South Devon Railway Incident 22 June 2017

[whole diary]

[SandTEngineer]

Crikey, this could have turned out to be quite serious: https://www.gov.uk/government/news/dangerous-occurrence-on-the-south-devon-railway

[ChrisB]

And it took them three days to report it. Heads will roll, I suspect.

[alexross42]

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!

[Adelante_CCT]

I agree, regardless of how well the door was 'locked', the carriage should never have returned to service.

[Tim]

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

[Fourbee]

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).

[broadgage]

IMHO^▸ (in my humble opinion), 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.

[stuving]

I never realised "retention toilet" referred to retaining passengers...

[SandTEngineer]

Bit more on the incident here: http://www.steamrailway.co.uk/steamnews/2017/7/11/raib-investigating-dangerous-occurrence-on-the-south-devon-railway

[onthecushions]

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

[JayMac]

I can see no excuse for the carriage being in service, no matter how secure the door was locked.

[Electric train]

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^▸ (Rail Accident Investigation Branch) and ORR^» (Office of Rail and Road formerly Office of Rail Regulation - about) will issue some guidance to heritage railways 

[Chris from Nailsea]

From the Rail Accident Investigation Branch (RAIB^▸ (Rail Accident Investigation Branch)) website:

Dangerous occurrence on the South Devon Railway

Investigation into a dangerous occurrence on the South Devon Railway, 22 June 2017.


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 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.

[SandTEngineer]

The RAIB^▸ (Rail Accident Investigation Branch) 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

[trainer]

Reading this report gave me pause for thought about some of the smaller heritage railway's ability to deal with H&S^▸ (Health and Safety) 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.