South Devon Rly: floorless toilet

[BestWestern]

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.

Indeed, some HST trailers still fitted with ancient door handle/lock units have no facility to secure from outside, so that sounds plausible. I don't feel it likely that a carriage key or BR1 key lock would be prone to 'vibrating unlocked' on a train travelling at 20mph all day.

 

[Waldgrun]

When I used to deal with 4 Vep and 4 Cig units, quite often we would find a toilet "locked out" by a Guard, because of a fault more often in the Gig stock than the Vep (Cig's used air pressure to pump the water up from underfloor tanks, Vep's direct drop from roof tank). To "Lock out" the toilet the outer door knob was removed, the bar between the two knobs removed. Then placed on the towel rack, and the door then closed. Then a label was fixed to the door, which could only be opened with a carriage key. So I will be interested to see what happen. There is likely to be more than one person at fault and when you are dealing with the public you have got to go beyond idiot proof!
It would seem that something on the lines I described was done, see http://www.steamrailway.co.uk/steam...ngerous-occurrence-on-the-south-devon-railway

 

[Adlington]

From the updated RAIB page about this incident:

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.

 

[shredder1]

At least in Turkey its only a hole in the floor.

 

[Adlington]

At least there is a floor.

 

[BestWestern]

From the updated RAIB page about this incident:

Interesting...

On a lighter note, I can't help but be amused that the flawless toilet still had a bog roll provided! In case of extreme desperation presumably

 

[Adlington]

On a lighter note

I can't help but be amused that the flawless toilet still had a bog roll provided

That's only to be expected in a flawless toilet.
OTOH I expect your auto-correcting spell checker, unlike the toilet, isn't flawless.

 

[BestWestern]

On a lighter noteThat's only to be expected in a flawless toilet.
OTOH I expect your auto-correcting spell checker, unlike the toilet, isn't flawless.

Well, it was almost flawless... Just the one minor issue

 

[generalvegitable]

On the plus side, it must have been about the only train toilet in the country to have enough paper in it ...

 

[tsr]

See, if the toilet had enough blue roll, instead of toilet paper, it would have been fine.

Blue roll fixes anything.

 

[CC 72100]

See, if the toilet had enough blue roll, instead of toilet paper, it would have been fine.

Blue roll fixes anything.

They also did not use Black and Yellow tape, what rookies!

 

[BestWestern]

They also did not use Black and Yellow tape, what rookies!

It's about six quid a roll, I'm not surprised!

 

[Waldgrun]

They also did not use Black and Yellow tape, what rookies!

I take it you mean Hazard Tape, well that doesn't stop all, I can tell you! I once had to close a station exit, because the local yobs had managed to jam shut an iron gate, which had spikes on the top! So I couldn't not permit the use of that exit, but I had one complete prat, push his cycle through the tape, and ignored the notices I had placed out and my verbal warnings,he didn't find it much fun having to get himself over the gate and his bike!

 

[43096]

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.

Disagree as a) it is a requirement to report such an incident and b) they allowed a vehicle into service that should never have been in traffic, regardless of the toilet being locked out of use.

There was also a potential fire risk here with a spark from a brake block or from the kettle hauling it igniting paper in the toilet (toilet roll clearly visible in the photo for starters).

 

[2HAP]

RAIB Report published. Inadequate Safety Management System, inadequate fitness to run proceedure, fix and patch culture.

https://www.gov.uk/government/uploa...677419/180130_R022018_South_Devon_Railway.pdf

The RAIB observed during the investigation that the South Devon Railway’s maintenance regime did not identify the extent of the deteriorating condition of the carriage structure, and the railway’s fitness to run process was not being correctly applied.

The RAIB believes that the investigation has also identified an important lesson likely to be applicable to other heritage railways, about applying appropriate standards for vehicle maintenance, to ensure that the examination regime which they have in place will identify the foreseeable deterioration of vehicles, before it reaches a stage that may affect safety.

 

[Cowley]

Having read the report now I only hope that all railways have a good look at this and learn from it.
It really does make you shudder the more you think about it, feels a bit like the railway preservation movement lost one of its nine lives with this one.

 

[YorkshireBear]

Having read the report now I only hope that all railways have a good look at this and learn from it.
It really does make you shudder the more you think about it, feels a bit like the railway preservation movement lost one of its nine lives with this one.

Indeed this incident could have easily been the end for some heritage railways with the public perception then reducing revenue significantly.

 

[Shenandoah]

Given the severity of this occurrence - a child put into great danger - and given the publicity (BBC etc) I hope other heritage type railways have since made thorough inspections of their rolling stock.
One of the principal issues for heritage and tourist railways is that the focus is always on the motive power rather than rolling stock, which always seems to play second fiddle.

 

[mushroomchow]

The quality of heritage rolling stock is very hit and miss, which is to be expected with limited resources, but this incident was certainly taking it to the extreme - the carriage should never have been in service. I'm not in the slightest bit convinced that its use was a necessity of a stretched coaching fleet either - the SDR has neither a rolling stock shortage or visitor numbers that would result in standing passengers if the coach was taken off the rake.

Thank goodness nobody was hurt.

Sometimes, for us enthusiasts in particular, the laid-back approach to operations on more bucolic lines is what makes them special - I certainly enjoyed my recent trip to Cottesmore, wandering around and admiring the rolling stock while the Sentinel shunted wagons at relatively close quarters, which along with the opportunity for any visitor to walk up and drive the loco under instruction for a mere tenner is something that you'd never get on a "big railway". I hope this is seen for what it is - an isolated incident and an example of issues with rolling stock maintenance and a fleet rostering failure - rather than a green-light for stifling changes to the fundamental operation of lines under the guise of Health & Safety.

 

[AngusH]

It seems, if anything, more serious than originally reported

The child entered the toilet, and as the door opened and the child stepped through it, he fell forward because the floor was missing in the compartment he had entered. A more serious accident was only prevented by the quick reaction of the mother who grabbed the child’s arm and prevented him falling through the opening and onto the track below.

(from RAIB report)

My reading is that it seems the child actually started to fall and was caught, rather than simply held back from entering.

(additional)

The mother stated that the child fell forward towards the track, breaking his fall on the brake pipe.

(additional 2)

61 Had the mother not grabbed her child as he fell, he is likely to have been seriously injured and possibly killed.

 

[Adlington]

BBC has a story on the accident, following the publication of the RAIB report.
Interesting snippets:

[T]he carriage remained in service until June, when the boy was saved by his mother who grabbed him before he fell on to the track. Train operator South Devon Railway (SDR) declined to comment.
[...]
An SDR spokesman said that it would not be commenting until a separate investigation by the Office of Rail and Road had finished.

 

[notverydeep]

BBC has a story on the accident, following the publication of the RAIB report.
Interesting snippets:

Given the contents of the RAIB report and the ongoing ORR investigation, it would seem at least reasonably likely that there will be some form of prosecution of the SDR or its staff for the apparent breaches of Health and Safety law.

 

[BestWestern]

The unwillingness of the SDR to offer any sort of comment is unfortunate, and gives the appearance of them being both unprofessional and rather petulant.

 

[Shenandoah]

The unwillingness of the SDR to offer any sort of comment is unfortunate, and gives the appearance of them being both unprofessional and rather petulant.

Possibly the lawyers have advised against comments, given how media often report what they think they heard rather than what was actually said.
However the publicity given to this occurrence cannot be doing the railway any favours.

 

[Darandio]

Possibly the lawyers have advised against comments, given how media often report what they think they heard rather than what was actually said.

The media don't have to hear or misreport anything, the SDR simply releases a statement for copy/paste, no mistakes need to be possible then.

But they didn't, and that is rather poor form.

 

[JN114]

The unwillingness of the SDR to offer any sort of comment is unfortunate, and gives the appearance of them being both unprofessional and rather petulant.

Didn’t the SDR state they would not be commenting while the separate ORR investigation is still ongoing? That’s fairly standard in all industries while a formal investigation is still ongoing.

 

[njamescouk]

the raib note, in bold, that their recommendation may apply to other heritage railways.

 

[BestWestern]

Didn’t the SDR state they would not be commenting while the separate ORR investigation is still ongoing? That’s fairly standard in all industries while a formal investigation is still ongoing.

They did, however given what happened and that the RAIB are reporting there were significant failings beyond just the incident itself, some sort of response to demonstrate acknowledgement and offer some degree of reassurance would have been a sensible move.

 

[Chris M]

Perhaps they did say something like "we acknowledge the RAIB's findings but will not be commenting further until the ORR investigation, which is still ongoing, is completed." but this got trimmed by a journalist to just the "not commenting at the moment" part?

edit: It seems they actually did more than that, the first item on the "News" section of their website is South Devon Railway responds to RAIB Incident Report:

Following publication of the Rail Accident Investigation Branch (RAIB) report today (Tuesday 30 January) into an incident on the South Devon Railway (SDR) on 22 June 2017 involving a young boy, his mother and a missing floor in a closed train toilet cubicle, the South Devon Railway Trust, a registered charity, has responded to the RAIB’s findings and recommendations.

An SDR spokesman said:

“The South Devon Railway accepts that safety on a moving train was badly compromised on this isolated occasion and which could have resulted in serious injury to a female passenger and her young son.

“We regret that this incident took place and apologised at the time, and do so again now, to the lady and the family involved for the trauma which they suffered.

“As we have stated from the outset, something clearly went wrong as evidenced by the incident having taken place – it simply should not have happened.

“Since then, we have been working closely with the RAIB and the Office of Rail & Road (ORR) in their investigation.

“As a result, the South Devon Railway has fully satisfied the requirements of the ORR’s Improvement Notice.

“We have certainly learned lessons from this regrettable incident, and acted quickly to make the necessary improvements required by both the RAIB and ORR.

In view of the ongoing ORR investigation you will no doubt appreciate that it would not be appropriate for the South Devon Railway Trust to comment further at this time.”

Statement ends

 

[gazthomas]

This is a really shocking incident and a reminder to other railways that they can’t be complacent and must have robust management systems in place