THE MOON AND THE TORONTO TRANSIT COMMISSION
CASA LOMA/RUSSELL HILL SUBWAY ACCIDENT AUGUST 11th 1995
INQUEST DAY ONE - 8TH JAN 1996
Contrasting with the estimated 100 degree Fahrenheit heat at the accident site, the Subway inquest resumed on a sunny very cold day in January in Courtroom A of the Coroner's Building. The same cast of characters seemed to be present as in November.
Today the jury made its first appearance. Lead by one of the 2 women on the 5 man jury, they were sworn in and after some legal preliminaries, Dr Huxter, the Coroner stated that the purpose of the Inquest was:-
1) The public ascertainment
2) The public attention
3) The public response
of/to an accident.
Although the room was much as described in my previous report, there was now the addition on one of the walls of a large diagram of the track between St. Clair West and Dupont. The signals involved are shown along with the gradient, curves and chainages.
Mr. Punter, the Crown's attorney proceeded with his opening statement in which he referred to the recent TTC report of the accident dated January 3rd 1996 and to a parallel police report. He said that they came to substantially the same conclusions.
Mr. Punter then described the basic operation of the subway, how the signals work and the relation of this to the Transit Control Centre (TCC). He said that the TCC was a "significant contributing factor" to the accident, details of which will no doubt be forthcoming. I have always viewed the "Control" centre as a monitoring function.
Describing in a general way the subway operations of August 11th 1995, he said that there were intermittent problems with the signals between St. Clair West and Dupont throughout the day and that the signal maintainers had been called to the scene. He stressed, more than once, that the signal which was causing the main problem, SP53, was NOT looked at. He also made strong note of the fact that when motormen are communicating with Transit Control, they tend to refer to the geographical location of a signal rather than it's actual number. So that SP65 for example is referred to as the second signal past St. Clair West (southbound). He indicated that throughout the day there seemed to be confusion between what the drivers were reporting as a signal and Transit Control's interpretation of which signal was being referred to.
The signal maintainers were called at around 10:15 a.m. and after searching about, replaced a couple of relays. At 5:46 p.m. run 29 failed to clear SP53, run 30 tripped through, run 31 after several attempts to contact TCC reported failure of SP53. The signal maintainers were never sent to SP53 at any time during August 11th up to the accident.
Run 34, operated by Mr. DeSantos, was requested to tie down the trip arm at 6:00 p.m. He operated his train, run 34, in a start stop manner until he came to a final stop at SP53. Mr. DeSantos will testify that he was not trained in tying down a trip arm. (Please note; I did not pester any of the participants for name accuracy. If accuracy is required, please refer to the official record. Also note that I do not intend to repeat the description of the general operations of the subway; Operating, signals, maintenance etc. Where appropriate, as you will see in what follows, I will describe some specifics. If there are enough requests for me to do so, I will prepare a monograph on this subject to be published separately.)
Mr. Punter also described some methods of "cheating" that had been heard about such as using Hi Rate keys, Trip Cock isolation, pinning; although they hadn't seen any real evidence of this. How naughty!!!
Run 35 was supposedly Mr. Jeffries first run of his second day on the job. His first day was already marred by a trip at the X6 signal in the York Mills area. What an unfortunate man to have had so much happen to him in such a short period of time !!!! What a strange organization, the TTC, that would let it happen to him!!!!!
The Crown then finished the opening remarks by listing the proposed witnesses to be called:- Staff Sergeant Staples - Accident Reconstructionist, Passenger McNab from run 35, Passenger English from run 34, Dr Deck – pathologist, various TTC witnesses to testify in the areas of Rail, Signal, Instruction, Equipment, and Management and the crews of both runs 34 and 35 with a hint that Mr. Jeffries would testify as to how the School helped him to pass a test at 100% which he was supposed to pass at 100% !!!!!! Mr. Punter will also call Members of the Police, Ambulance, Fire and TTC Emergency response, Consultants JLA with reference to the Productivity Improvement Unit and Consultants Regina Hill who identified Signal Maintenance as a problem. It was pointed out that Mr. Leach hired these two consultants and Mr. Gunn fired them on the basis that that was what he had been hired for!!! Even though Regina Hill was fired, they produced a report that was presented to the TTC on May 18th, 1995 but it wasn't read until after the accident having "been lost in some boxes"!!!!! Just another of many Consultants reports that are bought, paid for and ignored !!! Others to be called are Mr. Sam Lu of LKS Systems Ltd. and Dr John Senders of the University Of Toronto - to testify on Mechanical and Human Failure.
Mr. Punter opined that the inquest would take about four to six weeks to conclude.
In the afternoon, Staff Sergeant Staples gave evidence about the dynamics of the crash. As most of this has been covered pretty well in the press, I wont go into detail here except to add a few facts which may be of interest. He had a large number of photos and a couple of videos to display.
Car 5721 was the lead car of run 35, the attacking train. Car 5343 was the last car of the attacked train - run number 34. There are approximately 45 steps in the Russell Hill Emergency Exit - about the height of a three story house. The photos and SS. Staples evidence indicate that both trains seem to have "integrated" themselves with each other for about 18 feet, approximately the area of the first section if one considers a car to have four sections each section being centred on a passenger door set. Transport Canada have no responsibility for the TTC subway though their assistance was sought and provided. Ken Rankin was assigned as TTC contact with several TTC employees assigned to various teams to provide information. Generally Run 35, the attacking train, got underneath the anticlimbers of run 34 and pushed run 34 to the roof of the tunnel. The front bogie of run 35 was pretty well undamaged and was used for various tests. In a dynamic test carried out on Thursday August 17th, 1995, it was apparent that the first view of the rear of "run 34" from "run 35" took place somewhere between 223 and 240 feet from "run 34". SS Staples tested the trip cock isolating alarm we installed a few years ago on his simulated run 35 and found it didn't work until the equipment mechanic "gave it a good whack with his spanner"!! For SP77GT to show a lunar white, blocks SP71 and SP65, the tracks ahead of these respective signals, must be clear.
1) We are obviously going to hear a tremendous amount of evidence which will be aimed at showing that we have allowed 45 years of operating the subway, without an attributable accident, to have lead us into a large state of complacency. In today's evidence this was hinted at in the areas of training and in communications between trains and the Transit Control Centre - especially with reference to the exact location of trains with respect to the signal system. This was further evidenced by Staff Sergeant Staple's still unclear, despite his exposure, knowledge of the Signal System. To put this into context, which was not done today, I will explain that there are two types of signal in the subway. Automatic signals, generally three aspect; red, yellow and green and Interlocking signals, generally seven aspect; red, yellow and green over red yellow and green over yellow. Both these types of signals may be grade timed which means that the green of an automatic and the top green of an interlocking signal are replaced by a lunar white. In the original design of the subway system in the fifties, it was intended that the automatic areas be policed by the staff on the train themselves, there being no place for the trains to go except forward in one direction and the assumption on the part of all concerned that train crews had a responsibility to operate their trains in accordance with the rules. Where there was choice or potential conflict of movement (in the areas of switches), the interlocking signal was provided to enforce compliance with instructions as to movement. In the automatic areas a train could “key-by” at will until the driver came upon an indication of a different type of decision; another train, a clear signal or an interlocking signal. Automatic signals have no control or indication at a central point such as the many local operating panels, the major panels at St. George and Eglinton and the panel at Transit Control at Hillcrest.
2) Interlocking signals, on the other hand, have indications at these panels of their current aspects and control over these aspects. Interlocking signals DO NOT have a key by facility except as provided by a mutual agreement between a train and Transit Control which is mechanically enforced. Over the years, as a result of incidents which have caused concern but which have not lead to the depths of horror as experienced last August 11th, controls have been added to the automatic areas which are supposed to be in agreement between a train and Transit Control but which are NOT, REPEAT NOT, mechanically enforced. This has lead to abuse of a system which was not designed to do the things we expect of it today. The vast majority of this is in the area of removing responsibility from the operators of trains but not replacing that responsibility with a suitable compliance enforcement system. Without hearing any of the evidence yet in this regard, I think this is where we may find ourselves in for a good dollop of criticism.
3) In all my years of exposure to the Subway, I had never heard the term "pinning" (maybe "pinging"). I had definitely heard of, and witnessed on numerous occasions, the operating of a train at such a speed in a grade timed section that no yellow lights are seen. For a clear aspect on any signal to be displayed it is first necessary to prove the position of the train stop in the down or clear/safe position. When the trip arm is in the proven lower position the signal changes it's aspect to the appropriate clear indication. As can be imagined, it is possible for a train to be in such a position that the trip arm is on the way to clear and is just below the trip cock on the train, i.e. it wont trip the train but it's not yet in a position to clear the signal and there is some reaction time in the signal mechanism to clear the signal. A good operator can run a train from Sheppard to York Mills through that very straight clear downhill section without seeing a clear signal without too much difficulty, in fact it almost seems that the Power signs are positioned to give this effect. Pinning is described as operating the train at a speed so close to being caught that the trip cock just clips the trip arm on it's way down but not enough to open the air reservoirs and the sound of this contact can be heard/felt in the drivers cab. A "good ride" if you can get it!!! It has always been my view that the operators with some experience relieve the boredom by practicing these skills and good luck to them, the passengers appreciate a fast safe ride. However, IT IS ATROCIOUS THAT A MAN ON HIS SECOND DAY IS BEING ENCOURAGED TO PRACTICE THESE SKILLS EITHER BY HIS MATES OR BY THE TTC. If even the slightest evidence of this is elicited, then we should be, along with local 113, very roundly criticized and found at fault.
4) Despite a number of reports during that day that there were problems in the southbound area between St. Clair West and Dupont, there was a real failure in communicating to the Signal Maintainers exactly what the problems were and which signals were at fault. Before a Taxi Driver is allowed out in the London area he has to have a proven knowledge of London streets. Our subway is far less complicated and we have provided all sorts of indicators of "where I'm at" that I would have thought it was the least we could expect from a motorman that he would know where he was. During the installation of CTDIS I heard thousands of calls going out to crews to ask where they were and they didn't respond. It was common knowledge among Transit Control staff that the reason this happened was the drivers didn't know where they were and waited until they came into a station to confirm the position to themselves before reporting in on the car to wayside system.
5) Despite Herculean efforts by the Transportation Department to cover their rear ends with so much paper that nobody can be blamed for anything, we still are unable to chastise a Mr. Jeffries for passing a signal (the day before) and not hauling him in because we didn't know it had been fixed. Fixed or not, signal violations are something that are not considered seriously enough by the Transportation Department to warrant anything other than a mild finger wagging. It will be interesting to see how long it takes for the current "pass a red and you're fired" policy to be watered down. Anyone who has been around the subway long enough has heard stories about signal violations that would curl your hair. We are very lucky to have got away with it as long as we have. August 11th was pay back day for many a past unreported undisciplined incident.
6) Despite the invention and use of modern information systems, the inquest is extremely backward in presenting data so that all in the room can see and hear. Pieces if paper are passed around to a selected few, photos on white board are not presented in such a way that all can see them. There is only one TV monitor to view the videos and as this is faced to the jury and defence council, others do not see the videos. This is a severe fault on the part of the Coroner's Office and definitely needs improving.
7) If I was a jury member who didn't know anything about the subway, I would be extremely confused by the supposed overview evidence presented so far. I hope, for their sakes, that there will be a lot more clarification of the facts before the opinions start to flow.
8) Even though the School of Instruction (Operations Training Centre) has trained tens of thousands of Subway operators, what sort of training are we giving that would allow a driver on his second day of duty to pass so many red signals and warnings and still carry on at what is reported as the full speed of 30 miles per hour ??? Obviously we are NOT instilling a healthy sense of fear into these operators that they are responsible for millions of dollars worth of lives and equipment. This is a problem with the modern day attitude of "we mustn't insist on anything and everyone must be allowed to do what they want". What the TTC needs is a good dose of the militarism of Bill Brundrit (a past Manager of the Transportation Department) and this, I hope, will be one of the outcomes of this inquest.
And that, folks, is my report for Day 1. Day 2 starts at 9:30 tomorrow!!
Dave Irwin 8 January 1996