THE TSE REPORT REDACTIONS

BACKGROUND

Transit Systems Engineering is a transit system consulting firm based in Emeryville, CA that has worked for the TTC in the past. TSE was retained by TTC management to investigate the Osgoode incident of June 12, 2020. Their report of the investigation was submitted to TTC management on February 3, 2021.

Members of the Board of the Toronto Transit Commission were provided with a heavily-redacted (blacked out) version of the TSE report at a closed meeting on June 16, 2021. This redacted version was posted on the TTC website: ttc.ca. At that time, TTC management announced that a “complete” report would be given at the September Board meeting. Instead, TTC management gave an unredacted version of the report to the Board at another closed meeting on July 7, 2021.

Nearly one thousand words (25 per cent) of the TSE report were redacted by TTC management. Why? Differing explanations for these redactions were offered by TTC CEO Rick Leary and Mayor John Tory. So, the real reasons for hiding one-quarter of the report are not known. The most common speculation is that the redacted sections are criticisms of a wide range of TTC management’s misjudgements and operational failures that led to the Osgoode incident. Whatever the reasons, ATU Local 113 was able to obtain an unredacted version. Below are the sections of the TSE report that were redacted.

Words in bold type are brief summaries of the main points that were redacted.

Words in italicized type are key points in the redactions. _____________________________________________________________________

No evidence of clear and adequate instruction on move to northbound track from Transit Control to pocket train crew; no evidence crew received and understood a move order; it is imperative that Operators confirm instructions by repeating them back to Transit Control.

Therefore, it would seem reasonable that the instruction given to operators be conveyed in a way to minimize any potential mistakes. Information should include status of the signal(s) that must be observed, the position of switches that will be checked before crossing, the train run number operating ahead of the train receiving instruction (if applicable), and the clearance granted to the train before further instruction will be required. Most important, it is imperative that all operators for the intended move receive the instruction and repeat that instruction back to Transit Operations to assure receipt and comprehension of instructions. There is no documented evidence that the instruction from Transit Control included detailed directions to the operators of Run 123. There is also no evidence that the operators of Run 123 received and understood the requirements for moving the train out of the Osgoode pocket track in manual mode. This leads to question as to how the training and enforcement of Toronto Transit Commission rules for operators and controllers are conducted, and how operational reviews, and refresher courses are organized.

It is recommended that Toronto Transit Commission review and revise, as necessary, the training material as well as training schedule, refresher training and enforcement of the rules governing safe operation of revenue service operators on Line 1. The objective of such review

and revision is to ensure understanding and competency of operating personnel to carry out their responsibilities in an operating environment wherein both automatic train control and wayside manual mode are used concurrently. The revisions should include clear instructions to operating personnel on the process to be used to implement and enforce the provisions and safety rules associated with using manual mode in ATC territories. Further, to the extent that it is necessary to continue to use certain legacy terms, the revisions should clarify such legacy terms (for example “favorable”). It is imperative that clearly understood instructions be given, and legacy terms be clarified to ensure no misunderstanding by operating personnel.

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TTC must review and revise, as necessary, training materials, schedules, refreshers, and enforcement. Clearly understood instructions must be given; Clarify “legacy” terms

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No overrun protection at Osgoode interlocking; if signals had been implemented as normal, oncoming northbound train would have auto-stopped or slowed.

Based on the video “of near miss from TR 5601 Forward Cam” as provided, there appears to be no overrun protection at the Osgoode interlocking, which increased the operational risk for the northbound train 114 movement on the main line. The video shows that when Run 123 entered the interlocking and passed the axle counter and Signal X8 defining interlocking limits, Run 114 continued to move on the main line at full authorized speed, without a brake application when approaching the station platform. The normal route locking safety standard for unrestricted trains passing a restrictive signal and entering an interlocking is to put all signals protecting an established interlocking route to restrictive. Such protection, if implemented at Osgoode Interlocking, would normally have caused train 114 to immediately brake to a stop or at a minimum slow the speed prior to any fouling by Run 123. The video clearly shows that Run 114 proceeded at full authorized speed under ATC system control into Osgoode Station without any effort to stop or slow the train.

Imperative that operating personnel be given additional training and testing re: manual mode vs. ATC.

Since the manual mode of operation in ATC territories has the potential to create misunderstandings by operating personnel that could compromise the safety and reliability of the ATC revenue service, it is imperative that operators are aware of the difference between the manual mode and ATC mode. It is recommended that additional training and refresher courses, as well as testing and operational simulation, be conducted on a regular basis. The goal is to ensure that operators and affected TTC personnel are fully aware of the operating modes when utilizing the automatic train control system.

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TTC wants to minimize “wayside” equipment but traditional tripping devices stop the train much faster

However, the site-specific configuration at Osgoode interlocking could have been designed using an automatic trip stop to enforce a “stop” aspect at Signal X8. Tripping devices are much faster to stop the train when it violates a wayside signal and can therefore substantially reduce the distance a train can travel when it is tripped.

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GAMA feature at Osgoode deactivated; would have prevented potential crash; need to assess staff levels at Transit Control

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It is recommended that Toronto Transit Commission draft and implement a new operating rule to regulate the activation/deactivation of the GAMA feature at specific locations of Line 1 where this feature is needed to ensure safe operation. It is also recommended that Toronto Transit Commission assess the tower controller workload at the OCC as well as its organizational structure to determine if modifications are warranted.

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Decommissioned trip stops should be clearly identified (paint suggested) to avoid confusion caused by two signalling systems

[T]he TSE Team believes that the implementation of such markings or identifications should address any confusion by the operating personnel related to the operational status of wayside signal equipment.

It is recommended that TTC uses appropriate marking or identification (for example, paint sprayed or sign at a location) to identify decommissioned wayside signal equipment. Such marking or identification should be clearly transmitted to the operations staff. It is also recommended that operations staff be available to convey to the motor persons, on an as needed basis, the status of the Line 1 operating conditions. TTC should consider using wayside supervisors to focus and assist train operators, and monitor radio communications in the newly affected areas.

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Conclusions

The TSE Team has analyzed incident data and documents received from TTC and summarized its findings and recommendations in this report. Since the Osgoode interlocking incident, TTC has published several operational notices with the intent to prevent the occurrence of similar incidents in the future. It is understood that the ATC project is placing a significant burden on its staff and that assistance in performing their assigned duties is a factor in the undertaking. Many of the requirements for the manual operation into and out of the interlocking have been documented in the information sources published prior to this incident – the question is how they are transmitted to the TTC staff and enforced on a daily basis. There is evidence from the interviews conducted by TTC that ongoing and rapidly changing operation to support the ATC project implementation, along with putting the new signal system into operation, may be placing difficult burdens and challenges on the TTC operating staff. Conducting service delivery tasks under such additional burdens and challenges could result in hazards to normal operation. The identification of these hazards is difficult due to the ongoing significant physical and operational changes to the signal system. The new ATC system is technically sophisticated and has a different architecture and supporting infrastructure. However, some of the traditional safety functions were not provided by the ATC system and were handled as exported hazards to TTC. The TTC operating staff is now tasked with managing service delivery and ensuring safety for all operating modes and operational scenarios. For these reasons, the TSE Team has recommended a Phase II study that is based on a quantitative fault tree analysis to identify and quantify operational risks. Phase II will focus on performing a functional comparison between the original fixed block wayside signal installation (base case) and the new ATC system based on CBTC Technology (ATC case). Further, Phase II will perform a review of TTC’s operating rules and procedures and will recommend changes as appropriate. The main objective of Phase II is to assess if the implementation of the ATC system has complied with the “Minimum Performance Requirements”, i.e., that the new ATC system is as safe or safer than the previous wayside, fixed block signal installation. Once the Phase II analysis is published, the recommendation would be for the Authority to form an operations group to work with the TSE Team. During this collaboration, the operations group would be charged with a systemwide (Line 1) review of changes needed to complete the process of mitigating the identified hazards. It is further recommended that this group have a dedicated and consistent presence to assist in assuring the tasks associated with the Phase II study, as well as existing rules and regulations, are properly implemented.

Final TSE Report Document (unredacted) TSE Report (redacted) - _Transit_Systems_Engineering_Osgoode_Interlocking_Incident

Video Message from President Carlos Santos: The Osgoode Incident

Conclusions