Lack of awareness of fellow workers blamed for fatality

(Canadian OH&S News)

A lack of awareness of nearby co-workers contributed to the death of a worker last year, the Toronto Transit Commission (TTC) said in a recently released final investigation report.

At about 4:45 a.m. on Sept. 14, 2012, TTC employee Peter Pavlovski, 49, a roadmaster and supervisor in the TTC’s Rail Infrastructure Department, was struck and killed by a work car on subway tracks just north of Yorkdale Station, said the report, released on Oct. 21. His co-worker, a track mechanic, suffered serious head lacerations and contusions to his chest and legs. The operator of the work car experienced serious chest pains, and underwent treatment for a heart condition.

On the morning of the accident, Pavlovski and the track mechanic were inspecting track defects beyond the bounds of an established work zone, but neither worker had requested permission from the Transit Control Centre to conduct a walking inspection, as required by the Subway Rule Book, the report said. Consequently, the control centre did not make a radio call to alert work car operators of the workers’ presence.

The TTC’s report identified three causal factors in the accident:

* The two-person track crew did not notify the Transit Control Centre of their intention to enter the southbound track for a walking inspection;

* Both the roadmaster and track mechanic were not aware of the approaching work car in time to avoid contact; and

* The work car operator was not aware of the presence of workers at track level in time to avoid contact.

TTC issues nine-point corrective action plan

TTC management has responded to recommendations contained in the report with a nine-point corrective action plan and status updates:

* Review protocols and practices between the Rail Infrastructure Department and Transit Control Centre with an emphasis on non-revenue maintenance. Status: A track level serious injury prevention team has been established;

* Implement a corporate-wide process for reporting, investigating and communicating all safety-related incidents. Full implementation is expected by the third quarter of 2014;

* Refit all work cars with brighter LED headlights. Status: Completed;

* 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 dangers of approaching trains. Status: Feasibility study of permanent watchperson duties to be completed by February 2014; awareness campaign now under way;

* Review applicability of new warning device technology for those performing maintenance at track level during non-revenue hours. Status: Completion expected by May 2014;

* Review work car operator duties, including any physical barriers or ergonomic issues related to the cars. Status: Consultation and evaluation under way; to be completed January 2014;

* Evaluate the use of the blue light system used during revenue service and its applicability to non-revenue maintenance. Status: Permanent operating rules committee to be established in November 2013;

* Conduct a thorough review of the Subway Rule Book to identify changes required to specifically address non-revenue maintenance. Response: Will be included in the operating rules committee to be established; and

* Establish a formal governance process for the rule book that considers all track users and fosters continuous improvement, as well as provides authoritative interpretations and effective enforcement of all rules. Response: To be included in the operating rules committee.

In addition to the TTC’s own investigation, Ontario’s Ministry of Labour, assisted by the Toronto Police Service, conducted a full investigation of the incident, but decided against laying any charges.