RAIB publishes South Devon Railway accident report

The Rail Accident Investigation Branch has published its report on an incident which occurred on the South Devon Railway last year, in which a child nearly fell through the missing floor of a carriage lavatory while the train was in motion.


A child nearly fell through the floor of BR Mk 1 Second Open No. 4805 on June 22 2017 on the South Devon Railway. SDR

On June 22 2017, a passenger and her child on the 1pm Totnes Riverside-Buckfastleigh service attempted to use the lavatory in the fourth carriage, BR Mk 1 Second Open No. 4805, just after the train had departed Staverton.

According to the RAIB’s initial report: “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.”

While the RAIB’s Rail Accident Report doesn’t apportion blame or establish liability, it is critical of the SDR’s safety management systems and maintenance regime. In its report, the RAIB says: “The RAIB found that the method of securing the door was inadequate, so that over time the door became less secure to the extent it was possible for the child to open it. The risk associated with the absence of the toilet floor was not sufficiently appreciated nor adequately managed after the carriage was allowed to enter service.

“The RAIB also found that the South Devon Railway had no formal competence management assessment for staff involved in carriage maintenance. Both of these factors led to no-one detecting that the door had become unsecure.

“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 has made one recommendation to the South Devon Railway to commission an independent review of the actions it has taken since the accident to address the deficiencies in its processes.

“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.”

Commenting on the RAIB’s findings, Simon French – the Chief Inspector of Rail Accidents, said: “Britain’s heritage railways carry over 9 million passengers every year. People are travelling for pleasure, and they don’t expect any nasty surprises during their journey. When a mother, enjoying a happy day out with a small child, is suddenly faced with a life-threatening hazard, it is important to find out what went wrong.

“Our investigation found that the railway’s safety management system was not operating properly, and had not been reviewed for many years. A flawed management structure contributed to poor decision-making. Staff were expected to do jobs which they were not really qualified for.

“We have recommended an independent review of how the railway manages the safety of its operations. I hope that the rest of the heritage railway sector will also look carefully at this report, and take action to make sure that the same thing cannot happen on their railways.”

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