'God shouted . . . We listened'

In the wake of the 1995 subway collision, the TTC made massive changes to its operations and emergency procedures

By JEFF GRAY
Saturday, August 6, 2005 Page M2

It’s up there on the wall, in every senior Toronto Transit Commission manager’s office: A close-up, colour poster that shows the wheel of a subway car, the rail and a metal device, about the size of your forearm, attached to the tracks.

To the trained eye, says the TTC’s deputy general manager of corporate affairs, Lynn Hilborn, it shows a worn subway wheel, riding on beat-up tracks. And it shows that little metal trip arm, meant to flip up and trigger a train’s emergency brakes, failing — just as it did one Friday rush hour in August, 1995, allowing one train to plow into another, taking three lives.

The photo, taken during a technical reconstruction of the crash, hangs on the wall as a symbol of the catharsis the entire organization experienced after it happened, and as a caution to its staff never to allow it to happen again.

“God whispered in our ears,” says Mr. Hilborn, a long-time TTC official, who had trouble sleeping for at least two years afterward. “In fact, some would say God shouted in our ears. We listened.” He says that in addition to obvious, and unacceptable, wear and tear on the wheel and the track, the photo shows the subway wheel nudging the bolt at the base of the trip arm, rendering it useless. Despite regular inspections, no one noticed the problem.

But far from reducing the crash to one faultily installed part, the picture tells the story of the TTC a decade ago — a muddled organization, officials say, that had let safety standards and everyday maintenance slip. It’s a lesson transit commission officials say they have now learned, pointing to extensive changes made to operations, driver training, the signal system, emergency procedures and safety standards since the 1995 crash.

David Gunn, the TTC’s chief general manager at the time, flew back from his Cape Breton summer home to deal with the crash. He knew the organization’s problems ran deeper than a series of badly installed trip arms, which were replaced almost immediately after the accident, across the system.

“The TTC had become somewhat complacent, sort of living on its reputation,” says Mr. Gunn, now head of the American rail agency Amtrak.

Long before a grim meeting with his senior staff the Monday after the crash, Mr. Gunn knew the TTC’s bloated and confused management structure, based on concepts like “business units,” wasn’t working. But even he was surprised that morning in a boardroom at the TTC’s Davisville headquarters at how removed senior managers were from day-to-day operations.

He asked the assembled brass to detail how the signal system, which had failed spectacularly, was supposed to work. But a clear answer wasn’t forthcoming.

“It suddenly became obvious to me that the people in that room couldn’t explain it,” Mr. Gunn says. A signal foreman still in his hard hat, promoted soon afterward, was called in to explain the system, and how to fix it.

The straight-talking Mr. Gunn, who would later baldly state that the TTC “killed three people,” stresses that those managers were “not bad people.” But the bloated organizational culture had blurred the lines of accountability, putting people in charge of departments doing technical work they did not understand and allowing maintenance to slide.

Worse, Mr. Gunn says, the TTC’s engineers had been hived off into a separate unit concerned with the design and construction of four new subway lines. (Only one, the Sheppard line, would be built.) “The engineering people had been put off basically in Neverland, basically worrying about the four new subway lines, not worrying about the day-to-day operation.”

Almost right away, Mr. Gunn began reorganizing, reverting to what he called a “19th-century railroad model” with surface routes separated from the subway and “general superintendents” with technical expertise held responsible for tracks, signals, subways cars and so on. New staff from the railways and from the military were brought in.

“When you wanted to talk signals, there was one person, the general superintendent … and if you’re going to build a new subway line, that guy is going to tell you what kind of signals to put in it,” Mr. Gunn says. “You are not going to have some consultant or somebody else. And that was a sea-state change in the way we treated the maintenance folks… . It is very traditional. And it works.”

At the same time, the transit commission launched a massive re-evaluation of its safety standards and procedures, calling for more than 200 changes even before a coroner’s inquest would add its own a year later. Among them was a new, $70-million high-tech transit-control centre, which opened last year.

Mr. Hilborn says “99.9 per cent” of the recommendations have been implemented, with a new speed-control system (which will set off an alarm at headquarters if a subway driver is going too fast anywhere on the system) to be installed next year.

Some of the changes seem obvious now. For instance, subway operators were given just 12 days of training (they now get 30), and given the answers to their tests to prevent them from failing. This lax approach extended to a lack of discipline for drivers who ran red signals. At the time, not all red lights meant the same thing, and emergency breaks were meant to kick in should the driver confuse them. (The driver of the runaway train, then 37-year-old Robert Jeffrey, was on his second day on the job, and fled his cab when he saw the impending collision. He would leave the TTC a few years later.)

The transit commission’s communications system, now upgraded, meant that paramedics trying to rescue passengers in the tunnel couldn’t use their own radios. As well, water leaks in tunnels, many of which have been plugged, were shorting out signals. Officials went over the entire system, looking for signs of aging or wear and completely redesigning the TTC’s maintenance rulebook. The system, Mr. Hilborn said, was aging rapidly, and the TTC’s maintenance standards hadn’t kept pace.

“It’s like someone middle-aged waking up one morning and saying, ‘I’m not the 30-year-old guy or the 20-year-old guy I used to be. I’m now 40 years old. And now I’ve got to start taking care of myself.’ “

This led to the now-sacrosanct idea of the TTC’s “state of good repair” budget, for which, in the wake of the accident, the TTC was able to secure more than $1-billion over five years from the newly installed Conservative provincial government of Mike Harris, which was bent on cutting costs. While the Harris plan no longer exists, the TTC continues to have a state of good repair budget, which is non-negotiable and is always funded first, before money goes to expansion or anything else.

With calls for the TTC to focus on maintenance of the current system, the province also quashed its subway expansion plans, with the exception of the Sheppard line.

TTC officials insist that the subway system has never been safer, and point to a glowing external safety audit, just completed by the American Public Transit Association, to prove it.

But Mr. Hilborn acknowledges that there is of course no way to absolutely guarantee safety in the TTC’s tunnels, no matter how many precautions are taken. However, he says a similar accident now is significantly less likely than it was in 1995.

“Our job is to think ahead of the curve as best we can… . Hopefully, one does one’s best effort. That’s what due diligence is all about, to ensure that an accident does not occur.”




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