South Devon Rly: floorless toilet

[Adlington]

An unpleasant experience on a heritage railway:

As a train from Totnes Riverside to Buckfastleigh was running 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.

Full story (RAIB)

 

[YorkshireBear]

That is a fairly serious incident which could have very easily led to death. I hope all who work/volunteer in the sector use it as further justification that no, health and safety hasn't gone mad, this is real.

 

[DarloRich]

how on earth was that allowed to happen? A serious oversight somewhere.

 

[westcoaster]

how on earth was that allowed to happen? A serious oversight somewhere.

And some, who passed the stock fit to run/ who prepped the stock. All questions that need answering.

 

[AnthonyRail]

could it have not just fallen out during travel? wet floor from vibations?

 

[rich r]

could it have not just fallen out during travel? wet floor from vibations?

The panel wasn't replaced after maintenance. Quite why it was released back into service without making really sure (more than just a sign on the toilet door) that nobody could open that door I'm not sure.

But then, this is a heritage railway and from previous RAIB reports, it appears that lapses in procedures like this really aren't that uncommon.

We'll see what the report says when it comes out I guess.

 

[AM9]

could it have not just fallen out during travel? wet floor from vibations?

No, - as the linked report said:

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.

So it would seem that the inspection to pass the stock as fit for use either failed to check the measures that should have prevented entry to the compartment or missed whatever notice had been given completely. Either way, the toilet wasn't checked visually before return to service.

 

[gg1]

Aside from the fact it should never have been in service in that condition anyway, why was the floor panel not replaced when the work on the brakes was complete?

I can only think of two possibilities, either there wasn’t enough time to do so before the carriage was required back in service, or more worryingly it was because there was still further work required on the brakes/wheelsets.

 

[alxndr]

It's very fortunate that this didn't end much worse than it did. If that had been a lone passenger or the mother had been distracted then it could be a very different story that we're reading.

 

[syorksdeano]

Hands up. When people saw this on the news who thought it might be about a pacer?

A serious lapse has occurred here, but what action could be taken?

 

[Yew]

The BBC Suggests (http://www.bbc.co.uk/news/uk-england-devon-40555782)

Staff had previously placed a notice on the door and attempted to secure it to prevent it being opened, but those measures were not effective, the RAIB said.

I'm interested what the attempts to secure the door entailed.

 

[broadgage]

Whilst the full story is yet to emerge I have a suspicion that the toilet door had been locked with a carriage key, and that vibration did in time unlock it.

I am aware of two similar cases, one on the national network and one on a heritage line. Neither had any serious consequences fortunately.

Ideally the affected vehicle should have been taken out of use.

A risk assessment MIGHT permit of it remaining in use, subject to a more reliable means of securing the door, such as a padlock.
AND a sign that reads "DANGER NO FLOOR" rather than "out of order".
AND subject to frequent inspections by the guard to ascertain that the door remains secure.

 

[Townsend Hook]

A risk assessment MIGHT permit of it remaining in use, subject to a more reliable means of securing the door, such as a padlock.
AND a sign that reads "DANGER NO FLOOR" rather than "out of order".
AND subject to frequent inspections by the guard to ascertain that the door remains secure.

'Danger of death' would be the one to go for, but if that particular sign is going up you really have to question what that carriage is doing in public service.

 

[headshot119]

Aside from the fact it should never have been in service in that condition anyway, why was the floor panel not replaced when the work on the brakes was complete?

I can only think of two possibilities, either there wasn’t enough time to do so before the carriage was required back in service, or more worryingly it was because there was still further work required on the brakes/wheelsets.

Or it's the usual problem with maintaining trains that are 40-50+ years old and there wasn't much left to reattach the floor to.

 

[broadgage]

Without waiting for the enquiry report, we can be at reasonably certain of SOME of the facts.

Firstly the toilet floor was missing, a picture clearly shows this and there is no serious suggestion that the picture was in any way faked or out of context.

Secondly we know that a mother and child accessed the toilet readily.

Thirdly we know from a statement released by the relevant railway, that the floor was removed for maintenance work, rather than say it falling off, or breaking.

It seems clear that the train was in public service, there being no suggestion that the mother and child were anyone other than normal customers.

What we do not yet know, is why the train entered service with the toilet floor still missing and without the toilet door being RELIABLY secured shut.

As already stated, I consider it probable that the toilet door was locked by means of a carriage key and subsequently vibrated open/unlocked.
This is conjecture and supposition on my part, but IMHO reasonable conjecture.

 

[Adlington]

I consider it probable that the toilet door was locked by means of a carriage key and subsequently vibrated open/unlocked.

If vibrations caused by the train movement can unlock a door, there is something very wrong with the lock design.

 

[SpacePhoenix]

Apart from the surface that people would stand on, what else comprises the floor structure that was missing?

 

[JN114]

Credit to the SDR management for actually reporting the incident to RAIB. Very easy for these kind of incidents to be swept under the carpet.

 

[dosxuk]

Credit to the SDR management for actually reporting the incident to RAIB. Very easy for these kind of incidents to be swept under the carpet.

Not when they've left that in the depot as well...

*gets coat*

 

[Adlington]

Credit to the SDR management for actually reporting the incident to RAIB.

In this case reporting is not a good will, it's an obligation:

Types of accidents and incidents other than any occurring within the Channel Tunnel System which must be notified to the Rail Accident Investigation Branch immediately and by the quickest means available

[...]

9. An accident or incident which under slightly different conditions might have led to a death, serious injury or extensive damage to rolling stock, the infrastructure or the environment.

(my emphasis)

 

[JN114]

In this case reporting is not a good will, it's an obligation: (my emphasis)

I'm well aware of the reporting criteria; having had to do it for the big Railway.

As I implied a less professionally run railway could easily have not reported the matter; and gotten away with it - after all no harm was done. The fact that the SDR management have recognised the seriousness of the incident and made the report is to their credit.

 

[pmh_74]

Deleted.

 

[Dr_Paul]

Very easy for these kind of incidents to be swept under the carpet.

Not the happiest of phrasing in this instance, when it was the floor that was missing.

 

[atillathehunn]

Credit to the SDR management for actually reporting the incident to RAIB. Very easy for these kind of incidents to be swept under the carpet.

Yes, easy, apart from the BBC article which has been shared 6,563 times since it was published 10 hours ago.

 

[JN114]

Yes, easy, apart from the BBC article which has been shared 6,563 times since it was published 10 hours ago.

And how did the incident come to the BBCs attention?

Surely it's not a coincidence that they published the article; asked for comments and so on on the day the RAIB announced they were investigating.

 

[158747]

Probably a more reliable way to secure the toilet door would be to have removed the door handle so that it could not be opened.

 

[bnm]

The SDR reported the incident to the RAIB two days after it occurred. Following details emerging on social media.

Make of that what you will.

 

[fireftrm]

And how did the incident come to the BBCs attention?

Surely it's not a coincidence that they published the article; asked for comments and so on on the day the RAIB announced they were investigating.

The RAIB notification (press release?) is quite possibly how the BBC came to know of it? However, 3 days after was when it was reported to RAIB and it is probably a Schedule 1 incident which must be reported immediately?

 

[satisnek]

Never knew it was possible to remove the toilet floor from a Mark 1. I always thought the carriage floor was continuous panelling. You learn something new every day.

 

[The Lad]

I'm not sure if you can normally lock MK1 doors effectively from the outside without removing the handle, you wouldn't want some little imp locking people in. Some railways as fireftrm knows have installed additional locks.