INQUEST DAY NINETEEN - Monday 12th February 1996



         On what must have been the coldest morning of the year so far, the Inquest into the deaths caused by the Subway Accident on 11th August 1995 resumed today after a week's adjournment.


         Dr Huxter opened the proceedings by reading a prepared statement to the jury:-


Coroners Inquests are public forums to find out Who died, When they died, Where they died, How they died and by What means did they die. They are to determine the Terminal and Root causes of deaths in order to prevent the same circumstances from causing death in future. So far, counsel have conducted themselves correctly. There have been specific problems with documents causing significant delays in the start of the Inquest and it was entirely appropriate that the Inquest be delayed so that all documents submitted could be examined. The influx of materials is increasing and has resulted in the reworking of the witness schedule. Dr Huxter wished to ensure the jury that all evidence will be presented and no deals have been made to avoid hiding potential evidence. He said that he wants a reasonable closure to exist in the intermittent way in which evidence has been produced and he proposes to take action to prevent abuse.


         To this end, Dr Huxter requested the media present to alert the community that the inquest is anticipated to conclude during the week of February 26th 1996 and that anyone with evidence to present should get in touch with the Coroner's office by that date.


         Certain documentary evidence is to be handed to the jury out of turn in order that the jury has some necessary background information. This evidence will be presented in due course in the proper manner. Dr Huxter indicated he would take "...a very dim view..." of the appearance of any evidence before it is officially presented.


         Mr. Anthony Facchini, an operator from the Bloor/Danforth subway was on the stand most of the morning. He has been with the TTC for 17 years, a subway operator since 1988 and was a Metro cop for three years prior to joining the TTC. He had no problems with subway training although he felt it took 6 months before he felt "sure" of the job. He had no trouble with understanding the signals but the prepared speech about approaching red signals at speed was re-iterated. He has tripped a number of times. The Car to Wayside system is a cause of many malfunctions. All in all he considers subway operation to be an easy job.


         On one occasion, a terminal Inspector put his train on Hi Rate, as he was behind schedule, but Mr. Facchini refused to operate the train in Hi Rate and would not leave the terminal until the train had been set back to low rate. No explanation for this strange behaviour was offered and none was sought.


         The main emphasis of Mr. Facchini's evidence was an incident which happened to him on July 17th, 1990. He was approaching Kennedy station with green signals and a train was ahead of him waiting to enter the station which, if he hadn't used his gut feel to slow the train, he is convinced there would have been a collision. In cross by Mr. Leck, it turns out this is the situation we had heard about earlier from Mark Reidak where a track relay had been dropped and had caused a wrong side failure. This resulted in a reworking of the work method for transporting track relays which Mr. Reidak had described.


         In Mr. Facchini's opinion, the signal lights act up all the time (this is Bloor/Danforth experience as he has only operated Yonge/Spadina a couple of times). A number of times, the witness referred to the signals as "our eyes" and we "have to be able to trust our eyes". As a result of this incident, Mr. Facchini does not trust the signal system any more but he still likes to operate in the subway. He considers the discipline change since August the 11th to be detrimental to moral. He advocated the use of Station to Station control by Transit Control when there are signal problems. He is proud to be a TTC employee.


         Mr. Punter got his Flashlight recommendation, AGAIN!!, along with Safety vests, Flags and Hard Hats!! Mr. Facchini would also like to see changes to the signaling system so that the approach of red lights at speed is removed. He would like to see the Power, Series and Off Markers standardized as to appearance, height from rail and colour. Operators should have first aid courses at TTC expense. More light is required in the subway, either as extra headlights on the train or in improved tunnel lighting. He would also like to have operators have a debriefing about a month after they start subway operations.


         Mr. Gomberg had Mr. Facchini tell the jury that he has been advising other operators not to trust the signal system. August 11th did not come as a surprise to him, he had been expecting it. He admitted there would have to be a gross breakdown of the signal system to have a green signal displayed with a train just ahead.


         Ms. Savin had Mr. Facchini describe subway operation as non-repetitive work - it is a living. He talks all the time about Lunar Whites and signal problems with other motormen. He thought he had a Lunar White but had tripped a couple of times since 1988. Signal problems such as track-down/red-signal are a daily problem. He reports all signal difficulties to Transit Control and Transit Control in turn broadcasts the information to the line (which did not happen to his liking in the 1990 incident).


         In response to Mr. Leck, Mr. Facchini said he did not understand why the discipline procedures had changed since August 11th.


         Mr. Bill McNaught an operator who is also a member of the Bloor/Danforth Health and Safety Committee was on the stand for the rest of the day.


         Before he commenced his testimony, he presented numerous reports, with copies for all and sundry at which point Mr. Punter got somewhat disturbed at the time it was taking and the overall volume of material being presented.


         Mr. McNaught had a prepared statement which he read along with synopses of the various reports. He would have much preferred to stand and wave his evidence in the manner of a high school principal but Sergeant Evans "insisted" he sit!!


         The bulk of Mr. McNaught's presentation consisted of the analysis of data he had received from the TTC with respect to the number of incidents of signal failures and violations for the first ten months of 1995.


         He charged the Ministry of Labour and the TTC of "being in bed with each other" when it came to enforcement of the Health and Safety laws. It was my impression as an impartial witness that both the Union (Mr. Falzone) and the TTC (Mr. Leck) were not at all happy about the fact that these Health and Safety committees exist. I suppose they see them as abrogation of rights. By the way Mr. Falzone introduced himself in the manner all lawyers have introduced themselves except today, Mr. Falzone identified himself as representing Local 113 and Mr. ROGER Jeffrey!!




1)      A lot of discussion is going on about what the Subway Rule book says about the aspects of a signal after a Lunar White has been passed. In the 1973 rule book,  "...the next signal, which is red, will clear..." is defined as part of the description of what happens when a Lunar White is passed. It appears the new edition of the rule book (in the touchy, feely, permissive society style) says the next signal "should" clear. Many witnesses are using this change in wording to suggest that the signal system is not safe and is not operating correctly. The word "will" should be returned!!


2)      Much mention has been made of the improvements that are taking place since August 11th, specifically to the Car to Wayside system. In typical non-communicative TTC style, the people this will effect the most, the operators, seem to have been left out of the information loop.


3)      If we have only killed three people in 41 years, why are we beefing up discipline for signal violations now?? In my opinion, anyone violating an automatic signal should report it immediately to Transit Control, reset and proceed as per the rules for safe operation. Anyone violating an Interlocking signal should be removed from the Subway Operations for ever with NO chance of parole!! The operations staff need to be trained as to the reasons signals exist, how they are designed and what the consequences of disobedience can be. This training is very obviously lacking.


4)      Mr. McNaught focused clearly on the details of the problems with the signal system only hinted at so far in this inquest. He presented a litany of failure that is just short of horrifying in it's breadth and pervasiveness. This situation is corroborated by the fact that the TTC is about to hire 36 new Signal Maintainers at a time when the blood letting at the TTC is reaching mammoth proportions. It is further testimony to the short sightedness of the Chief General Managers Savage and Leach who had no concept of maintenance except as a drain of resources from non transit expenditures like Equal Opportunity Departments, Leasing of "vacant" space in the public areas of Stations for shops and fashion displays, Vast expenditures (usually of time rather than cash) on the United Way and previously described expenditures on so called system improvements like the Materials System which offer little in the way of true cost savings.


5)      Mr. McNaught has also discovered what I called the FNC syndrome at the TTC. In detailing some signal problems in the Greenwood Wye, he described a report written by Mr. Jim Thomas as being full of detail but no information. He has discovered our pension for Form Not Content !!


          Day 20 starts at 9:30 a.m. tomorrow.


                 Dave Irwin   -   12th February 1996




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