Office of the Chief Executive10/21/13 10:01 PM
Yorkdale Fatality Investigation Report
In the early morning hours of September 14, 2012, the TTC lost one of its own when Peter Pavlovski was struck and tragically killed by a work car on the southbound subway tracks, just north of Yorkdale Station. Peter was a husband, father, son, brother and uncle; he was a family man. He was also a colleague and dear friend to many of you.
I made a commitment then that the TTC would leave no stone unturned in its investigation into Peter’s death and the serious injuries suffered by his co-worker. The Work Car Operator was also hospitalized with a heart condition following the incident. This Wednesday, staff will table its accident investigation report with the TTC Board. The Yorkdale Fatality Investigation Report will also be made public today.
The report’s outcomes were shared with Peter’s family and co-workers last week. It’s important that you, as TTC employees, are also aware of the report’s findings.
The Ontario Ministry of Labour also investigated this tragedy and concluded no charges would be laid.
Three causal factors have been identified as contributing to this incident. Nine corrective actions have been tabled for action; I intend to implement each of them.
1. The two-person track crew did not notify the Transit Control Centre of their intention to enter the southbound track for a walking inspection.
2. Both the Road Master (Peter) and a Track Mechanic were not aware of the approaching work car, RT-4, in time to avoid contact.
3. The Work Car Operator was not aware of the presence of workers at track level in time to avoid contact.
Corrective Action Plan
1. Review protocols and practices between Rail Infrastructure Department and Transit Control Centre with an emphasis on non-revenue maintenance consistent with the need to ensure safe passenger service. Response: Track Level – Serious Injury Prevention Team established.
2. Implement a corporate-wide process for reporting, investigating and communicating all safety-related incidents. Response: full implementation by third quarter 2014.
3. Refit all work cars with brighter LED headlights. Response: completed.
4. Pending review of track-level warning technologies, assign a dedicated Watchperson for all walking inspections at track level, as well as create an internal awareness campaign around the danger of approaching trains. Response: feasibility study of permanent Watchperson duties to be completed by February 2014; awareness campaign now underway.
5. Review applicability of new warning device technology for those performing maintenance at track level during non-revenue hours. Response: complete by May 2014 for 2015 budget submission.
6. Review Work Car Operator duties, including any physical barriers or ergonomic issues related to the work cars. Response: consultation and evaluation under way, to be completed January 2014.
7. Evaluate the use of the blue light system used during revenue service and its applicability to non-revenue maintenance. Response: permanent operating rules committee to be established in November 2013.
8. Conduct a thorough review of the Subway Rule Book to identify changes required to specifically address non-revenue maintenance. Response: part of the permanent operating rules committee noted in Corrective Action No. 7.
9. Establish a formal governance process for the Subway Rule Book that considers all track users and fosters continuous improvement, as well as provides authoritative interpretations and effective enforcement of all rules. Response: part of the permanent operating rules committee noted in Corrective Action No. 7.
This past year has been an extremely difficult one for Peter’s wife, their three young children, extended family and their many, many friends. I have been moved on more than one occasion at the support and friendship those of you who knew Peter have shown his family.
The TTC, like all public transit systems, makes safety a priority in all that it does. Safety, as you know, is one of the seven strategic objectives in our Corporate Plan. And while the TTC has a long and proud commitment to safety, we can, and must, always strive to do better. Each of us has a role to play in ensuring our own safety and the safety of our colleagues.
Chief Executive Officer
October 21, 2013
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