SDR to review safety management

The South Devon Railway (SDR) should engage an external party to review its safety management system and the way it is implemented in practice, after a child almost fell through the missing floor of a toilet compartment in one of its coaches on June 22 2017.

The recommendation was made by the Rail Accident Investigation Branch (RAIB), after a full investigation into the incident. RAIB calls for revisions to be made to the heritage railway’s systems if needed, including: governance, policy and leadership; management control and communication; risk assessment and identification of additional control measures; how the competence of employees is developed, assured and maintenance; and monitoring, review and auditing of compliance to the safety management system. Any changes identified as necessary by the review should be implemented and reported to the Office of Rail and Road.

The accident happened shortly after the train left Staverton station, when a child went to enter one of the toilet compartments in Mk 1 Second Open 4805. As he entered it, he fell forward because the floor of the compartment was missing. His mother grabbed his arm and prevented him falling through the opening and onto the track below.

Both toilet cubicles at that end of the carriage had been locked out of use because repairs had not been completed. But although the doors were secured, the child was able to open it. The child’s fall was broken by the brake pipe.