On April 3, 2024, the advocacy group TTCriders submitted a request to the City of Toronto Auditor General for a review of TTC maintenance practices. This arose both from the July 2023 SRT derailment and other recent events on the subway including a broken switch and a flurry of slow orders.
Full disclosure: I was asked to review a draft of the TTCriders letter and suggested minor edits, but am not a party to their request.
Both in the staff presentation at the TTC’s September 26, 2023 Board Meeting and in comments responding to TTCriders, the TTC has been quite clear that it regards the root cause of the SRT derailment to be loose mounting bolts for the reaction rail. This does not tell the full story, especially in light of consultant reports that were published well after the September 26 meeting.
The published version of the Network Rail report is dated August 23. The Hatch report is Sept 28. Gannett-Fleming’s is Oct 12. Systra’s is Nov 30. For an extensive review of these, see my previous article:
A common thread in the consultant reports was that inspection and maintenance practices were inadequate, staff were not trained in the potential danger of defects that they discovered, and many staff were juniors who had not fully qualified as track inspectors. At the time, this was treated as a problem limited to the SRT. Recent events suggest that poor practices extend beyond to the rail network generally, and this is a more pervasive problem than originally reported.
The staff presentation in September was part of a larger review of the SRT replacement service, and the report title gives no hint that the derailment is part of this. Elsewhere in the same agenda, the CEO’s report celebrates the “Farewell to the SRT” event but makes no mention of the derailment reviews.
- Line 3 Bus Replacement Update
In the TTC’s review of these reports, presented in the April 11 Board meeting agenda, these suppositions are countered, although not entirely convincingly. It is fair to assume that most people will not be familiar with the detailed reports and will take the TTC’s rebuttal at face value. [The April 11 report is discussed later in this article.]
TTC spokesperson Stuart Green said CEO Rick Leary ordered the external reports the night of the derailment to get answers on what happened while including links to the reports posted on the TTC website. He also said the matter was discussed at the Sept. 26 TTC board meeting.
“TTCriders was represented at this same meeting so presumably they heard the same information and are fully aware what the root cause was,” he wrote.
CityNews April 3, 2024
Certainly TTCriders and anyone else attending the September 26 meeting or playing the video later “heard the same information”. The problem lies in being “fully aware” of the root cause which was not the loose bolts, but the failure to detect and correct the problem, and more generally the state of inspection work and staff training. A related problem identified by the consultants was that previous repairs at the derailment site had created a weakness in the reaction rail which, combined with loose bolts, made the failure causing the derailment more likely.
The September presentation noted the difficulty of inspecting the reaction rail supports which required hands-and-knees posture to peer under the track in all manner of weather and lighting conditions. In practice, this level of inspection was rare because it was so difficult. Oddly enough, the Vancouver SkyTrain system uses a separate test, striking the support bolts with a tool, and listening for a dull “thud” instead of a clear “ping”. The “thud” indicates a loose bolt requiring closer inspection.
A common indication that there were problems is scuffing of the reaction rail. This was noted at several locations on the line. One does not have to peer under the track to see this early indicator of a developing problem. However, scuffing could also result from minor clearance problems with specific cars and this would not necessarily be interpreted as a location warranting detailed reaction rail review, especially if the marks had been seen repeatedly.
The most damning item is in the TTC’s own Maximo defect tracking system as reported by an inspection team two weeks before the derailment (July 9, 2023). The item highlighted below shows the reaction rail was “raised 1/2 inch on the approach end”. This was a defect serious enough to be visible without the usual difficulty of inspecting under the reaction rail. A related oddity is a two-week gap in reporting of any further problems leading up to the derailment.
In summarizing the investigation at the September meeting, TTC staff stated that the “immediate cause” of the derailment was the failed anchor bolts. Further, the consultants had recommended that if the SRT were to resume operation through November, then all of the newer bolts installed from 2016 onward should be tested and retrofitted as necessary. This work would have required “time well beyond the planned closure date”, and so the line remained closed. (See meeting recording.)
The estimated scope of this work implies a pervasive problem that was either undetected or whose potential severity was not understood, or worse ignored.
An important distinction here is that the term “immediate cause” has morphed into “root cause”. No matter the frequency of track inspections, the loose bolt problems would not be detected because they were not visible.
A further concern is the manner in which consultant reports were quietly posted on the TTC’s website with no announcement in November and December 2023. My coverage of them was the first that some TTC Board members I have spoken with knew about them.
The documents are posted under the Projects page for the future of Line 3 SRT replacement service, hardly a location one would look for technical info on the derailment. Three of the reports were posted in mid November and one in December. It is easy to verify that they were not there earlier by looking at Internet archives for the page on October 2 and December 7, 2023. The first three reports went up almost two months after the Board meeting, not “a few weeks” as expected. However, there was no media release about them nor were they brought to the Board’s attention.
At the September meeting, Councillor Matlow asked whether there could have been a reduction in maintenance or negligence due to the anticipated shutdown of the line. The Gannett-Fleming consultant replied that there were multiple possible causes for the bolts coming loose, but did not address the frequency of inspections.
Staff and consultants reiterated that inspections for problems of loose bolts were very difficult and they would generally not be spotted. It would not matter how often a walking inspection passed potentially defective reaction rail mounts because these were not visible. Indeed, there was an inspection on the morning of the derailment that found no issues.
The Network Rail consultant mentioned marks on the reaction rail surface in passing, but then talked about the impossibility of seeing bolt problems because they are under the reaction rail, and movement was seen only with a train passing. He also said that issues were being reported and fixed, but this is contradicted by the Maximo logs which show a reaction rail lifted 1/2 inch at the site two weeks before the derailment (see above).
One major problem with the Maximo records is that there is no explicit log of repairs made in response to problem reports. Moreover, the consultants noted that almost all issues were logged with a relatively low priority for repairs. I attempted to FOI the repair work orders. However, the TTC advised that the only record was that a defect report was closed, and that there was no information on the actual repair work. If true, this makes post-incident review of the nature of repairs, if any, impossible.
In September, Matlow asks whether there was an increase in maintenance on the aging system. Staff replied about the 2016 plan to replace the anchors which was well-intentioned, but as we know from the reports there were design and installation issues that eventually caused the failure.
Councillor Holyday pursued the anchor design issue. The replies mentioned that there were other locations with scuff marks but mostly from different causes. There was no mention of a problem, flagged by consultants, of repairs that created a weak spot due to cuts in both layers of the reaction rail at various points including the derailment site.
Matlow asked CEO Leary about how the TTC will prevent another accident, and Leary talked briefly about changes already underway and lessons learned. He then mentioned a planned November report, but this was the unfunded capital projects report, not a more detailed SRT report.
Leary pivoted to the Line 2 trains and signal system, and funding problems that could lead to shutdowns. He explicitly mentioned avoiding having old vehicles in service in the future. This ignored his original support for rebuilding Line 2 trains for a 40-year lifespan, and of keeping conventional signals because ATC would have been incompatible with these trains. Now he has changed his position.
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Steve Munro 