Track inspector killed after being struck in Toronto’s subway system
The 49-year-old Toronto Transit Commission (TTC) worker was struck and killed in September 2012 in the subway system by an approaching work car. Neither Pavlovski nor the subway car driver were aware of one antother’s presence, a transit service investigation has revealed.
Released late last year, the TTC report indicated Pavlovski, who was a roadmaster and supervisor with the rail infrastructure department, had been conducting a track-level inspection just north of Yorkdale station — a stop near the track’s north end — when he died. His co-worker, a track mechanic, was seriously injured and the work car operator was hospitalized with a heart condition.
A communication breakdown was the foremost factor leading to the fatal incident, according to the TTC. Pavlovski’s two-man crew did not notify the Transit Control Centre of their intention to enter the southbound track for a walking inspection — meaning neither the inspectors or work car were aware of each other’s presence.
"If you get down to the root cause of why they didn’t call in, we found it was largely procedural in terms of the relationship between the workers who are doing the maintenance and the Transit Control Centre," said John O’Grady, the TTC’s head of safety and environment.
Of particular concern is that there was no designated watch person to keep an eye out for approaching vehicles, poor lighting on the cars and that — despite an internal phone system with outlets every 500 metres or so underground — the crew failed to notify the control centre.
"The protocols under which that relationship worked needed to be improved. And also that the rules reflect the different risk profile of maintenance when there are trains operating in revenue service and when they aren’t," O’Grady said. "The rules, the risks, aren’t going to be the same. So that was the underlying reason pointing to the corrective action."
That corrective action plan includes nine objectives, all of which the TTC plans to implement by the end of 2014. It includes reviewing protocols between the rail infrastructure department and control centre, establishing a track level injury prevention team, implementing a corporate-wide process for reporting, investigating and communicating safety-related incidents and refitting all work cars with brighter LED headlights. As well, the transit service intends to assign a dedicated watch person for track level walking inspections, review its warning systems and work car operator duties, evaluate the use of the lighting system used during service and non-service hours, and review the official subway rule book.
Following Pavlovski’s death, the Ontario Ministry of Labour (MOL) also launched an investigation, but decided not to lay charges.
Further complicating the matter is that Yorkdale station was undergoing construction — which brought forth a slew of new safety risks.
"Construction workers on transit projects, including those working on subway tracks, must be aware of things such as contact with moving vehicles — working cars, trains — musculoskeletal injuries from lifting and or the use of equipment and tools, slips, trips and falls, contact with electrical equipment or potential exposure to designated substances," said Matt Blajer, spokesperson for the MOL. "Beyond the risks associated with any construction project, transit sites have risks such as the isolation of electrical power — for example, ensuring power is isolated to site of construction — signage and traffic control plans, as well as appropriate personal protective equipment, and means to summon assistance in concert with a site-specific emergency plan."
Because maintenance work typically happens during off-hours, visibility also played a major role.
"It’s a different environment at night, and that needs to be considered. And why they didn’t see the train coming speaks to the quality of the lighting on the work car," O’Grady said, adding that a watch person (currently not mandatory under the TTC rule book) would have reduced the risk. "In lieu of a watch person there are at least five or six companies marketing track level warning devices which would provide an alarm to the crew at track level and also to the train operator."
But one thing the TTC need to account for is human nature, according to Bob Kinnear, president of the Amalgamated Transit Union Local 113, which represents TTC staffers.
Human nature can lead to danger, Kinnear said, acknowledging a TTC project which looked at behavioural science of its workers.
"What the (TTC) report suggests — and probably accurately so — is that they did not have permission to be on the southbound track. But human nature is, they’re already at track level, they want to have a quick look at something. ‘Oh, we’ll just have a quick look,’" he said. "This behavioural science program was supposed to do exactly the opposite... when those situations arose, the red flag was supposed to come up and they were supposed to say to themselves, ‘Hey, no, that’s not how we do things.’"
In order to mitigate those risks, as well as others associated with transportation and construction work, Kinnear suggested revamping the TTC’s communications system as well as installing indicator lights on catwalks to let work car operators know if there is occupancy at track level.
"I think when you have workers working in the very confined work areas that they work, under very difficult and dangerous conditions, working with heavy machinery, I think it’s next to impossible to guarantee the safety of every worker," Kinnear added. "In saying that, I do believe that some of the measures I’ve spoken about may have or would have at the very least reduced the possibility of that occurring."
However, the focus for the TTC at this point is worker engagement. That includes roundtable discussions at all employee levels to brainstorm methods of improving safety.
"The bottom line is that the set of rules that govern maintenance during non-revenue hours will be credible with the workers, and the people working under those rules will enforce them amongst each other and they will provide stronger protection for them as well," O’Grady said. "That’s really the bottom line — we need a rulebook that is credible and doable and is widely adhered to."
