INQUEST DAY NINE - Thursday 18th January 1996



         With the completion of Mr. Peter Leahy's testimony this morning and Miss Sharon Bone, Supervisor of the Training Centre and Mr. Gord Webb, Superintendent of Transit Control Services on the stand, the inquest has made a subtle change in direction and starting to focus in on the background. Since Day 1, we have been at track level but now we are starting to pull away to some of the more encompassing functions. Interestingly, I was thinking that this is about the point at which the British system of Railway Inspectorates would start to come to the conclusion of the actual cause of the accident and make recommendations as to the future conduct of the railway. However, in this case, Mr. Punter has made "dark hints" about things to come and we started to see some of that today.


         Maybe it's about time I came clean with a story that some around the TTC are aware of but it is relevant to the situation the organization now faces. In my never ending battles with Al Chocorlan about how the Management Services Department should be run, I was being dressed down by him one day for some way out remark I MAY have made (!!) when he made the following pronouncement. "The TTC does NOT make mistakes!!" This statement was made under duress. I was probably goading Al more than usual and this was his retort. He was quite serious. His comment has been confirmed by many others but he was the first official that I had ever heard say it with the force of an instruction. I am now witnessing how the TTC is going to describe August the 11th. Was THAT not a mistake?? We'll see!!


         Mr. Leahy was questioned by Brian Leck on some of the aspects of the training as it pertains to the Subway. He established that there has been a considerable amount of training on the part of the operator as he has gone through surface training prior to subway training. This allows the trainee to concentrate on learning about the subway without the associated functions. This was accomplished in the 12 day period in effect when Mr. Jeffrey went through. In the meantime, it appears that with the expansion to at least twenty days, although the majority of time is spent operating, there is exposure to some of the operational aspects of the subway. I get the impression this is still being sorted out. Although Mr. Leahy raised the question of the English language, when pushed, he declined to comment.


         Miss Sharon Bone then explained her functions as the Superintendent of the Operations Training Centre. She explained to Mr. Punter that she had not actually been a trainer, feeling that she was given the job because of her demonstrated administration skills. In concert with suggestions from her staff, Miss Bone requested her Manager, Edelgard von Zittwitz, to increase a previous 10 day training program to 15 days. The compromise of 12 days was the result in effect in August 1995. Miss Bone opined that the reason for not granting the request was budgetary.


         During this part of Miss Bone's testimony, the high priced help in the form of Mr. Gerry Brolley and Mr. Arnold Dube appeared in the court room to see how things were going. In their presence, Mr. Punter had Miss Bone agree that the general managers were responsible for not approving projects designed to improve the Operations Training Centre. An indication by Miss Bone that she was aware of these presences was noted.


         Mr. Punter then got into the area of psychological testing and the English language. It appears we had psychological tests until 1987 when it was felt it was an intrusion on the individual (!!). Miss Bone would not be drawn into the English language discussion either. The witness was also of the opinion that attendance at the school after basic training is not seen now as punitive but supportive. No matter how many people tell me that, I think that an operator who is not going to be paid for training and has to attend on his own time is not going to look on it very favourably. Miss Bone is of the opinion that a lunar white signal has a safety component. Mr. Falzone got Miss Bone to agree that a red signal will have a train stop in the trip position - my he's a crafty one !!!!


         After lunch, Mr. Leck went over some aspects of the rule book with Miss Bone. He specifically got her to describe that an operator approaching a signal that has been indicated to clear by a previous lunar white will have a train stop in the raised position until the signal clears.


         Mr. Webb had given the jury a tour of Transit Control yesterday and references during his testimony referred back to that tour. He described Transit Control Centre as having two functional areas - Power Control and Communications. It is interesting to note that the culture seems to have absorbed Signal Control into the Communications area. I guess this happened when they took the glass wall down and "incorporated" Signal Control into the general TCC area. In describing the signal system, he made assumptions that others had explained the signal system. Not yet!!


         Mr. Webb described the stress in Transit Control brought about by the necessity to hold conversations in short (adjectiveless) phrases. He also reckoned that the close proximity in which 11 people (13 counting Power Control) on duty on August 11th was also a contributor to stress. He had used this stress vector in designing procedures for the operation of Transit Control.


         One of the things that makes our operating communications work as it has for the last few decades is the mantra beaten into every TTC employee, whatever his job, that whenever anything happens - "Call Transit Control !!". By minimizing the importance of a call from a janitor, Mr. Punter is laying the groundwork for "censoring" the communications to Transit Control. I hope someone dissuades him from this path. I also detect him laying the groundwork for a Transit Control that can effectively manage a situation which only happens once every forty one years.


         Then they played the tape!!! I'd forgotten how awful that Car to Wayside phone system is. An edited tape of just the subway channel and only those calls affecting the line between St. Clair West and Dupont on August the 11th was played. Of course the thing that is noticeable is the constant drone of the carrier broken only by barely decipherable communications between the Subway and Hillcrest. (I caught Dr. Huxter exchanging pained glances with Mr. Punter !!!) Each call from the subway was unanswered for at least two attempts by the operator, most by three or four and when Control responded the operator didn't reply. Trying to get over the noise as well makes this form of communication as primitive as it is possible to get.


         Operator positional confusion was rampant and this communication channel is so bad, it's no wonder neither party wants to stay on it long enough for either Transit Control or the operator to fully understand each other. If anything comes out of this inquest, surely it will be an improvement in this particular concern.


         Although evidence was presented that operators are not trained in tie downs of train stops, a clear invitation to do so was issued by Transit Control to the operator of Run 34 at the SP53GT. Mr. Webb indicated that as the operator may have been an inspector or an inspector may have been present, this was not an unusual request. What the court is unable to understand at this stage (and probably never will, given the record) is that there is a form of shorthand which has been developed over the years as a result of stress and poor communications channels. These forms of shorthand seem strange to the uninitiated but the cognoscenti are aware !!!!! Given that Transit Control must have looked like a bomb went off after the realization struck of what had happened, the Car to Wayside was strangely quiet, or at least the edited version we heard today was.




1)      I hope that other Senior Management will attend this inquest, especially if they are likely to be called. It may be seen as waiting to pounce on some poor unfortunate employee who hadn't been reamed out as I was by Al Chocorlan and is not too sure about what should be said. This is no place to hide from the truth, and any Management attendance can ONLY be looked upon as being totally in support of efforts to ensure that this unfortunate MISTAKE is not repeated again. This incident can only be healed by a corporate effort to root out the causes and deal with them effectively. That's what a Coroners Inquest is for and is thus a different forum than the Railway Inspectorate which has somewhat more limited powers.


2)      From the evidence presented, it is interesting to do some sums once in a while. Today I started thinking about Sharon Bone's evidence about the potential increase in training from 10 days to 15. Last year there were 66 operators who took Subway training (60 the year before). If there are approx. 5000 operators, give or take a few, working on average a 210 day year, that's  approx. 1 million man days of operator effort. If 66 operators had 3 extra days of training, say 200 days, that's 200*100/1000000% or 0.02% of the work year. I've wasted more time than this thinking about it. When one considers that we don't want to ask a psychological question in case we offend somebody, it's a pity we can't spend 0.02% of our budget on satisfactorily training someone for whom we have such feeling!!!!!


3)      On a personal note. I wish to thank all of my readers who have shown their support of these efforts. I am very gratified to receive such support. Knowing that I am being "read", there may be a thought that I will "tone down". Fear not!! This is one of the founding members of the Spoon and Hipwaders Club speaking. Thank you all very much for your interest and support.


        We reconvene tomorrow at 9:30 a.m. for Day 10.


                 Dave Irwin   -   18th January 1996




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