January 30, 2018

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Transport safety

Missing train toilet floor: safety management system ‘flawed’

The Rail Accident Investigation Branch (RAIB) has issued its report into an incident in which a child nearly fell through a missing toilet floor at South Devon Railway on 22 June 2017.


At around 13:15 hrs on Thursday 22 June 2017, a mother and her three-year-old child were travelling on a South Devon Railway train from Totnes (Riverside) to Buckfastleigh.

Shortly after leaving Staverton station, while the train was travelling at about 20 mph (32 km/h), the child left his seat and went towards a toilet on the train, followed by his mother walking a short distance behind.

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.

The child suffered minor bruising, and both mother and child were shocked. The accident was reported immediately to the railway company, but the RAIB was not advised of what had happened until 25 June 2017.


In April 2017 the South Devon Railway had carried out a repair to this carriage. The location of the repair was difficult to gain access to and required the floor of the toilet cubicle to be removed.

The railway’s management decided that the door would be secured and notices placed on the door, allowing the carriage to enter service with the toilet floor missing. 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.


Simon French, Chief Inspector of Rail Accidents said: “In this case, the railway company took out the toilet floor, to get at and fix a leaking brake pipe. The engineers found a lot of previously undetected rust and rot that was going to have to be dealt with. It seemed like a good idea to seal up the toilet door until the whole carriage could be got into the workshops for overhaul, but that was not easy to do securely, and the door came open.

“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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