|
Title: South Devon Railway Incident 22 June 2017 Post by: SandTEngineer on July 10, 2017, 10:17:25 Crikey, this could have turned out to be quite serious: https://www.gov.uk/government/news/dangerous-occurrence-on-the-south-devon-railway
Title: Re: South Devon Railway Incident 22 June 2017 Post by: ChrisB on July 10, 2017, 10:26:27 And it took them three days to report it. Heads will roll, I suspect.
Title: Re: South Devon Railway Incident 22 June 2017 Post by: alexross42 on July 10, 2017, 12:14:16 Unbelievable and I'm surprised that the SDR would even allow a carriage back into service in such a state as that, even with a supposedly lockable door is it worth the risk?
Thank goodness for the quick reactions of the Mother! Title: Re: South Devon Railway Incident 22 June 2017 Post by: Adelante_CCT on July 10, 2017, 12:41:22 I agree, regardless of how well the door was 'locked', the carriage should never have returned to service.
Title: Re: South Devon Railway Incident 22 June 2017 Post by: Tim on July 10, 2017, 14:45:08 scary stuff. I am sometimes apprehensive as to what state I will find the floor of a train toilet, But I always expect there to be a floor
Title: Re: South Devon Railway Incident 22 June 2017 Post by: Fourbee on July 10, 2017, 16:21:06 On a turbo it's more likely to be water than anything unpleasant. The water is ejected from the basin tap so feebly some of it trickles across the surface and onto the floor (that's in the non-accessible toilet).
Title: Re: South Devon Railway Incident 22 June 2017 Post by: broadgage on July 10, 2017, 20:05:30 IMHO, it might have been acceptable for the carriage to enter service with the toilet floor still missing, PROVIDED THAT the door was reliably and securely locked. I not would not consider the normal lock, operable by a carriage key, to be adequate for this purpose. However a reasonable quality padlock or a household type door lock should be acceptable.
Whilst we do not yet know how the door came to be unlocked/openable by a passenger, I have a strong suspicion that it may have been locked by a carriage key and subsequently vibrated open. I am aware of two somewhat similar incidents, one on the national network and one on a different heritage line. Neither had any serious consequences, but the potential was clearly present. Title: Re: South Devon Railway Incident 22 June 2017 Post by: stuving on July 10, 2017, 20:10:29 I never realised "retention toilet" referred to retaining passengers...
Title: Re: South Devon Railway Incident 22 June 2017 Post by: SandTEngineer on July 12, 2017, 22:06:03 Bit more on the incident here: http://www.steamrailway.co.uk/steamnews/2017/7/11/raib-investigating-dangerous-occurrence-on-the-south-devon-railway
Title: Re: South Devon Railway Incident 22 June 2017 Post by: onthecushions on July 12, 2017, 22:35:20 Without commenting on the matter, Mark 1 doors are secured either with a T-key (square drive) or with a BR1B conventional key (such as the toilets). The problem is that the doors are of wood and so are dimensionally unstable with humidity changes, making them hard to open/close at times and also causing the lock tongue to be misaligned. The pictures do appear to show notices taped to the doorway but at high level not toddler level, where a parent's eye would be. I do think that heritage railways pay too much attention to steam locos (boys' toys) and too little to their customers' travel experience in the coaches. Relieved that no harm was done. OTC Title: Re: South Devon Railway Incident 22 June 2017 Post by: JayMac on July 12, 2017, 22:47:33 I can see no excuse for the carriage being in service, no matter how secure the door was locked.
Title: Re: South Devon Railway Incident 22 June 2017 Post by: Electric train on July 13, 2017, 17:28:50 I do think that heritage railways pay too much attention to steam locos (boys' toys) and too little to their customers' travel experience in the coaches. Not true of all, the GWSR do sterling work rebuilding 50 plus year old Mk1. The question should be asked why remove the floor to fix the brakes? Mk 1 all the brake rigging is accessible via a pit underneath the coach or by jacking it up. I sure the RAIB and ORR will issue some guidance to heritage railways Title: Re: South Devon Railway Incident 22 June 2017 Post by: Chris from Nailsea on July 16, 2017, 22:45:31 From the Rail Accident Investigation Branch (https://www.gov.uk/government/news/dangerous-occurrence-on-the-south-devon-railway) (RAIB) website:
Quote Dangerous occurrence on the South Devon Railway Investigation into a dangerous occurrence on the South Devon Railway, 22 June 2017. (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/image_data/file/64831/s300_South_Devon_Railway.jpg) The missing floor (courtesy of South Devon Railway) As the 13:00 hrs train from Totnes Riverside to Buckfastleigh was running between Staverton and Buckfastleigh, at around 20 mph (32 km/h), a passenger and her small child attempted to enter a lavatory compartment in the fourth carriage. On opening the door, they found that the floor of the compartment was missing, exposing the carriage wheels below. The mother was able to catch hold of the child and prevent him from falling. The child reportedly suffered minor bruising and both were shocked. The passenger reported the incident to the guard of the train, and the railway took action to secure the lavatory door. The incident was reported to the RAIB on 25 June. The carriage, an ex-British Railways Mark 1 Open Second, had been put back into service after repairs to its braking system, which had required the dismantling of the lavatory floor. The floor had not been replaced and staff had placed a notice on the compartment door and attempted to secure it to prevent it being opened. This had not been effective. Our investigation will examine: * the events leading up to the incident, including the repairs to the carriage and the actions taken to return it to service * the adequacy and suitability of the measures to secure the door * the railway’s safety management system, including the arrangements for managing the competence and fitness of the staff of the carriage and wagon department, and the systems in place for assuring the safety of rolling stock in service. We would like to speak in confidence (https://forms.dft.gov.uk/raib-incident-reporting/) to any passengers who may have been aware that the toilet door was insecure before the incident on 22nd June, or in the days prior to the incident occurring. Our investigation is independent of any investigation by the railway industry or by the industry’s safety regulator, the Office of Rail and Road. We will publish our findings, including any recommendations to improve safety, at the conclusion of our investigation. This report will be available on our website. The above quote is from the RAIB website, and includes their updated request (which I have highlighted in yellow) for any potential witnesses to come forward. Title: Re: South Devon Railway Incident 22 June 2017 Post by: SandTEngineer on January 30, 2018, 10:37:21 The RAIB report has now been published and looks quite serious for the SDR (and other similar preserved railways).
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/677419/180130_R022018_South_Devon_Railway.pdf Title: Re: South Devon Railway Incident 22 June 2017 Post by: trainer on January 30, 2018, 14:29:31 Reading this report gave me pause for thought about some of the smaller heritage railway's ability to deal with H&S issues within limited resources. It is good to see the SDR acted and is now showing that it is competently carrying out its duty to the public, its own volunteers and staff. There is a limited number of competent volunteers for all the heritage engineering (not just railways) in the country where the public have access and this report notes the self-confidence of some engineers to know when something is safe without needing to refer to outside standards or signing off work. Indeed, responsibility was actively avoided by not signing legal documents (p27, para 75).
This combined with the major management failures does indeed point up the need for a safety culture as good as that found on the main line. A question I have is: how thin can competencies be spread across the heritage industry before it becomes so amateurish as to be dangerous? The positive thing is that there is more good than bad practice, but it was only by chance that we are not reading about a death. Title: Re: South Devon Railway Incident 22 June 2017 Post by: grahame on May 14, 2018, 20:10:48 From The ORR (Office of Rail and Road) (http://orr.gov.uk/news-and-media/press-releases/2018/south-devon-railway-fined-after-boy-falls-through-missing-toilet-floor)
Quote 14 May 2018 .South Devon Railway Trust has today been fined £40,000 by Newton Abbot Magistrates' Court after they admitted putting passengers at risk by failing to adequately bar entry to a toilet cubicle which was missing its floor. The court heard that Anna Patch’s three year-old son narrowly escaped serious injury when he fell through the missing floor and had to be snatched to safety by his mother with his feet within inches of the rotating wheel below. The pair had been enjoying a ride on the heritage steam railway, which was making return trips between Buckfastleigh and Totnes in Devon on 22 June 2017 when the incident occurred. The Office of Rail and Road (ORR) investigation discovered that the entire toilet cubicle floor had been missing since 2 April and that an ‘out of use’ sign had been pinned to the door and an attempt made to secure the door with two screws when the carriage was put back into service sometime around 14 April. However, there were no ongoing checks to ensure that the door remained secure and staff working on the train were not informed of the missing floor. The carriage required structural repair and the ORR argued that it only remained in service once this issue was discovered because the busy Easter period was nearing when the company would normally run nine round trips a day. ORR, which brought the prosecution under Section 3(1) of the Health and Safety at Work 1974, found that at some point between 5 April and 22 June, the screws broke along with the door post meaning that the door could easily be opened. It also found that the company, which continued using the carriage for three days after the incident, had an inadequate Safety Management System in place which was approximately 10 years out of date and not fit for purpose Title: Re: South Devon Railway Incident 22 June 2017 Post by: JayMac on May 14, 2018, 21:29:33 A significant sum for a heritage railway, but I think they have got off relatively lightly.
Title: Re: South Devon Railway Incident 22 June 2017 Post by: SandTEngineer on May 14, 2018, 23:21:46 A significant sum for a heritage railway, but I think they have got off relatively lightly. Won't do their reputation any good though......thats worth a lot more than money. This page is printed from the "Coffee Shop" forum at http://gwr.passenger.chat which is provided by a customer of Great Western Railway. Views expressed are those of the individual posters concerned. Visit www.gwr.com for the official Great Western Railway website. Please contact the administrators of this site if you feel that content provided contravenes our posting rules ( see http://railcustomer.info/1761 ). The forum is hosted by Well House Consultants - http://www.wellho.net |