RAIB Investigation: South Devon Railway

If you get a regional train in Romania there is a good chance you’ll get an old skool toilet.

Unlike elections where the slogan is ‘vote early, vote often’ the slogan for CFR toilets ought to be ‘Go early and don’t go often’

 

Lets leave the toilet humour to one side, before we get flushed off course, now, i have several questions

how come the coach was allowed to remain in service with a known defect that potentially should have seen it red carded until the floor had been replaced,

if the door was locked out of use did anyone on board ie Guard check security of said door, whilst performing their duties , or did no one get told The WC in coach x has a serious defect and has to be kept securely locked out of use,

a simple action like the guard checking the door was in fact locked at the beginning of each trip should have ensured the public's safety .
Normally a door would be secured using a BR1 key, and BR Carriage key, this should have been done by a fitter as well as screwing a door shut, if the frame was damaged, or the locks rendered useless, then that is reason to either carry out a repair to ensure it can be locked , or to red card it, until a repair can be made.

 

Commercial pressures were allowed to overrule experienced competent Carriage fitters.

Maybe a lesson for all fitters when being pressured to let something not right run?

“Oh, if you are overruling me please can you put it in writing so that I can ask ORR for advice”.

 

Toilet doors do not have BR 1 locks as far as I know.

 

Over the years I have had to make a stand a couple of times, I have even had them bring in a consultant who totally agreed with me.

 

Good for you. Having had similar experiences in my normal job, I can appreciate that doing so can take some guts - but what spurred me on was the thought of how I'd feel if I let a dangerous situation go, and somebody ended up getting seriously hurt as a consequence.

 

Yes - and no - if you take the door handle off, then a carriage key will fit where the shaft between the inside and outside handles was (exactly the same as a traditional house door!)

It appears this whole episode could have been avoided by removing the door handle and locking the toilet off by ensuring it was closed with a carriage key. Removing the front plate of the 'Engaged ' sign and ensuring this was in in a locked position too would have been 'belt & braces' I feel these measures would have been 'managing the risk' adequately.

It is not surprising perhaps that 'the engineers must always be allowed to fail things' takes precedence here and indeed it is totally correct - an engineer must be listened to if they state something isn't safe to run and they must make that judgement regardless of whether they know that there is nothing else. However, engineers could also do to take more note (and be reminded in a timely manner by operators) of what level of serviceable stock is needed to meet operational requirements, and aim to ensure that enough serviceable stock is available. This involves planning and being clear what resources the engineers need to deliver. How often do maintenance, operations and commercial exist in 'silos', complaining about how each isn't getting what they need from the other but never perhaps making clear what this is until its lacking can be an excuse and it is too late to do anything about it?!

Steven

 

But another point was raised in the RAIB report, concerning the lack of floor. This is an extract from Page 20 of the RAIB Report 02 (2018):

"The removal of the toilet floor and the decay at the base of the partitions resulted in a loss of integrity of the structure of the toilet cubicle, because the floor was no longer tying the partition walls together. This meant the structure was no longer rigid, and the movement of the train may have resulted in the door frame and the door moving relative to each other. This movement caused the screws securing the door to become loose, fracture or fall out."
(my emphasis)

If that is the case (and I've no reason to doubt the RAIB on that point), then whatever system used to secure the door could have failed.

 

http://www.bbc.co.uk/news/uk-england-devon-44112957

The comments made about the railway make grim reading.

 

Indeed, as does the £40k fine.

 

Heavy fine for a very lucky near miss. Should serve as a warning in keeping systems upto date and procedures clear, and stock thats needs work out of service as this coach sounds like it should have been. But least taking the fault and a big money hit is better than losing the ability to operate

 

yes, learn from it, move on.

 

Plus costs...

 

I remember being quite shocked when I read about this the first time around, and quite as to what possessed someone to put a coach into service with bits of floor missing I really don't know.

 

commercial pressure, the " we need that coach do what you can to ensure it can be used" request, I'm a former C&W Fitter on another railway and Commercial will always need that extra seat, that extra coach, the question though is do you say no, or try to make that coach fit for traffic, make the wrong decision and something goes wrong, as in this case, and now its cost the railway far more than the loss of that coach,

 

So for the sake of... what? 48 seats and an optimistic max of £1500 or so in takings per possible trip the railway's now lost, what? 20 times or more of that?

Yeeeouch.

 

£13,035 !

 

Presumably not even that calculation - since presumably, the same visitors would have turned up regardless. So the difference between running the coach or not running it is not about an extra £1500 in revenue or not, but to what degree everyone gets a seat or not. Whether that coach ran or not on that particular day will have had essentially zero revenue impact. Long term, overcrowding is probably not great in terms of reviews people will leave on social media sites and the impression they give their friends, but short term, over crowding would have to be preferable to what happened.

Tom

 

Do we even know what rough train loadings would've been about that time? They run five coach sets down there, don't they? Would a single less coach have made such a huge impact?