MEETING DATE: May 31, 2000

SUBJECT: SUBWAY OPEN DOOR INCIDENTS

To receive the following report for information

None at this time

On April 18^th, 2000, eastbound leaving Keele, run # 75 was experiencing an "air leak" which caused the main reservoir air pressure to drop to 80 p.s.i. from the normal operating pressure of between 120 to 135 p.s.i. in the guard’s car of the train. The guard took what he believed to be necessary action in order to correct the problem.

After opening the passenger doors at Dundas West station, the guard left the fifth car and proceeded to the fourth car, where he heard an air leak. The guard activated the "coupler isolation valve" in the fourth and fifth cars in an effort to stop the air leak. Continuing to hear the air leak, he performs a midpoint isolation. These activities were done without the Transit Control Centre’s knowledge or permission. These actions electrically isolated the trailing two cars from the first four cars. The guard then activated the passenger door "close" button from the fourth car. All passenger doors on the first four cars closed normally, and the guard failed to notice the doors on the last two cars remained open as the train departed Dundas West station.

A customer, on the trailing car, seeing the doors open activated the Passenger Assistance Alarm (PAA) in an effort to bring the issue to the train crew’s attention. As there were no immediate results, the same customer activated the Passenger Guard Emergency Valve (PGEV) at the cab of the trailing car. The brakes activated however, due to the coupler isolation the braking was insufficient to stop the train and it continued through the tunnel with the passenger doors open. The guard while in the fifth car also activated the PGEV from the guard’s cab with the same result. The guard then called the operator and ordered the train stopped. The train was immediately stopped in the tunnel, and the guard closed the doors on the last two cars. Moments later the guard entered the sixth car and proceeded to the cab at the trailing end and deactivated the PAA in that car.

The train proceeded to Lansdowne station where the customers were "off loaded" and the train taken "out of service". There were no reported injuries. The delay was aggravated further when the incident train went disabled again east of Dufferin station and had to be coupled and pushed to Greenwood Yard by the following run #76.

Once the magnitude and possible consequences of the situation were identified, the TTC initiated a full investigation into the incident. Subway Transportation and Rail Cars and Shops Departments provided full and co-operative support to the Safety Department leading the investigation. Briefly described below are the significant findings and remedial actions taken to date:

• The drain valve on the bottom of the main reservoir on the fourth car of the train was found in the open position, believed to be caused by a piece of debris at track level, possibly a plastic grocery or garbage bag. All valve handles on vehicles servicing the Bloor/Danforth subway line have now been secured in the closed position by a plastic tie-wrap. This improvement will be completed on all vehicles servicing the Yonge/University/Spadina subway line by May 31, 2000.

• The "coupler isolation valves" were activated by the guard, without the knowledge or permission of Transit Control. Access doors to "coupler isolation valves" are being modified to allow the placing of a seal. The purpose of the seal is to reinforce the necessity of requesting permission from Transit Control to perform coupler isolations or mid-point isolations.

• Removal of the coupler isolation procedure during known air leak situations from all subway training programs is being considered.

• The guard changed positions from the fifth to the fourth car and isolated the couplers between those two cars. A notice has been issued that states "All guards MUST perform their duties from the fifth car at ALL times unless permission is granted from Transit Control, effective immediately".

• The guard initiated what he believed to be actions that would improve the situation, when in fact the situation became worse. Subway training and re-certification will be strengthened, as necessary, to reinforce to operating personnel the need to obtain Transit Control’s authorization to isolate or alter any equipment, as well as proper "guarding" procedures.

• The feasibility of implementing a door interlock device or sensor on the "H" cars that will not allow the doors to be opened while the train is in motion is being reviewed by TTC Engineering staff.

Unrelated to the incident at Dundas West, on May 12, 2000 at 7:30 am the doors on run #94 opened while the train was leaving platform two at Kennedy Station. A Surface Route Supervisor was the guard trainee in car 5637. With the doors closed, the trainee believed he could close the guard’s window by using the door control buttons. He activated the red buttons causing the doors to open while the train was in motion. The instructor intervened immediately and ordered the guard trainee to close the doors. A tower supervisor on-site confirmed that the doors were open for approximately two seconds. There were no reported injuries.

The window in the cab is manually operated and not interlocked with the door controls. Although the direct cause of this incident was the trainee did not following proper procedures, a standard or means to determine a trainee’s competency level before being allowed to operate a TTC vehicle in revenue service is being pursued. This incident further reinforces the need for a door interlock device or sensor.

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May 23, 2000

13.34.34