Findings from four external expert reports have not yet been shared at a public TTC Board meeting
Toronto, ON (February 22, 2024) -- The TTC was warned in advance about two of the “contributing factors” to the July 2023 derailment of the Scarborough RT and had stopped doing some preventative maintenance work, according to external consultant reports. The four reports were discovered on the TTC’s website by independent transit expert Steve Munro, but have not been reported to TTC Board members in a public meeting. Transit advocacy group TTCriders is urging accountability and transparency about the reports’ findings.
“TTC management needs to answer for why they failed to act on warnings about Scarborough RT maintenance, why they stopped some preventative maintenance work, and why external expert reports have been kept quiet instead of being shared publicly at a TTC Board meeting,” said TTCriders director Shelagh Pizey-Allen. “These reports raise troubling questions about how maintenance and inspections happen across the entire TTC subway system, not just the Scarborough RT. Toronto residents and transit users need honest answers and accountability.”
One of the four external consultant reports notes that “in early 2023,” the TTC received external advice that defects were not being managed effectively and that additional staff should have been helping to patrol the tracks. The consultant report by Network Rail Consulting states:
“In early 2023, I expressed my concern to Track about restricting track inspections to patrollers only. The following hierarchy of inspection was proposed to address this issue…” (p. 12, NRC report, emphasis added).
“In early 2023, I investigated the defect and priority classification and presented a revised defect priority regime to TTC Track and Engineering as the defect numbers throughout the TTC system are far higher than expected, currently around 12,000 in total for all defect types, thus making effective defect planning impossible to reduce in number.
Using colour codes is not an effective way to manage defects. Instead, I proposed using a monthly coding system which allows a better level of planning for the more severe defects and allows for defects to be moved up the priority scale as reported by the patrollers” (p. 13, NRC report, emphasis added).
The consultant report written by Systra Canada concludes that while the root causes of the Scarborough RT derailment on July 24, 2023 are known and “come from a failure of the reaction rail anchors which caused the reaction rail to lift,” the “derailment can also be explained by several contributing factors” (p. 21, Systra Canada report). Of the seven factors listed, two were identified by Network Rail Consulting in early 2023: The poor prioritization of defects and lack of experience of track patrollers.
The same report notes that another contributing factor was the reduction of preventative maintenance work after the TTC announced that the Scarborough RT would be closing in the future. The “anchor bolts were never subjected to preventive maintenance” (p. 20, Systra Canada report) and “the reaction rail was no longer maintained in a preventive way leaving only the 72 hours track patrols to detect any potential issues” (p. 16, Systra Canada report).
The consultant reports contain potential clues as to why the TTC introduced widespread “Reduced Speed Zones” (RSZs) on the subway network in late January 2024. The Network Rail Consulting report recommends that track inspectors be trained in the risks of “combination defects” and notes that “realising the impact of multiple defects in the same location would change the priority and could require an RSZ” (p. 12, NRC report).
“The fact that the TTC introduced Reduced Speed Zones across a significant part of the subway system in late January 2024 adds to our concern about maintenance and safety across the system,” said Pizey-Allen. “Are there concerns that are only now being discovered? Why have track conditions been allowed to deteriorate so badly?”
The TTC Board received a presentation about the Scarborough RT derailment in September 2023, but the four external consultant reports have not been reported to a public TTC Board meeting or published as part of a meeting agenda.
Highlights from key consultant reports:
Network Rail Consulting report, published August 23, 2023: https://cdn.ttc.ca/-/media/Project/TTC/DevProto/Images/Home/About-the-TTC/Car-Derailment-Investigation-on-the-SRT-System-within-the-TTC-Network.pdf
At the time this report was written, forensic analysis and identification of root causes were still ongoing. However, the Network Rail Consulting report states that “the following can be attributed to the accident:”
- “Lack of sufficient training on the reaction rail;”
- “Prioritizations of reaction rail defect;”
- “Removal of reaction rail defects;”
- “Focusing only on red and yellow defects; and”
- “Gaps in the TTC track standards;”
- “Relying solely on patrollers inspecting the track and having no mandated hierarchy for track inspection.”
The Network Rail Consulting report makes a number of recommendations, including two that the TTC was warned about previously:
- “Proposed Hierarchy of Inspection”: The report states that “in early 2023, I expressed my concern to Track about restricting track inspections to patrollers only,” and that an inspection hierarchy was proposed.
- “Revised Defect Priority Regime”: The report states that the TTC is not using an effective system to manage defects and notes that Network Rail proposed an alternative system in early 2023.
Systra Canada report, published November 30, 2023: https://cdn.ttc.ca/-/media/Project/TTC/DevProto/Documents/Home/About-the-TTC/TTC_final_report_Line_3_SRT_Version-D_2023-11-30.pdf
Seven “contributing factors” to the derailment were identified by the Systra Canada report:
- “Data Migration from MOWIS to MAXIMO,” a change in the software that the TTC uses to track defect data; the report calls for this migration to be “reviewed and better documented”;
- “New anchor bolt design,” which the report calls “questionable” and which lacks supporting engineering documentation;
- “Reduction of preventive maintenance” after the line was announced to be closing.;
- A lack of “top cap painting,” which made it more difficult for track patrollers to detect issues with the condition of the reaction rail;
- “Training and experience of track patrollers.” The report found “the experience of the track patrollers is low” and suggested their training be updated;
- “Priority level.” The priority given to defects was described as “problematic” because of a lack of criteria and because defects are evaluated individually, so a combination of defects is not considered when assigning a priority level - meaning the severity of defects were underestimated;
- “Reaction Rail height measurement,” which the report says should have happened more frequently.
The Systra Canada report makes six recommendations:
- “Improve communication and training between maintenance personnel,” and involving personnel such as forepeople, roadmasters, and other roles in the track patrols;
- “Improve the priority level definition,” in order to interpret the severity of defects and “assign an appropriate priority level to a combination of defects”;
- “Define a clear inspection program for track survey” [this recommendation is specific only to the Scarborough RT, as the investigation did not evaluate processes used on subway lines];
- “Improve maintenance organization” by clarifying the roles and responsibilities of different departments;
- “Audit the engineering review process” to make sure future “design changes such as the new anchor bolt design is reviewed diligently before being released”;
- “Update maintenance procedure documentation.”
- Track geometry is meant to be checked once a year and that “the last passage has not yet been confirmed by TTC, but it seems to be in 2018 or 2019, which is a long time until 2023 without geometry survey” (p. 14, Systra report).
Hatch report, published September 28, 2023:
https://cdn.ttc.ca/-/media/Project/TTC/DevProto/Images/Home/About-the-TTC/Scarborough-Rapid-Transit-SRT-Vehicle-Accident-Investigation-Report.PDF
Gannett Fleming report, published October 12, 2023:
https://cdn.ttc.ca/-/media/Project/TTC/DevProto/Images/Home/About-the-TTC/SRT-Derailmnent---Ellesmere-Station---Forensic-Assessment-Report.pdf