The TTC has released the reports investigating the cause of the hydraulic fluid spills from subway work cars during the first half of 2024.

• Work Car Hydraulic Leak Incidents Update

This report contains six sections:

PDF Pages	Content
1-6	Covering report from TTC management
7-13	Attachment 1: Management action plan
14-56	Attachment 2: Root Cause Assessment of Leaks by Hatch
57-99	Acuren Group report: Failure Analysis Examination of a Hydraulic Hose
100-120	Timeline of events on May 13, 2024
130-144	APTA (American Public Transit Association) Peer Review of Incident Management

See also:

• Hydraulic Oil Spills on the Subway
• TTC Streetcar Overhead Maintenance Audit
• The Scarborough RT Derailment Technical Reports
• The Unhappy State of SRT Track
• Revisionist SRT History at the TTC
• Line 3 SRT Replacement Service and Derailment Investigation
• Ten Questions About the SRT Derailment

Introduction

The primary report among these is from Hatch, a consulting engineering firm with rail industry expertise. Their task, as they state clearly, was to determine the underlying technical reasons for each incident, but not to delve into TTC operational practices.

There are many cases cited of inadequate vehicle inspection and maintenance, lack of procedures and standards, undertrained staff, and poor record-keeping to document the history of affected vehicles. These are not isolated incidents, but ongoing problems.

The Management Action Plan consolidates all of the recommendations from Hatch and APTA together with their current status. Many are “complete” and others are “in progress”. What is clear from the extent of the list is that many problems, some quite serious, required action by the TTC. How did the system get into that state in the first place?

The TTC management report looks only at the hydraulic fluid spills, but does not consider the wider context of two previous reviews of maintenance and record keeping: the Streetcar Overhead Section, and the post-mortem report on the SRT derailment. There is a sense that “we have fixed this” through the substantial implementation of consultant recommendations, but without the broader context.

On a more general level, there are two obvious questions:

• How many more sections or processes within the TTC suffer from similar issues, and are problems just waiting to surface?
• Is the lower maintenance standard really confined only to work vehicles, or have staffing and funding limitations affected support for revenue vehicles and infrastructure too?

The management report states:

Both reports [Hatch and APTA] identified common root causes, and while they found that the TTC’s practices are typical of the industry, they recommend implementing a more robust preventative maintenance program of procedures, training, and quality control modeled after what the TTC has in place for revenue service vehicles. [Management report at p. 1]

The comment about TTC practices being “typical of the industry” is telling. If the situation described in the reports really is typical, the transit industry is in perilous condition. Saying “everybody else does it this way” does not explain how work car maintenance is nowhere near what one would expect from a once pre-eminent transit system in North America.

The Hatch report described the situation differently:

The lack of detailed documentation for the design and maintenance of the work car fleets is highlighted as a major issue in this report, especially for the repair of hydraulic hoses. However, Hatch’s experience with other major transit agencies in North America like TTC, suggest that design and maintenance documentation supplied by work car OEMs does not usually contain detailed information on the installation of the hydraulic hoses except when mandated by a procurement specification or used for very specific applications (e.g. rigid hoses, specialty hoses and fittings, and components that are hard to procure and/or have long lead times). [Hatch at p. 39]

That remark refers to the availability of documentation, not to day-to-day maintenance practices.

The APTA report is silent on practices at TTC compared to other systems.

This is a significant discrepancy between the management report and the documents from Hatch and APTA, and one cannot help seeing this as “spin” to put TTC practices in the best possible light.

Summary of Incidents

The table below gives an overview of the incidents reviewed by Hatch.

Date	Description
Sun Jan 14	Car RT56 spilled 10L of fluid between Sherbourne and Donlands Stations. Cause: Hydrostatic hose failure
Wed Jan 17	Car RT17 spilled 120L of fluid between Eglinton West and Dupont Stations. Cause: Filter O-ring failure
Sat Feb 10	Car RT7 spilled 5L of fluid in Greenwood Yard during a pre-departure inspection. Cause: A faulty hydraulic filter O-ring
Mon Apr 22	Car RT41 spilled 50L of fluid while shunting into Greenwood wye north of the yard. Cause: O-ring failure
Mon May 13	Car RT56 spilled 100L to 140L of fluid at Spadina Station (Line 1) and other locations while it was being towed back to Greenwood Yard. Cause: Abraded hose Service effect: Line 2 was shut down for over 12 hours as the affected area was greatly expanded by moving a leaking car through the system rather than isolating it for inspection and repair.
Wed May 15	Car RT84 spilled 200L of fluid on the trackbed north of Eglinton Station. Cause: Excessively worn driveshaft clutch plates seized and disintegrated leading to further damage including a severed hose.
Thu May 16	Car RT41 leaked 0.25L of fluid on the trackbed at Keele Station. Cause: O-ring failure under a pressure sensor
Sun May 26	Car RT18 leaked 30L of fluid onto open track between Victoria Park and Kennedy Stations. Cause: Incorrect hose and fitting used in a previous repair cause a hose failure.

Some of these incidents were cleaned up before affecting revenue service, or occurred in yards where there would be no effect. This does not minimize the severity of so many failures in such a short time span. Some of the cleanup efforts required multiple passes to complete satisfactorily.

One outcome of this review is the recognition that clean-up of spills requires better handling than in the past, but the basic issue is that the spills should occur less frequently, if at all, in the first place.

Readers who want to see complete details and photographs of these incidents should peruse the Hatch report.

One key point should be knocked on its head: back in May, there were questions about possible sabotage given the spate of events in a two-week interval. The investigation showed that all incidents were due to component failure from lack of maintenance, or of incorrect maintenance. The May 13 incident was a direct result of the routing of a hose through a floor grate where it would chafe and eventually fail. “Sabotage” was a red herring at the time, and remains so today. [There is an extensive review of the metallurgical condition of the hose and the floor grate in the Acuren Group report.]

TTC plans to up its spending on work cars. It is worth noting that a plan to refresh and expand the work car fleet under former CEO Andy Byford was sidelined when Rick Leary took over as, initially, was the plan to renew the Line 2 fleet.

The TTC’s 2024-2033 Capital Budget and Plan includes $34.0 million of approved funding for work car overhauls and $63.4 million toward work car procurements.

TTC staff will include a funding request in its 2025 Operating Budget submission to establish a more robust work car preventative maintenance program.

This statement is a clear admission that the program now in place is inadequate. A related issue is that the backlog of necessary work is directly related to work car availability, and in turn that drives the longevity of slowdown orders on the subway.

Record Keeping and Standard Procedures

During their investigation, Hatch found that many of the maintenance records were incomplete and did not give a true picture of work that had been done on each car. Moreover, the absence of standard inspection regimes and checklists meant that (a) staff had no guidance on when and what type of work that should be done, and (b) there was no collection of records indicating that required inspections and repairs were regularly carried out.

A common point in these incidents is the likelihood that some components were only replaced when they failed, not as part of a routine inspection and maintenance regime.

The limited availability of reference documentation and inadequate configuration control is impacting millwrights’, coach technicians’ and other tradespersons’ ability to perform effective component repairs and replacements. [Hatch at p. 7]

There has been a great deal of discussion recently at TTC (particularly at its Audit & Risk Management Committee) about an Enterprise Management System and detailed condition records of all system components. The records excerpted in the Hatch report show that records for cars are uneven and do not produce vehicle histories.

Problems with record-keeping were cited in the Streetcar Overhead Section review by the City’s Auditor General, and there are also questions about the completeness and accuracy of records related to the SRT. Any centralized asset management system is only as good as the data fed into it and the structures it provides for tracking and managing both regular and emergency maintenance.

The May 13 Service Outage

The May 13 incident caused a major outage thanks to inappropriate response to the hydraulic leak. The size of the leak was not clearly understood, nor was the fact that a reservoir of fluid had built up within the affected car. This dripped out onto the tracks as the car was towed back to Greenwood from the location where it failed.

RT56 was working on the northbound track at Spadina Station on Line 1 when it failed. Much of the escaping fluid went into a catch basin below the car that happened to be sitting above it, rather than pooling at track level. The car was towed south on the northbound rail to Museum Station, and then north through the wye to Lower Bay Station. If it had remained there for inspection and repair, the track from Yonge to Donlands would not have been coated with fluid, but the decision was made to continue to Greenwood Yard. This turned a minor problem into a major service outage.

In the list of recommendations from Hatch and APTA, a common factor is that they affect multiple sections within the TTC and emphasize the need for communication between them. This is an organizational and cultural issue that can be dangerous when responsibilities are unclear.

The May 15 Clutch Plate Failure

The hydraulic fluid spill was caused by a series of events. First the excessively worn driveshaft clutch plates seized and disintegrated, enabling the driveshaft to rotate freely unconstrained. The flailing driveshaft then hit the housing cage, causing the housing cage to impinge on a hydraulic hose at the fitting area. The force of the impact severed the hose from its fitting, causing the evacuation of hydraulic fluid onto the rail bed. [Hatch at p. 28]

The failing component has been replaced three times (in 2012, 2017 and 2019) although it is expected to last much longer. This suggests that the environment where this operates is more severe than typical use, and regular inspection is essential.

At the time of the incident, TTC did not have inspection criteria for the clutch plate. TTC has since obtained a clutch plate maintenance procedure and appropriate service interval from the clutch OEM, providing TTC maintenance a basis to identify condemning limits for replacement. This will allow TTC maintenance to establish an inspection regimen for the clutch plate component. [Hatch at p. 29]

Personnel and History

Hatch flags issues with the depth of experience of some maintenance staff, the mentorship process between senior and junior employees, and difficulties with staff retention.

This is compounded by the absence of standard procedures which could guide junior employees and avoid dependence on “old hands” who know from experience what needs regular attention. Documentation exists for some systems on some cars, but changes over the years bring a drift between original manufacturer recommendations and the cars’ current configuration.

Technicians now inspect work cars before they enter service, and this has reduced failure incidents. The degree of reduction is not cited in the report.

The APTA Review

The APTA review reports similar technical findings to Hatch for various incidents, but covers other areas, notably communications and information sharing.

APTA echoes the Hatch observations about maintenance procedures:

Relatively small hydraulic leaks (mostly with hoses) should be expected to occur with work cars, given the nature of the work they perform and the environment they operate in. Proper inspection and maintenance of work cars is essential to prevent larger leaks from occurring. At TTC there are only generic instructions for the periodic inspection of work cars, but vehicle specific documentation is required. At the time this peer review was conducted, the only guide for the periodic maintenance of work cars available to millwrights was the original equipment manufacturer maintenance manuals. Additionally, work car cleaning is not being performed during every scheduled service interval. This will help improve the inspection of hydraulic systems by making it easier to identify wear or damage on hoses and components prior to a catastrophic failure. [APTA at p. 3]

If this is a “peer review” by an industry association, this state of affairs does not align with the premise that the situation at TTC is on a par with the industry generally.

An important issue flagged in both reviews is the need for technicians to assist with problems when work cars are in service.

At the time when RT-56 experienced its hydraulic leak, there were no qualified work car maintenance personnel available to assess the condition of the hydraulic and mechanical systems on the car. This is in contrast to revenue vehicles, where qualified maintenance personnel are available during revenue service hours to assess equipment if a revenue vehicle becomes disabled on the main line. The delay in assessment by qualified work car maintenance personnel meant that RT-56 was moved without fully knowing the extent of the hydraulic fluid leak nor if the leak was contained. This ultimately resulted in a service interruption of 730 minutes (from 6:50 a.m. to 7 p.m.), including during peak revenue service operations.

[…]

The panel suggests evaluating usage of work car maintenance personnel to be available to assist when track and structure work cars are operating on the main line in the event they become disabled. The panel also suggests conducting exercises/drills on work car recovery from the main line with both operators and maintenance personnel to reinforce procedures. Additionally, the panel suggests reviewing or revising the post-incident review/investigation process to ensure that key facts of the incident are captured. TTC should also consider developing a policy on who can authorize the movement of a disabled work car to ensure that it can be moved safely. [APTA at pp 4-5]

APTA noted that post-incident reviews for non-revenue incidents (e.g. work trains and off-hours maintenance activities) are not as thorough as for revenue service.

In the case of the May 13 hydraulic leak, the fact that it was never established in the post-incident investigation who authorized the movement of RT-56 identifies that there was a breakdown in communication. Generally, TTC’s incident management and procedures involving revenue vehicles and streetcars are very good and meet or exceed industry standards. However, nonrevenue incident management and procedures need to be improved and aligned with that of the incident management and procedures for subway vehicles and streetcar. […] both present the same level of service disruption risk. [APTA at p. 5]

APTA also noted a desire by the TTC Board to be better informed about operational events.

Over several years, the Board has drifted away from day-to-day matters and treated its role primarily as business managers for precious taxpayer dollars. The fact that operational details, procedures and planning can have a direct effect on business viability seemed to escape them.

There is also a growing demand for transparency and accountability at transit agencies from the public, which includes the expectation to provide clear and timely updates during a service disruption. Currently, the public’s expectations for information, both content and timeliness, during a major event exceed TTC’s capacity. [APTA at p. 6]

Communications to the public, a watchword of the Byford era, dwindled under Rick Leary, and information sources are fragmented on the TTC’s site as I have written many times. Fixing this requires acknowledgement that something needs to be done, that the current organization is less than suited for what riders need.