A report following an incident where a mother and her three-year-old child nearly fell through the toilet floor of a moving train, has found the floor had been missing for months, since April 2017.
The report by the Rail Accident Investigation Branch (RAIB) also stated the door of the cubicle was insecure allowing the child to enter and the train crew were unaware of that.
The pair had been travelling from Totnes to Buckfastleigh on the train on 22 June 2017. Shortly after leaving Staverton station, while the train was travelling at about 20mph, the pair opened the door of the lavatory compartment on the fourth carriage. They found that the floor was missing, exposing the wheels below.
The mother managed to catch hold of her child and stop him falling. The small boy is reported to have suffered minor bruising while both were in shock.
The report stated even the toilet door had to be secured using screws, with the engineering manager not regarding that as a risk.
The report also lists the maintenance and preparation of the train as inadequate.
South Devon Railway failed to notify RAIB of the accident immediately.
The RAIB said they have not come across a situation like this, where a toilet cubicle floor had been removed and the carriage was returned to service.
South Devon Railway said the accept safety on their moving train was "badly compromised" on that "isolated occasion".
The RAIB have recommended an independent review of SDR's safety management system and for changes mentioned in the report to be taken up by not only SDR but other heritage railways.