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METRO TRANSIT RAIL SAFETY — RAIL ACCIDENT FINAL REPORT INTRODUCTION Date & Time: (08/25/14 1:06 p.m. Location: Green Line Main Track 1 at Chatsworth Street (St. Paul) LRV: 206x245x254 Operator: 72196 Brief Descripti Westbound Green Line train struck a trespasser that was walking in the right of way. INVESTIGATION METHODOLOGY The Safety Department is responsible to conduct an investigation of rail accidents and relies heavily on the expertise of law enforcement and emergency services personnel (where appropriate), rail operations and maintenance staff, as well as its own experience. This report is formulated on observations at the incident scene, interviews with appropriate personnel, review of other agency and internal reports, and follow-up analysis. The involved agencies, personnel, and applicable reports are summarized below. DISCUSSION OF EVENTS AND ANALYSES Facts Surrounding the ‘Accident and Initial Response: Chatsworth St. is @ north/south street that crosses the LRT tracks at grade in the middle of University Avenue. The LRV departed Victoria St. station and accelerated; the horn could be heard sounding for a prolonged period prior to the collision. The trespasser crossed from the south side of University Ave to the right of way at a location other than a crosswalk. He went between the tracks by utilizing the space between a catenary pole and the inter-track fencing. After crossing to Main Track 1, the trespasser walked westbound toward Chatsworth St. prior to being struck (see figure 1). The trespasser admitted to police that he was wearing headphones and that he saw but did not hear the train. The trespasser sustained @ compound fracture to his left leg, a severed Achilles tendon, and a large head laceration. The LRV was operable from the scene. Investigatio The accident was investigated by MTPD, along with Rail Operations and Safety staff. Reports Reviewed: SSR #560904 Train Operator's accident report Responding supervisor's report MTPD internal accident report Final Accident Report: 8/25/14 Green Line ~ Accident @ Chatsworth St. Page of 4 Event Recorder Data Reviewed: ‘The LRV’s event recorder was downloaded and reviewed. The download shows that the train departed Victoria Station westbound and began to accelerate. The high horn showed being sounded continuously from 13:07:44.2 until 13:07:54.0. (This is consistent with the onboard audio recording of the horn being continuously sounded | for 9.8 seconds leading up to the accident.) The event recorder indicated that when the horn was initially sounded, the LRV was operating at a speed of 33.8 MPH, but continued to accelerate. The posted track speed for this section of track is 35 MPH, The train continued to accelerate until reaching a top speed of 38.8 MPH. In total, the train exceeded the posted speed limit for 7.8 seconds, all during the period of time during which the horn was being sounded as a warning to the trespasser on the tracks ahead. At 13:07:52.5 and at a speed of 35.8 MPH, the emergency brake was applied The train came to a stop at 13:07:59.0, for a total stopping time of 6.5 seconds. ‘According to the Knorr braking table, a train traveling at 36 MPH should take approximately 7.38 seconds to stop. The results were reviewed by a representative of, Siemens, the manufacturer of the LRV. The Siemens representative noted that at the Point the train exceeded the posted speed limit, the operator moved the master controller handle into the first position of braking. This position is used as a form of Cruise control on these type LRVs and the train would not slow below that speed until more braking was applied. The Siemens representative also noted that during the time the horn was being sounded, the train made a more gradual application of the brake (not consistent with an attempt to avoid an imminent collision) until the last moment, Video Reviewed: “The LRV's video was downloaded and reviewed. The train departed Victoria St. station and accelerated. Shortly after leaving the station, the LRV could be heard sounding the horn for over 9 seconds. Its difficult to determine exactly where the trespasser came from, but a small dark area in the video can be seen moving from Main Track 2 side to Main Track 1. It appeared this person might have used the space between the catenary pole and inter-track fencing to cross through. As the train approached Chatsworth St., the trespasser became clearly visible walking in the right ‘of way in a westbound direction (with his back to the train). The trespasser was never ‘observed making any motions or indication of his awareness to the presence of the LAV. Aloud “thud” was recorded by the on board microphones as the pedestrian was struck by the LRV. After impact, the LRV came to rest with the operating cab ‘occupying the western crosswalk of Chatsworth St. The interior cameras of the LRV recorded the trespasser lying on the eastern end of the grade crossing on Main Track 2sside. The video also revealed passengers activating the emergency door releases, and exiting the train onto the right of way shortly after the colision. Those who exited the train stayed on scene and told police that they exited the train to “lend assistance” to the injured party. Interviews Conducted: ‘The train operator was interviewed by MTPD and Rail Safety. Drug/Alcohol Test Results: ‘The operator was tested for drugs and alcohol post accident ay Il I ‘Other: This accident was reported to SSOA within the two hour threshold and was reported to the NTD. Final Accident Report: 8/25/14 Green Line ~ Accident @ Chatsworth St. Page2of 4 ‘Analysis of the Facts: CONCLUSIONS ‘As the LRV accelerated westbound away from Victoria St. station the operator reported to police that he observed an individual in the right of way and sounded the horn and applied emergency brake. Our investigation found that the train was sounding @ warning all the while the ‘trespasser was in sight, while not applying sufficient braking to stop the train short of the hazard. At the posted speed of 35 MPH, the Knorr braking table indicates a stopping time of 7.14 seconds. Even at the maximum speed of 38.8 MPH shown by this train, the Knorr table indicates a stopping time of 8.09 seconds. Instead, the operator began sounding his horn at a speed of 32 MPH and continued to sound it for 9.8 seconds while accelerating to a higher speed, in fact a speed in excess of the ‘maximum allowed, resulting in insufficient time to stop short of the person on the tracks ahead. When he determined that his warning attempts were going to be unsuccessful in averting the collision, it was too late to stop the train. Had the operator began more aggressive braking at the same time he began sounding his, horn, its likely that this accident would have been prevented. Transportation management reviewed the operator's work history and determined that over the previous three day period, the operator had worked in excess of 13, hours of overtime. The day prior to the accident, the operator reported that he was off work for eight hours, though reviewing his HASTUS mark up, it was discovered that the operator was only off for 6 hours and 58 minutes. Transportation management also determined that on the day prior to the accident, the operator was on duty for sixteen hours and ten minutes, which is in violation of Metro Transits sixteen hour ‘maximum on duty time rule. On Monday 8/25/14, the operator checked in at 3:36 ‘a.m, The video recording of the check could not be played but the audio of the job brief does not indicate any fatigue related issues. Though hours of service rules were violated and this operator has a demonstrated pattern of working many hours, fatigue could not be concluded to be a factor in this accident. Ultimately, the trespasser has to be accountable for his actions, as the LRT right of way is not intended as a place for 2 pedestrian to walk. However, the train operator observed the person in the right of way and took no immediate action to prevent the collision when there was enough time to stop and avoid. Rather, the operator merely sounded the horn and went into emergency brake only at a point when the collision was inevitable. Primary Cause: Pedestrian trespassed into the right of way, placing himself in the dynamic envelope of the train Contributing Factors: (Operator failed to react to the hazard and control his train in @ manner that could have prevented the collision. Final Accident Report: 8/25/14 Green Line - Accident @ Chatsworth St. Page3 of 4 [ Other Findings 7 | Comments: This is the second consecutive accident investigated (and the fourth this year) where speed in excess of the posted limits was found in the related investigation. This could seem to imply a pattern of non-compliance with basic rail rules and procedures that should be addressed. So far in 2014, operator actions have been the primary cause or contributing factor in seven of 26 collisions (27%). This is in stark contrast to the prior 9+ years, where operator actions contributed to or were the primary cause of only 3 of 79 collisions (4%). Operator training and compliance seems to be a factor that needs further attention. While fatigue cannot be determined to be a factor in this incident, the investigation process did reveal that the involved operator had violated the company’s policy on hours of service on the prior day. Metro Transit needs to adhere to stricter compliance with its own policies to manage fatigue. After the accident, several passengers left the train by activating the emergency door releases and entered the right of way. This could have caused additional problems with other train movements or the flow of traffic itself on University Avenue. All of the above items should be subjects for discussion at an After Action Review to be scheduled in the near future. Should any additional information surface that would alter or change any of the above conclusions, the Metro Transit Safety department reserves the right to amend this report and forward any such revision to the State FINAL REPORT INFORMATION Safety Oversight Agency (Minnesota Department of Public Safety). Prepared By Eric Anderson, Rail Safety Officer Date 8/27/14 Reviewed By John MacQueen, Rail System Safety Manager Date 8/27/14 Reviewed By | Michael J. Conlon, Director- Rail & Bus Safety Date | 8/27/14 Final Accident Report: 8/25/14 Green Line ~ Accident @ Chatsworth St. Page 4of 4