RAIB Investigation: South Devon Railway

The must have been a serious deficiency in the safety culture. I hope that has changed from top to bottom because otherwise we shall be reading about the SDR again. They left a carriage which had nearly killed someone in service for 3 days after they had been delivered the starkest warning of all that there was a problem. The fine is significant for them I am sure, but they were lucky not to get a bigger one.

 

Simon,

This is moving away from the issue at hand a bit but the quality of platform staff varies dramatically from line to line and the size of the outfit concerned does not seem to be a factor. Railway A may have staff who are well schooled and proactive, At railway B, staff may rely on chattering through loudspeakers rather than actually dealing with visitors. Someone I know witnessed passengers being given totally inaccurate timetable information at one railway visited.

Lack of proactivity (daily checks and so forth) seems to have been a factor in the present instance.

Paul H

 

How arms length is the relationship between the SDR and SDR Engineering? Clearly there has been a serious lapse of engineering and safety management standards on the operational railway, yet SDRE has, as far as I am aware, a good reputation. Seems odd that there were clearly safety deficiencies which some seem to ascribe to small size, possible lack of contact with other railways for knowledge sharing etc. and yet on their doorstep they have a heavy engineering firm which, if nothing else, must see a fairly constant flow of engineering managers from many other railways and owning groups?

Tom

 

You would be either thick or desperate to put a coach into service with a section of floor missing. It isn't a big job to at least replace the floor panels in order to provide a safe walking surface.
How did the vehicle pass a fitness to run examination ?

Bob.

 

My impression was that the people I dealt with were keener on dressing up or painting their project than in the safe operation of the railway. When the dog first went under my first reaction was to look for the guard or platform staff. I could see no one (but as the loco was running round and the dog was under the train I wasn’t going to spend 10minutes hunting for them).

 

Hence my puzzlement about what seems a disconnect between the operational railway and the Engineering business.

Tom

 

Tom,

You've just asked the question I was going to ask - I find it difficult to reconcile one against the other.

Certainly I hope whoever felt that carriage was fit to run should not be let near a heritage railway in any operational capacity again.

Not. Good. Enough.

 

Whoever took the decision surely believed that screwing the door shut was an appropriate temporary solution; better than setting the indicator to "ENGAGED" and removing the handle. That turned out to be a mistake, but is understandable from the point of view of that individual. Where the system failed very seriously was the absence of procedures to ensure that what seems OK really is OK and remains OK.

Edit: PS. All over the place I see doors that are labelled as to be kept shut (for prevention of fire spread) held open by wedges of by just by jamming on the floor or on a carpet. When challenged, the persons responsible always rationalise.

 

If it was passed fit to run - the RAIB report suggested that the FTR process was pretty broken.

 

IMO that doesn't excuse it.

The only time you should see running lines through a carriage floor is on those carriages where the toilet is an open funnel down to the ground.

 

Amongst all this, does anyone know if any action has been taken upon the recommendation made in the RAIB report, viz.

 

It doesn't. However, what matters now is not what happened last year, but what positive actions the SDR are now taking to get their staff and volunteers working to acceptable standards - and staying there.

They - and railway preservation - have had a very lucky escape; now is time to take the advantage of the opportunity of that narrow escape to make sure that things are done right, consistently. In South Devon above all, but also elsewhere - I'd raise your question about the SDR's response to the RAIB recommendation, and ask what other railways are doing in light of this.

 

But how will they know they are substandard? And how will they learn?

 

I don't think giving inaccurate timetable information is a matter for the RAIB somehow or life-threatening in any way.

 

professional management standards.

It should be quite obvious to anyone that a dmu door that won't close other than on it's safety catch, with the handle obviously at half cock, is not safe and yet I saw that vehicle in service for several trips on one line. Quite simply, the Guard was not doing his job properly by allowing that and it's a management failure that he didn't act.

 

I wasn't saying it was. It does suggest though that the individual concerned was poor at communicating, which can involve safety issues.

PH

 

Safety is everyone's responsibility. In a functioning safety culture it would not have mattered if the FTR process had fallen down (even in good situations such things can happen), but someone would have felt empowered to raise a hand and say.... "This is not acceptable. Stop". It is the fact that several people must have "walked" by that I find concerning. Hopefully the SDR will emerge from this to be a paragon.

 

On a slightly different t(r)ack.
If the SDR cannot find the wherewithall to fit a piece of plywood flooring back down to a toilet floor.
Where are the resources coming from to extend to Buckfastleigh?

 

From the BBC report:
A Rail Accident Investigation Branch (RAIB) report said the toilet floor on the carriage train, built in 1957, had rotted and been removed last April.
The carriage remained in service until June.
The ORR found that at some point between 5 April and 22 June the screws holding the door shut also broke, along with a wooden post, meaning it could easily be opened.
Given that this near disaster happened about ten months ago I suspect any heritage railway worth its salt, including the SDR, have upped their game by now and reviewed their procedures. Most Heritage lines do have lines of communication between themselves and I am sure this topic has been the subject of board or other responsible groups meetings.