operator said it would be studying the findings thoroughly.
West Midlands Trains said the death was a "terrible tragedy" and that it was vital it and the wider industry "learns from this awful episode".
The RAIB investigation found the driver, was walking between two trains when one of them was moved by another driver, trapping him and causing fatal injuries.
It also found the man, who had been working on the railways for 34 years, had not used one of the depot's safe walking routes and the other driver did not sound a warning before moving the train because "local instructions did not require this".
Although the driver had failed to seek permission to move the vehicle, as required, it said this probably would have been granted.
Risks at depots
The report said the driver of the train only became aware of his colleague being trapped when his train failed to couple with the other vehicle.
West Midlands Trains was urged to carry out "effective assessments" of the risks at depots and to review working practices.
Simon French, Chief Inspector of Rail Accidents said: "When I started on the railway in 1982 one of the first things that was drummed into me was to take care around vehicles, and to only go under or between vehicles when you were quite sure they were not going to move.
"That is as true now as it was then."
However, he said West Midlands Trains had also failed to "understand or sufficiently manage the risks".