1995 Russell Hill Subway Accident - Inquest

Inquest

The jury at the coroner's inquest produced 18 recommendations:

1. Reform of the Railways Act (1950) to provide oversight of the Toronto Transit Commission.
2. The TTC should submit to an independent safety audit every two years, beyond that done by APTA. This independent agency will be set up under the revised Railway Act.
3. Completion of the "Due Diligence Checklist" of deficiencies identified by the TTC.
4. The Province and Metro commit to a "State of Good Repair" funding policy; repair to take precedence over new works (see Sheppard line); future capital funding based on the State of Good Repair. The jury indicated that underfunding since the mid-1980s has contributed to the deterioration of the system and had jeopardized the safety of the Toronto Transit Commission.
5. Improvements to the Operations Training Centre starting with the hiring of an accredited adult training specialist. The updated training package should include at least: realistic pass / fail grading, annual refresher for all operators, emphasis on the meaning of the signal system, route supervisory accompaniment for at least one day of complete runs after training completion.
6. An updated Operations Training Centre to include a suitable subway simulator.
7. A comprehensive review of the signal system with emphasis in the following areas: Lunar Whites, removal of signal identification markers, consistent placement of signal aspects, progressive speed control, expansion of IPHC to identify headway and train separation, all trip valves activated and relocation of reset.
8. Elimination of auto key-by facility and implementation of raised trip arm immediately after train has passed.
9. Advanced implementation of the new subway communications system.
10. Improved communication within the organisation.
11. A new Transit Control Centre including the updating of the skills of TTC staff.
12. The current Transit Control Centre should only be responsible for Operations. Such things as intrusion alarms, facility maintenance, public information, media relations and other related concerns should be handled by an adjacent facility.
13. Emergency response exercise every five years with "everybody". Yearly reviews by the Safety department
14. Improved predictive and preventative maintenance with computer assist where applicable.
15. Review of equipment procurement with respect to quality control. The procurement of cheap equipment (the Ericsson train stops) is a misuse of resources and a serious safety issue.
16. Traceable design criteria and standards for track, signal and subway cars. No modifications without approval of design review authority.
17. Train operators and the TTC must identify signal malfunctions by signal identification numbers. Review of the discipline system to allow for signal malfunctions. Operators reporting for duty to meet an inspector so that "State of the road" information can be passed on. Rookie operators not to be scheduled together.
18. The office of the Chief Coroner is to convene a press conference one year hence to provide all parties with an update on the implementation of these recommendations.

The 18 recommendations were taken by the TTC and turned into a 236 point 'Due Diligence Checklist' of items to be addressed. Each year the Toronto Transit Commission receives a report on the outstanding items. As of the August 2009 update only 2 of the 236 points have yet to be addressed. The two outstanding items relate to a speed control system that is currently being implemented that will reduce the dependence on signals for speed indication.