Courtroom A was filled with most of the players - Robert Jeffrey (who according to news reports was recently re-hired as a bus driver after killing three people and ruining the reputation of the Toronto Transit Commission), Union representatives, lawyers, many media, members of the deceased's families and various and assorted spectators.


         Dr. Huxter opened the proceedings by thanking the Jury for their hard and dedicated work. He also commented on the thoroughness of the police investigation and the work of Sergeant "I only draw breath to serve you" Evans for his support during the inquest.


         In a departure from usual procedure, Dr. Huxter had Helen Byrne, the jury foreman, read the verdict and recommendations:-




         The verdicts into the deaths of Hui Xian Lin, Christina Munar Reyes and Kinga Klara Szabo were accidental death as a result of the Subway Crash. The jury then made 18 recommendations as follows:-


1)      Reform of the Railways Act (1950) to provide oversight of the Toronto Transit Commission.


2)      The TTC should submit to an independent safety audit every two years, beyond that done by APTA. This independent agency will be set up under the revised Railway Act.


3)      Completion of the "Due Diligence Checklist" of deficiencies identified by the TTC.


4)       The Province and Metro:-

a)     Commit to a "State of Good Repair" funding policy

b)    Repair to take precedence over new works (read Sheppard Subway !!)

c)     Future capital funding based on the State of Good Repair.          The jury indicated that under funding since the mid-1980's has contributed to the deterioration of the system and had jeopardized the safety of the Toronto Transit Commission.


5)       Improvements to the Operations Training Centre starting with the hiring of an accredited adult training specialist. The updated training package should include at least:-         

-realistic pass / fail grading        

-annual refresher for all operators         

-emphasis on the meaning of the signal system          

-route supervisory accompaniment for at least         

one day of complete runs after training         



6)      An updated Operations Training Centre to include a suitable subway simulator.


7)       A comprehensive review of the signal system with emphasis in the following areas         

                    - Lunar Whites

- removal of signal identification markers         

- consistent placement of signal aspects         

- progressive speed control         

- expansion of IPHC to identify headway and            

train separation         

- all trip valves activated and relocation of reset


8)      Elimination of auto key-by facility and implementation of raised trip arm immediately train has passed


9)      Advanced implementation of the new subway communications system.


10)     Improved communication within the organisation.


11)     A new Transit Control Centre including the updating of the skills of TCC staff.


12)     The current Transit Control Centre should only be responsible for Operations. Such things as intrusion alarms, facility maintenance, public information, media relations and other related concerns should be handled by an adjacent facility.


13)     Emergency response exercise every five years with "everybody". Yearly reviews by the Safety department


14)     Improved predictive and preventative maintenance with computer assist where applicable.


15)     Review of equipment procurement with respect to quality control. The procurement of cheap equipment (the Ericsson train stops) is a misuse of resources and a serious safety issue.


16)     Traceable design criteria and standards for track, signal and subway cars. No modifications without approval of design review authority


17)     Train operators and the TCC must identify signal malfunctions by signal identification numbers. Review of the discipline system to allow for signal malfunctions. Operators reporting for duty to meet an inspector so that "State of the road" information can be passed on. Rookie operators not to be scheduled together.


18)     The office of the Chief Coroner is to convene a press conference one year hence to provide all parties with an update on the implementation of these recommendations.


          Dr. Huxter thanked and excused the jury and them announced that due to:-          

- the inclement cold weather         

- filming of a movie on Grosvenor Street and         

- the OPSEU strike


         the media would be allowed to conduct their interviews in the lobby of the court but not the courtroom. He also said the jury had indicated that they did not wish to be interviewed and should be allowed to leave the court without harassment from the media.


         Frank Gomberg gushed thanks for the recommendations and Brian Leck opined that the recommendations were of great value.




1)      These recommendations, despite Brian Leck's endorsement and my general agreement, are going to mean a complete upheaval of the Toronto Transit Commission if they are embraced as totally as has been indicated by the various participants. The major change, which in my experience will be the most difficult to implement, is the one asking the TTC to improve it's internal communications. The TTC is staffed by an enormous number of people who have existed very successfully in an environment of knowing just that little bit more information than the next guy. In this situation, where jobs are being slashed left, right and centre, to expect that people, fearful for these jobs, are all of a sudden going to become paragons of communication's virtue is dreaming in Technicolor.


2)      Despite all the effort that has been made to make it clear to Metro and the Province that any future capital expenditure must be on bringing the system up to and maintaining a "State Of Good Repair", there are no baby-kissing photo opportunities in cleaning ballast at Union Station. We are in a time of an extreme funding crisis. We are losing passengers daily and we want to spend enormous amounts of very hard to come by cash on our day to day operation. No politician worth his salt is going to allow the Sheppard Subway to be delayed or denied so that ballast can be cleaned. We will be arguing this point for decades to come.


3)      A few comments on the individual recommendations:-


         R1) If the Railway Act is going to be reawakened, then beside any oversight provisions, a provision is required to ensure that funding for day to day operation is clearly laid out. We have to get past this silly nonsense that we are a business that can operate from Jan 1 to Dec. 31. Expecting managers to predict what is going to be spent next year based on what was spent this year with no "reward" for saving money this year is a fiscally stupid situation which we must change. But we will never be able to do it on our own because we are so tied into the budget process of Metro and we will need legislation to let us spend money the way Subway Construction does. We waste enormous amounts of money on budgetary management and we must also produce a budgetary system which requires an extremely small per cent in total of a department's effort to manage.


         R2) The jury recognized the value of the APTA audits and recommended further audits by "qualified rail transit experts". If anyone knows where these experts can be found if they are not in APTA, the NTSB or Transport Canada, please let Mr. Gunn know as soon as possible!!


         R7) Recommendation 7 deals exclusively with a comprehensive review and re-examination of the existing signal system with comparison to other transit authorities in North America.


         I herewith apply for the job. I don't come cheap!!


         This recommendation is so serious in its scope that I am going to deal with it in some detail. I would suggest extreme caution to anyone at the TTC from doing anything to the Signal System without a very complete and thorough understanding of what is there now and what is expected to be achieved as a result of any changes proposed.


         The recommendations with respect to the signal system made by this Coroner's jury is the result of a lot of people over the last two months completely misunderstanding the function of the signal system. I include in this "lot of people" the Coroner, the jury, the investigating police, the lawyers and, sadly, many TTC employees who should know better. My daily reports have mentioned on numerous occasions, to the point where my readers must have become bored, that an explanation of the signal system was not forthcoming. As we sit with the jury's recommendations in hand, 26 days of testimony, piles of documents many feet high and months of investigation behind us, this lack of knowledge on something so crucial to an understanding of what happened on August the 11th is appalling.


         R7i) "The use of the lunar white in conjunction with a red aspect. Red is to be seen as absolute."


         Enormous amounts of lawyer time have been spent over the last two months on the meaning of a red signal with a lunar white. (If I ever produce a book out of all these writings, it's title will be "The Moon and the TTC"!!) The phrase "counter-intuitive" has been used quite often to describe a train approaching a signal displaying a red aspect at speed. Dr. Huxter even suggested at one point that the signal system design be so simple that someone coming off the streets should have no difficulty recognizing what was expected of him. The signal systems we have today on all forms of railroad are the result of spending the last 150 years or so killing people in train accidents. A considerable amount of effort has been expended in designing the shapes and colours used in displaying information to the operators of railway equipment. For those wishing to understand this vital form of communication, I recommend highly Rolt's "Red For Danger".


         We have trained many thousands of motormen on our system over the last 40 years and all have managed to operate without killing passengers.


         The accident in Toronto was NOT caused by a driver misinterpreting a signal aspect. It was caused by a faulty train stop design and Mr. Robert Jeffrey learning how to break the rules too soon after the end of his training. By his own evidence, Mr. Jeffrey has been in love with the job of motorman for some years and has always wanted to be a motorman in our subway. He described how he rode the line and talked to operators whilst owing a restaurant in the Eglinton division area. He obviously knew all about running grade time areas without seeing clear signals. He knows, as others also described, about running to train stops rather than signal aspects - why else would the recommendation by some be that the train stop arms be painted white. Not so that we can see if anyone hit them, but so we can see them going down before the signal clears.


         There may be many reasons to tighten up our system but I don't believe fiddling around with the signal system is going to prevent one more incident.


         As the Lunar White is peculiar to only a few properties, there may be a reason to find a replacement but this requires a lot of study and thought before anything is done.


         R7ii) "Removal of the signal identification markers from the signal trees."


         This recommendation should be considered in light of recommendation 17i - "The train operators and TCC (Transit Control Centre) must identify signal malfunctions by signal identification numbers (markers)."


         There was no hard evidence presented to suggest that there was confusion between the signal identification markers and Lunar Whites. The signal identification marker is back illuminated by a low light emitting bulb with a distinct yellow quality to it. It is not brilliant in any way, in fact in my opinion a lot are unreadable until you are within just a few feet of them. On the other hand the Lunar White is a high light emitting lamp with colour correction filters which produce a concentrated bright white light.


         If there is any confusion of lights in the tunnels, it is with the blue lights associated with the power control system. These take on a distinct green aspect when viewed from a distance. They are also placed on the same side of the tunnel as the signals and are in DIRECT line with the signal aspects. In my experience these lights are the ones requiring attention. They were reported by Fred Miles in 1964 when I joined the TTC as being a problem and have been mentioned since but at the time there was no reason, or money, to change them. They do not appear anywhere in the Jury's recommendations or the TTC report (Russell Hill Subway Train Accident August 11, 1995 published by the TTC in December 1995) but they do appear in the Signal System Design Review. Yet signal markers, which have never been a problem, are. I think this was a lawyer inspired thought.


         R7iii) "Consistent placement of signal aspects on signal and repeater trees."


         Along with the approval of a bad train stop design at the time of the Spadina Line construction, this was another example of approval of a bad design and should be corrected as soon as possible.


         R7iv) "Consistent placement of wayside markers and signals with respect to performance characteristics for all train types."


         One of Dr. Huxter's favourite witnesses was Dr. Senders; after all, he hired him!! This recommendation flies directly against Dr. Sender's recommendation that the environment should be stimulating. As long as the RED aspect is properly positioned (the only aspect that is) all other lights can wander within tolerances. Obviously if the red is fixed, the yellow, green, lunar white,  will be fixed as will the signal markers, interlocking signal aspects etc. The placement of the wayside markers (not defined but I am taking the Power Markers to be the ones indicated here) is generally consistently high on the tunnel wall and all the rules in the world will not prevent operators operating by paint splashes, cross passages, puddles of water and whatever. From the evidence presented by Dr. Sender and from Mr. Jeffrey's performance on the day before the accident and on the day of the accident, the only effective placement of Power Markers is Automatic Train Control. As long as we have motormen operating trains we will have variations in the operation and the signal system catches any that are out of tolerance. The accident on August 11th was caused by a design fault in the signal system which, had it not been there, would have stopped Run 35 due to operator operation outside tolerance. Generally information should be presented consistently if it is to be of value.


         R7v) "Progressive speed control"


         Mr. LaForce of Philadelphia brought progressive speed control to the TTC. A document "Signal System Design Review Task Force" dated 27 Oct 1995 was presented during the Inquest but not discussed in open court. This document requires a very detailed analysis before any of it's recommendations are adopted. It mentions progressive speed control. The essence of signal systems is to keep them as simple as possible. This proposal adds a complication unwarranted in my view as it ignores the fact that we have a consistent system in Toronto. On Mr. LaForce's own evidence, the Philadelphia situation is quite different and therefore to suggest we use his orange seeds in our apples is to misunderstand the situation.


         R7vi) "Expansion of the existing TTC IPHC (Intermediate Point Headway Control) system to identify headway and train separation."


         The IPHC system is an offshoot of the CTDIS (Computerized Train Despatch and Information System). It was developed because the CTDIS system ran out of resources to implement the Despatching system for which it was originally intended. During development of CTDIS it became obvious that the provision of train run numbers (a run number is a unique train identifier) was required before we could implement despatching. Signal Systems don't care what train is where, as long as they are operating at a safe distance from each other and therefore run numbers are not important. Scheduling and headway control systems need run numbers if they are to be effective.


         The provision of data to the CTDIS system (and as I understand it, also IPHC) is not as clean as possible. It comes from the signal system at a point well removed from the actual track circuit being read. It travels over repeater relays of dubious quality, reed operated and slow time displaced coding systems that do not guarantee accuracy. It meant the provision of large amounts of computer programming to clean up the data.


         When a train is operating under surveillance of CTDIS/IPHC it is not under any form of safety supervision. Any result from the system that would indicate that a train was close to an unsafe situation would be given too late to Transit Control to do anything but watch the result on the mimic board. The only human being capable of reacting to an unsafe situation in our system (which does not have Automatic Train Control) is the motorman. We HAVE to rely on him for the safe operation of the system. No one else has the information or the time to react to any situation in which an individual train could be found. The only value of this recommendation is informational.


         R7vii) "Trip valve activation on cars 3 and 5 of subway trains and relocation of trip valve reset to a more accessible location."


         Part A.          No evidence has been offered either in court or hinted at as being present in some of the mountain of documents tabled that there was anything wrong with the trip valve on run 35. Or any other train for that matter. Trains are going to trip. That's what a train stop is for. If they don't trip, lets remove them. A large maintenance problem will be solved. To put so much emphasis on not tripping, as has been done since August 11th, is to emulate ostriches as nearly as we can. It has lead to the current (March 1996) atmosphere that the Subway is not a place to operate in any more and large numbers of experienced operators are reported to be leaving the subway for bus operation where the control of management is not as intrusive. I have already discussed this in daily comments and will not repeat it here.


         I handled the suspect bolt. It is obvious to me that this bolt has been preventing the trip mechanism at SP71GT from functioning correctly for some time. If there was demonstrated wear on the rail and wheel, there is definitely demonstrated wear on this bolt and it is obvious that it has been "attacked" by an extremely large number of train wheels before run 35 hit it on August the 11th. It is also obvious from the evidence presented by Dr. Sender that if the trip valves on cars three and five were in operation, no emergency braking would have been applied as the same wheel/rail/train stop scenario takes place each time a wheel passes the trip arm, i.e. it is driven down so that the trip valve lever passes over. Therefore this recommendation would NOT have prevented the accident on August 11th.


         If the Equipment Department feels that there is a problem with the efficacy of the trip valve levers, there was no evidence presented in court. This suggestion is another from Mr. LaForce of Philadelphia.


         Part B.          It has always been my understanding, reiterated by Mr. Allen of the OTC, that the idea of putting the trip cock reset rope outside was to re-enforce to the motorman that you can trip if you like but if you do you are going to get dirty in getting the train operating again and therefore there is an incentive to not trip even though it is SAFE to do so. Moving the trip cock reset to a more "convenient" position removes this incentive not to trip. We want drivers to trip periodically. It helps them to maintain a faith in the system. If they operate so that they don't trip for fear of repercussions etc., they will operate the line at 3 miles an hour and we might as well shut down .




         R8) This recommendation has also been commented on previously. I will only say here that the idea of changing the whole system for the want of a couple of extra signals here and there is going to make us more operationally incompetent. Raising a trip arm 5 feet in front of a train is not going to protect that train and the cost will be enormous. As I suggested previously, the jury should have recommended a maximum track length. This would have solved the problem with little cost to our operations and may, in fact, improve them.


         R14) Comprehensive predictive and preventative maintenance is easy to say but very difficult to achieve. In the 1970's I produced a Signal Maintenance Scheduling system which did all the things that have been discussed at this inquest. It was removed because the signal maintainers were not comfortable with it. It was implemented before computer systems were capable of the sophisticated human interfaces possible today. Such systems are expensive, not so much in their construction (which is not cheap), but in the management of the results. Before any work is done in this area, a complete analysis of what is expected by all interested parties is required. This is tough!!!


         R15) This recommendation deals with the need for quality control in procurement. It is not quality control in procurement that is required; it is quality control in specification writing that is required.


         The Toronto Transit Commission is a public body responsible for the expenditure of public funds and under these circumstances the rule of lowest bidder is paramount. Public bodies can do no less. Unless there is some demonstrable reason that the lowest bid is not suitable, it is very difficult in a public body to go for anything other than the lowest bid. A large amount of very good work is done by the Materials Department to ensure compliance to specifications. This is usually done in concert with the requesting department. If the requesting department cannot or will not put effort into the writing of a specification that describes in exact detail what is required, all the quality control in the world will not prevent material like the Ericsson train stop from being brought to the TTC property. Quality control of this sort is very expensive in that it requires a permanent staff of TTC employees who can produce such specifications. Sometimes these employees sit around for years doing little or nothing until they are required for this function - the Signal Design Section is a good example of this as they have gone for years without designing anything. This can also lead to "rustiness".




         When I heard that we had had a Subway accident on August 11th of such a serious nature that we had killed three passengers and that this accident was likely to be laid squarely at the door of the Signal System for which I worked and have an intimate knowledge, I was determined that I would be present at any public review of the accident as I know that the media is incapable of reporting anything approaching the truth. This is very evident in this accident and was particularly drawn to my attention in it's reporting of my own testimony.


         The last few months have been very instructive to me in the operation of a Coroner's Inquest. It is not the sort of review that I have experienced before when railway accidents happen. I have seen the result of the British and American systems in such cases. In this case, I believe we have had a much better outcome than the British and American systems and I am therefore a little fearful about the call for permanent review which is one of the recommendations of this Inquest and which tends to gloss over some details. I believe we have accomplished much more than just determining that a signal system design fault caused the accident which would have been the only report of the British and American systems. We are so safe here that we have not had to set up permanent review - there is nothing for them to review!!!! We got so much more from this process. Despite my concerns about some of the recommendations, the overall tone of the recommendations is to do something about the state of the TTC which lead to the accident other than just poor signal design. The analysis and evaluation of our management and budgeting system is very healthy in my view - even though not much is likely to come from it. We have had the opportunity to clearly identify where the areas of difficulty lie and it is up to us as an organization to fix ourselves. We are not likely to get much help from outside and we must therefore do something that is not to common around the TTC and that is to do some self-starting  and try to forget the NIH syndrome – NIH?? John Harben’s favourite – Not Invented Here!!.


         As an outside observer now, I wish Mr. David Gunn and the whole TTC staff success in this improvement effort. Go to it. You have only your pensions to lose!!



                 Dave Irwin    -    11 March 1996




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