THE MOON AND THE TORONTO TRANSIT COMMISSION
CASA LOMA/RUSSELL HILL SUBWAY ACCIDENT AUGUST 11th 1995
INQUEST DAY TWENTY - Tuesday 13th February 1996
WE DO NOT HAVE A SAFE SYSTEM
†††††††† Today was a day of technical experts of various sorts, two of whom were quite open about using the forum of the inquest to blatantly advertise their services to the TTC. We started off with Sam Lew.† Mr. Lew, despite his qualifications is a keen fellow who demonstrates the adage that a little knowledge is a dangerous thing. His "Selling Point" was an enhancement to the Intermediate Point Headway Control system which his company supplied. At some point in his work on IPHC he became aware of the potential of the system to measure the difference in train positions based on time and he extrapolated this to a system that could potentially avoid collisions. It would do this by determining that a train entered a track circuit a certain minimum time after a previous train had done the same thing. Although the success of such a system based on the data available is somewhat spurious, Mr. Punter made a great deal out of the fact that the TTC had not put in such a system.
†††††††† At some stage during the development of the IPHC system, Mr. Lew saw a track condition known as a track flick. He was convinced he had seen the second coming. In Mr. Lew's view, the flicking track was the reason for the signals turning red in an uncontrollable fashion and had obviously lead to the accident on August 11th. He informed the jury that the IPHC system was supposed to get "clean" inputs from the signal system and this was the first time that he had seen a suspect input. His software was designed on the basis that the track feeds would be perfect. He told the jury that our signal circuits are not what they should be. Mr. Lew is one incompetent fellow if he thinks signal system data beyond the vital circuits is infallible. A real chump and Mr. Punter isnít far behind for believing him.
†††††††† Keith Watling, the TTC's Chief Signal Engineer, took the stand and his only purpose was to deny that Mr. Lew had proposed his Train Avoidance System before August 11th. Another opportunity was missed to explain the Signal System. I guess it's too late now. Mr. Watling told the jury the Signal System was safe before August 11th and was still safe after. He also explained that it would not be possible to implement Mr. Lew's proposal for the $400,000 he quoted, as there was a lot of work to be done at TTC to implement such a system. If such a Collision Avoidance System was installed, we would not be able to maintain service. During both these witnesses testimony, Mr. Punter got into system design in front of the client; a practice I have discovered is totally counter-productive.
†††††††† The jury fellow who asks questions asked Mr. Watling why the various signal groups did not talk to each other. Mr. Watling could not answer the question.
†††††††† The third expert was John Senders.† Dr. Senders has been hired by Dr. Huxter. Dr. Senders is a psychologist and has been in various teaching and industrial situations that have given him a great insight into the field of error analysis. He explained in great detail how little things failing add up to big things failing. He suggested that even though Failure Mode and Effects Analysis is relatively new, it should be carried out after the fact on the old signal system we have at TTC. He described Mr. Watling as having a closed mind when it came to the safety of the system. Because there was an accident on August 11th, ergo the system is not safe and he doesn't believe it is any safer today. He's a plastic bubble man. His "Selling Point" is a hoard of University types flooding all over the TTC to do audits on everything imaginable. It would be quite cheap because the University would pay for the graduates. But the Glory!!
†††††††† Even though it was not (could not) be recorded on video, Dr. Senders is in agreement with Staff Sergeant Staples and Mark Reidak that the wheel drove down the trip arm. He based this opinion on the fact that these two gentlemen heard a click he could not hear. As these two gentlemen succeeded in destroying the evidence, it is not possible to say one way or another.
†††††††† His opinion of Mr. Jeffrey was refreshing. So far everyone; the Coroner, the Crown, Counsel of various sorts etc.; have treated Mr. Jeffrey like a little boy who unfortunately spilt the glass of milk. As an unfortunate situation for which he was not to blame. Dr. Senders offered two scenarios and didn't stress either, leaving his audience to judge.
†††††††† In the first scenario, there was a transient error which effected the Signal lights. Dr. Sender explained that, after a training course which had stressed adherence to signals, Mr. Jeffrey would be operating on the basis that every signal would be new to him and he would be keeping a close watch for every single light of whatever sort that he saw in the subway. Between the time that run 34 "stopped and goed" between St Clair West and SP53 and the accident which reset the condition, for the period that run 35 traveled from St Clair West to the rear of run 34, all signal lights went out and were therefore not seen by this new operator who would be certain to see them if they were alight.
†††††††† In the second scenario that Dr. Sender proposed, he described how he had learnt of the running of grade timed signals so that the clear aspect is NOT seen. He suggested that Mr. Jeffrey was training in this art of operating in the Grade Time area and he blew it!! In my opinion, Dr. Sender's second suggestion seems to be a little closer to the situation.
†††††††† Dr Sender is the first witness to accurately describe what is blocking the view of the Lunar White on SP77, the stainless steel gate that is there and has notices all over it as a result of previous inquests. Given the large number of people who have so far described this situation, it is appalling that an expert in error detection should be the first to accurately describe the scene.
†††††††† Dr Sender went into a lot of touchy feely detail about how human beings react to punishment, suggestion and reward. Although he talked a lot about it he still didn't explain how Robert Jeffrey was the first man in 40 years to kill someone on one of the "Safest" subways in the world - and WE HAVE the AWARDS to PROVE it!! Dr Sender did admit to the likelihood of complacency.
1)††††† I got a hint about Mr. Lew's qualifications when he said he had been involved with the disastrous Metron clock/advertising signs in the subway. He sees time as data, not as the governing force of the Universe. He thinks that you can play with time and do things in a few seconds that normal human reactions require minutes to accomplish; especially with the tools we have at hand.
2)††††† Mr. Lew hasn't a clue about how a subway operates. His experience has been in building security and advertising signs. His knowledge of our operations, despite his exposure during the design and development of IPHC, is pitifully lacking. My opinion of him at the end of his testimony is that he is a nutcase who should never have been allowed on the property.
3)††††† It came as a complete surprise to me that Keith Watling, the TTC's Chief Signal Engineer was unaware of the major problem I had with the CTDIS system, namely the poor quality of the information coming from the Signal System. I guess this points to the lack of communication everyone is talking about.
4)††††† Dr Sender said that the safest subway was one in which no trains were present. It is on this basis he must have said that our system is not safe - it is a system. We will never have a safe system in Dr. Sender's opinion. It is safe now in the opinion of most people who have responded to Mr. Punter's mantra. I guess we will spend the rest of time trying to achieve Dr. Sender's position. Errors are necessary to the evolutionary process in Dr. Sender's view and we should try to discover why errors occur and correct them rather than punishing people for committing them. It is with this view in mind that he suggested that Mr. Facchini, the operator who saw the green signals immediately behind a train in 1990, should be singled out for praise.
†††††††† In discussing his theories about people being at the blunt end and sharp end of situations, Dr. Sender believes our management does not believe in Safety First for real. He thinks that the staff at the sharp end, the operators of subway trains, for example, do not believe that The Seventh Floor is committed to anything but saving money and that safety comes secondary to that. Our complacency over the years, the diminishing presence of maintenance, the constant application of Safety awards to us that convinces us that this is true are all factors which lead to the accident on August the 11th. No single person is to blame, rather the system as a whole is at fault.
5)††††† With the poor though consistent coverage by the local media of this inquest, it is apparent to me that we need to find a better way of getting government information into the hands of the populace than the media. To see a TTC employee, Lynn Hilborn, groveling to this local bunch of bullies by handing out all sorts of reports they donít care about, demonstrates that we at the TTC have a lot to learn about getting on in this new communication age.
†††††††† Wednesday is a day off so "...Mr. Leck can prepare Mr. Gunn for his testimony on Thursday..." in the view of Mr. Punter!! We reconvene at 9:30 a.m. on Thursday.
†††††††††††††††† Dave Irwin†† -†† 13th February 1996