Investigation into a dangerous occurrence on the South Devon Railway, 22 June 2017.
As the 13:00 hrs train from Totnes Riverside to Buckfastleigh was running between Staverton and Buckfastleigh, at around 20 mph (32 km/h), a passenger and her small child attempted to enter a lavatory compartment in the fourth carriage. 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.
The passenger reported the incident to the guard of the train, and the railway took action to secure the lavatory door. The incident was reported to the RAIB on 25 June.
The carriage, an ex-British Railways Mark 1 Open Second, had been put back into service after repairs to its braking system, which had required the dismantling of the lavatory floor. The floor had not been replaced and staff had placed a notice on the compartment door and attempted to secure it to prevent it being opened. This had not been effective.
Our investigation will examine:
- the events leading up to the incident, including the repairs to the carriage and the actions taken to return it to service
- the adequacy and suitability of the measures to secure the door
- the railway’s safety management system, including the arrangements for managing the competence and fitness of the staff of the carriage and wagon department, and the systems in place for assuring the safety of rolling stock in service.
Our investigation is independent of any investigation by the railway industry or by the industry’s safety regulator, the Office of Rail and Road.
We will publish our findings, including any recommendations to improve safety, at the conclusion of our investigation. This report will be available on our website.
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