South Devon Railway - unsafe toilet

[Coryton]

If a child almost drops through a hole in the floor with consequences likely to be fatal then this was a safety critical defect IMO. I've no idea what happened or what systems were in place but the very fact that this incident happened in itself tells me that either those systems were inadequate or that they weren't properly applied.

 

I'd argue that things will sometimes go wrong even with the most robust systems. You never get 100% safety, just as many 9's after the decimal place as you can afford and justify.

 

But this does sound like an avoidable event.

[martin_wynne]

RAIB report released today: https://assets.publishing.service.gov.uk/media/5a6f202240f0b63b5e497a2e/180130_R022018_South_Devon_Railway.pdf

[Kris]

RAIB report released today: https://assets.publishing.service.gov.uk/media/5a6f202240f0b63b5e497a2e/180130_R022018_South_Devon_Railway.pdf

 

Not pretty reading that. 

[mow]

ITV coverage. 

 

http://www.itv.com/news/westcountry/2018-01-30/loo-floor-of-devon-steam-train-still-in-use-missing-for-months-report-finds/

 

BBC.

 

http://www.bbc.co.uk/news/uk-england-devon-42872877?intlink_from_url=http://www.bbc.co.uk/news/live/uk-england-devon-42802551&link_location=live-reporting-story

Edited January 30, 2018 by mow

[sem34090]

Post essentially deleted: I was wrong! 

Edited January 31, 2018 by sem34090

[Zomboid]

The RAIB report is likely to be a lot better (or at least fairer) than the rubbish that the mainstream media churn out.

[Neil]

I've put my own thoughts beside the ITV report. Of course no-one has to agree with me, and I'd be interested to hear other opinions. I will attempt to read the report in full later, having only briefly glanced over it earlier.

 

I suggest that you read the RAIB report in full, it lays the blame squarely with the railway and rightly so.

 

I've noticed that in this topic and others like the level crossing incidents one there are a good number of of members who find great difficulty in imagining that any fault could lie with any railway. While it's natural for us as enthusiasts to be supportive of railways it shouldn't blind us to their faults. In this instance it will do the heritage movement no favours if they fail to learn from the failings of the South Devon Railway.

[mdvle]

I've put my own thoughts beside the ITV report. Of course no-one has to agree with me, and I'd be interested to hear other opinions. I will attempt to read the report in full later, having only briefly glanced over it earlier.

 

(Definition of immediately? How could they have let the RAIB know until after they'd been able to stop, remove the coach and examine it to check the Mother wasn't fibbing!)

 

You really should read it - first part of the report, the summary (p7) - SDR took 3 days to notify RAIB.

 

Page 16 - section 23 - it appears RAIB was only informed because the mother, unhappy with response, contacted the railway for a follow-up which reached a different employee.

Edited January 30, 2018 by mdvle

[jjb1970]

Not pretty reading that.

I agree, not good at all. People should read the report, the actual report is in my view more damming than the media stories.

[Boris]

Yeah, an out of date safety case and no training/supervision in C&W on FTRs, I wonder if the ORR are considering any action against them?  It's also quite staggering that nobody was going to inform the RAIB/ORR and they were quite happy at the time to bodge the door shut again and let the coach back into service until more level heads disagreed.

[Glorious NSE]

I've put my own thoughts beside the ITV report. Of course no-one has to agree with me, and I'd be interested to hear other opinions. I will attempt to read the report in full later, having only briefly glanced over it earlier.

As others above, I think you should read the whole report, but some opinions on your comments above.

 

* The line in the news report is certainly badly written, but "months" is technically accurate as the coach was in service without the toilet floor for well over two months, between 13th April and 25th June (with the incident occurring on the 22nd June).

* The door might have been screwed shut originally, but it clearly wasn't secure at that point in time.

* Three year olds looking for a toilet absolutely do not do reading any notices. The notice may also not have deterred a foreign tourist or somebody with learning difficulties from trying the door, and wouldn't have prevented somebody falling against it due to train movement. 

* The exact mechanism that caused the child's bruising is surely irrelevant - it was caused during this incident, and would thus not have occurred had the incident not occurred.

* Any door that can be opened by a 3 year old either pushing against it or turning the handle is not "secured".

* The coach wasn't removed from traffic after the incident for 3 days, neither were the RAIB informed, i'm not sure that satisfies anybodies definition of "Immediately".

* As a parent of a 3 year old (and we have used this line in the last couple of years) then there are bits of a heritage train ride where it is absolutely reasonable to expect a parent to closely watch and hand-hold a young child as there is obvious risk (such as proximity to a train's external doors for example) - however there are other bits where you would have a reasonable assumption that they will be safe as long as you are in close proximity. Preventing your child from even touching a supposedly locked internal door for fear that it will suddenly launch your child beneath the wheels is not a reasonable assumption for any train passenger to make, and neither should it be. 

 

On the plus side, positive news from the report is that much has already been done to improve the safety culture there. 

[sem34090]

Fair points raised there, and most of them (fairly, justly and reasonably!) discount many/all of my points! I'll try and find a spare moment tomorrow to try and sit down and read the report in full.

[Talltim]

As others above, I think you should read the whole report, but some opinions on your comments above.

 

* The line in the news report is certainly badly written, but "months" is technically accurate as the coach was in service without the toilet floor for well over two months, between 13th April and 25th June (with the incident occurring on the 22nd June).

* The door might have been screwed shut originally, but it clearly wasn't secure at that point in time.

* Three year olds looking for a toilet absolutely do not do reading any notices. The notice may also not have deterred a foreign tourist or somebody with learning difficulties from trying the door, and wouldn't have prevented somebody falling against it due to train movement.

* The exact mechanism that caused the child's bruising is surely irrelevant - it was caused during this incident, and would thus not have occurred had the incident not occurred.

* Any door that can be opened by a 3 year old either pushing against it or turning the handle is not "secured".

* The coach wasn't removed from traffic after the incident for 3 days, neither were the RAIB informed, i'm not sure that satisfies anybodies definition of "Immediately".

* As a parent of a 3 year old (and we have used this line in the last couple of years) then there are bits of a heritage train ride where it is absolutely reasonable to expect a parent to closely watch and hand-hold a young child as there is obvious risk (such as proximity to a train's external doors for example) - however there are other bits where you would have a reasonable assumption that they will be safe as long as you are in close proximity. Preventing your child from even touching a supposedly locked internal door for fear that it will suddenly launch your child beneath the wheels is not a reasonable assumption for any train passenger to make, and neither should it be.

 

On the plus side, positive news from the report is that much has already been done to improve the safety culture there.

As ever, Martyn, you seem to put my thoughts into words better that I ever can.

Edited January 31, 2018 by Talltim

[phil-b259]

Fair points raised there, and most of them (fairly, justly and reasonably!) discount many/all of my points! I'll try and find a spare moment tomorrow to try and sit down and read the report in full.

 

In which case, can I request you consider editing what you have put down. The RAIB are very thorough and if they say something is wrong / inadequate / dangerous only a fool would try and claim otherwise.

 

For example the RAIB note that without a floor to help keep it steady, the whole doorframe and partition walls were free to flex about - and one screw driven in at an odd angle could easily have become ineffective due to the frame splitting etc.

 

If you were going to secure the door it with screws (1) there needs to be more than one of them and (2) they need to be inserted through a plank of wood secure biting into the partition wall and the door!

Edited January 31, 2018 by phil-b259

[brianusa]

In the interests of impartiality especially with this report and its implication that the SDR has a problem, its better that we as enthusiasts don't don too much sackcloth and ashes.  There could be many reasons other than those described in the report that we and the general public are not aware but we have to take the report as gospel, which is fair enough.  Hopefully as described, the SDRs adherence to recommendations will restore confidence in the railway.

 

Brian.

[phil-b259]

In the interests of impartiality especially with this report and its implication that the SDR has a problem, its better that we as enthusiasts don't don too much sackcloth and ashes.  There could be many reasons other than those described in the report that we and the general public are not aware but we have to take the report as gospel, which is fair enough.  Hopefully as described, the SDRs adherence to recommendations will restore confidence in the railway.

 

Brian.

 

Sorry, but given the RAIB's remit I would severely hope that there are NOT any 'reasons' which have been missed out of their report in any shape or form. Also there is no such thing as 'have to take their report as gospel' - It IS what occurred and no amount of second guessing or speculation that there are matters not addressed by them should be entertained.

Edited January 31, 2018 by phil-b259

[martin_wynne]

Reading the report, for me the most shocking aspect of the incident is not that it happened.

 

But that it was only an email of complaint from the mother 3 days later that caused it to be taken seriously. Had she not done that, presumably neither we nor the RAIB would ever have known about it. For all we know the offending coach would still have been in service, with a bit more sticky tape round the door.

 

Martin.

[298]

I've put my own thoughts beside the ITV report. Of course no-one has to agree with me, and I'd be interested to hear other opinions. I will attempt to read the report in full later, having only briefly glanced over it earlier.

The 1950s called, they want their atitude and that Mk1 back... (I've checked, it was built in 1957).

[royaloak]

Sorry, but given the RAIB's remit I would severely hope that there are NOT any 'reasons' which have been missed out of their report in any shape or form. Also the investigative body there is no such thing as 'have to take their report as gospel' - It IS what occurred and no amount of second guessing or speculation that there are matters not addressed by them should be entertained.

As a train driver I have read several recent RAIB reports where things I considered important to the incident were basically glossed over, they were mentioned but werent gone into in detail, that does not sound like an impartial organisation to me!

[Boris]

What surprises me about this (from my perspective) is nobody has queried that the Guard denied all knowledge of the toilet having no floor.  I thought guards on all preserved railways were required to carry out basic set checks each morning involving amongst other things ensuring the buckeye's are together properly.  Now to check a buck-eye thoroughly you either need to walk both sides of the set (impossible in a platform road) or physically get underneath to check the fishtails on the horizontal pins as well as checking basic stuff like the brake pipes are all connected.  How the hell can you NOT notice a 4x4 patch of daylight where there shouldn't be any?

 

Or is it because I'd expect my guards to notice that I'm judging another railway by those standards?

[Zomboid]

Unless the roof was also missing, would you really see daylight? Depending how it was parked you wouldn't necessarily get a massive amount of light through the frosted window.

To be honest if someone was going under there to check the couplers then not noticing something unrelated to the couplers is not unreasonable. I've certainly had situations where I've missed something "obvious" because it wasn't the focus of why I was looking at the object in question.

[sem34090]

I've now deleted the text of my posting: my opinions have been proved to be very wrong!

[phil-b259]

As a train driver I have read several recent RAIB reports where things I considered important to the incident were basically glossed over, they were mentioned but werent gone into in detail, that does not sound like an impartial organisation to me!

 

It would be interesting to see a few examples.

[phil-b259]

I've now deleted the text of my posting: my opinions have been proved to be very wrong!

 

Perhaps this is a useful reminder that when dealing with serious events posters that seek to dismiss official reports should be very careful to read IN FULL the document they are taking issue with.

[rodent279]

I have to say, toilets locked out of use is one of my bugbears when visiting preserved railways. No doubt there are good reasons for it, either from a safety point of view, or just because it doesn't work, but it's annoyingly common to have to walk halfway down a set to relieve oneself.

As an aside, having read the report, simply putting screws in the doorpost would seem to be the most temporary of temporary methods of securing the door. One or more proper metal hasp & loop type fixings, secured with a padlock, would seem much more long lasting.