The 56-year-old conductor fell from the train traveling from Mikulov to Břeclav last September near the Boří les stop. When he fell, he hit the steel structure of the bridge that the train was passing through.
The Railway Inspectorate, whose final report was brought to the attention of the website Zdopravy.cz, found during an inspection and verification attempt that the outer doors in the service compartment of the train were not reconstructed during the modernization of the 854 series, which is why they bear significant signs of wear. Lack of inspection and maintenance also contributed to this condition. At the same time, it was not possible to tell with the naked eye whether the door was properly closed.
“In this case, the door was insufficiently closed and upon contact it opened immediately and surprisingly without the need to exert much force or effort. As a result, there was probably a loss of balance on the part of the train driver (in a situation where, in addition, the train passed through an arch, where the centrifugal force acted on the train driver against this very door) and he fell out of the moving train through the open door onto the steel bridge structure. In these places, one passenger also noticed the fall of a large dark object on the right side in the direction of travel,” the report of the Railway Inspectorate states.
Exactly how the door was opened is unclear. However, during two test drives with a secured helper, the investigators found that it was enough for the helper to lean his body against the door to open it. This was also confirmed by a forensic expert commissioned by the police.
Based on this event, the Railway Inspectorate issued several safety recommendations to the Railway Authority. Czech Railways subsequently began to replace the doors. At the same time, until the exchange, employees were prohibited from staying in the service compartment of the train during the journey.