Update #2 - Carbon Monoxide Incident of February 7, 2006 (FOR INFORMATION)
Meeting Date: November 14, 2007
Subject: UPDATE #2 - CARBON MONOXIDE INCIDENT OF FEBRUARY 7, 2006
It is recommended that the Commission receive for information the updated Management Corrective Action Plan Checklist relating to the Carbon Monoxide Incident of February 7, 2006 which provides a status report on the progress toward closing the TTC Level 2 Investigation Recommendations and the Commission’s Recommendations.
On February 7, 2006, eight TTC employees were exposed to high concentrations of carbon monoxide while working on tunnel maintenance. They were rescued by Toronto Fire Services (TFS) and taken to hospitals by Emergency Medical Services. Four firefighters were also treated and released. Safety Department staff led a detailed investigation into causal and contributory factors and made several recommendations. Responsible department managers have developed corrective action plans. Toronto Fire Services have also implemented various improvements to their operational procedures. The investigation report was received at the August 30, 2006 Commission Meeting. The Commission requested a report back from Management on the status of the recommendations. The previous update was submitted to the Commission at the March 21, 2007 meeting.
In the immediate aftermath of the incident a number of urgent steps were taken to prevent a recurrence. These included the cessation of use of gasoline powered equipment for removal of man-made mineral fibre and all other underground work where a feasible alternative was available. In addition, air monitoring equipment was provided for all underground work which required the use of any fossil fuel such as diesel or propane. The subway ventilation equipment was brought up to a state of good repair on a priority basis and ventilation needs were immediately added to the work scheduling process to ensure that jobs with different ventilation requirements would not be scheduled together. These immediate actions served to prevent a recurrence of the same type of incident. An on-site audit by Safety Department verified compliance with these immediate steps.
More generally, the investigation identified four root causes and several contributory factors which could give rise to similar types of incidents. These root causes are the subject of longer term upgrades in equipment, procedures and training. These longer term actions are being tracked in the Checklist attached. Action has been taken on all the recommendations and many are fully implemented. Those that remain outstanding are being actively pursued and in all cases, the intent is being met, even though the action may not be complete and documented.
Management Corrective Action Plan Checklist
The investigation report made a number of recommendations to management. At the August 30, 2006 Commission meeting, a number of further motions were adopted by the Commissioners. The attached Management Corrective Action Checklist provides a detailed update on both the investigation report and on the Commission motions.
Some of these actions will be modified as experience is gained, to ensure the highest safety standards are implemented. These corrective actions will reduce the possibility of recurrence of serious incidents in Track and Structure maintenance to an acceptable level.
Management will continue to report to the Commission, until closure of all the recommendations.
TTC is committed to learning from all incidents and to sharing information to improve safety.
October 24, 2007