A train crash that killed a passenger could have been avoided if the driver had used an emergency brake system, an investigation has found.The driver said it had 'not occurred' to them to use the train's manual sander before the two trains collided head-on on the Cambrian line in mid Wales, in October 2024.Passenger David Tudor-Evans, 66, died 'as a consequence of the collision', the Rail Accident Investigation Branch (RAIB) said.Four other people were seriously hurt in what was Britain's first fatal crash involving multiple trains in more than a quarter of a century. If the sander had been activated, it would have released sand onto the tracks directly in front of the wheels and slowed the train.The accident happened on a rural section of the Cambrian line near Talerddig in Powys.The line is mostly single-track, but with loops to allow trains travelling in opposite directions to pass each other.Despite braking, a westbound Transport for Wales (TfW) train failed to stop as intended inside a loop and rejoined the single line too soon, crashing into an oncoming train run by the same operator. Two train crashed on a rural section of the Cambrian line in mid Wales in October 2024 David Tudor-Evans, 66, died 'as a consequence of the collision', a report has foundThe RAIB said this happened because the westbound train's wheels were sliding, which can be a particular issue in autumn when fallen leaves make tracks slippery.The class 158 trains involved in the crash have two systems – one automatic and one manual – to dispense sand between wheels and rails when extra grip is needed.It was revealed in an interim report in April last year that the westbound train's automatic system did not work in the moments before the crash. Several failures were to blame for this, including blocked hoses, electrical faults and incorrectly installed plates measuring the flow rate of sand.In its full report published on Thursday, the RAIB said the driver did not deploy the emergency sanding system, done by pressing a yellow plunger in the cab.The manual system was fully working when tested after the crash.Investigators calculated that the train would have stopped within the loop as planned if the manual sander had been used when the emergency brake was activated.The RAIB said a rule book for TfW drivers says they should deploy the emergency sander 'when a train is unable to stop in the usual distance', and its use may avoid a collision. Two trains collided head-on after one failed to stop on a loop of track and re-entered the singly track too earlyBut the driver – who was not identified in the report – did not recall 'any training' on the system and had not previously used it, according to the report.The driver said it 'had not occurred to them to use it on the night of the accident', the report said, which may be because they thought the train would slow down without further intervention.An RAIB survey of other TfW drivers after the accident 'revealed a lack of clarity' about the circumstances requiring the system to be used, investigators said.The westbound train travelled around 0.7 miles beyond its intended stopping position before the collision.It was moving at 24mph when the crash happened, while the other train was going at 6mph.Mr Tudor Evans was a passenger on the westbound train that re-entered the track in error.Three other people on the train – including the guard – were seriously injured, and at least 18 suffered minor injuries.Damage to the cab of the eastbound train trapped the driver, who was also seriously injured.The other five people on board that train reported minor injuries.The report made nine recommendations aimed at minimising the chance of a similar event happening in future.They include urging TfW to review how drivers are trained.Andrew Hall, the RAIB's chief inspector of rail accidents, described the Talerddig crash as 'a tragedy'.He said: 'Widely varying levels of grip between steel wheels and steel rails is an inherent issue for railways and a lot of effort goes into managing this and its possible consequences.'That can involve the way track and the surrounding area is maintained, the way trains and signalling systems are designed, and the way trains are operated and maintained.'The Talerddig investigation found factors associated with several of these areas, and related to the way different parts of the overall railway system interacted.'He added: 'I sincerely hope the lessons of this accident deliver lasting safety improvements.'Dave Calfe, general secretary at train drivers' union Aslef, said: 'Our thoughts are with the family of David Tudor Evans, who tragically lost his life that day, and with those who were injured, including our member.'We welcome the recommendations in the report and will assist their implementation to ensure incidents like this become even rarer on Wales's railway.'TfW was approached for a comment.