TTC releases report into fatal workplace accident of September 2012
October 21, 2013
The TTC has concluded its investigation into the workplace fatality of TTC employee Peter Pavlovski. On September 14, 2012, Pavlovski, 49, a Roadmaster and supervisor in the Rail Infrastructure Department, was struck and killed by a work car on the southbound subway tracks just north of Yorkdale Station. Pavlovski’s co-worker, a Track Mechanic, was seriously injured. The work car operator was also hospitalized with a heart condition following the incident. The Yorkdale fatality of September 14, 2012 - Final investigation report will be tabled with the TTC board at its meeting on Wednesday.
Three causal factors were identified and nine corrective actions for management to undertake have been recommended. TTC management agrees with all corrective actions prescribed and has committed to completing each of them in the timeline noted in the report.
The Ontario Ministry of Labour conducted its own investigation into the matter. No charges were laid.
- The two-person track crew did not notify the Transit Control Centre of their intention to enter the soutbound track for a walking inspection.
- Both the Roadmaster and a Track Mechanic were not aware of the approaching work car, RT-4, in time to avoid contact.
- The work car Operator was not aware of the presence of workers at track level in time to avoid contact.
Corrective Action Plan
- Review protocols and practices between Rail Infrastructure Department and Transit Control Centre with an emphasis on non-revenue maintenance consistent with the need to ensure safe passenger service. Response: Track Level - Serious Injury Prevention Team established.
- Implement a corporate-wide process for reporting, investigating and communicating all safety-related incidents. Response: full implementation by third quarter 2014.
- Refit all work cars with brighter LED headlights. Response: completed.
- Pending review of track level warning technologies, assign a dedicated watchperson for all walking inspections at track level, as well as create an internal awareness campaign around the danger of approaching trains. Response: feasibility study of permanent watchperson duties to be completed by February 2014; awareness campaign now under way.
- Review applicability of new warning device technology for those performing maintenance at track level during non-revenue hours. Response: complete by May 2014 for 2015 budget submission.
- Review work car operator duties, including any physical barriers or ergonomic issues related to the work cars. Response: consultation and evaluation under way, to be completed January 2014.
- Evaluate the use of the blue light system used during revenue service and its applicability to non-revenue maintenance. Response: permanent operating rules committee to be established in November 2013.
- Conduct a thorough review of the Subway Rule Book to identify changes required to specifically address non-revenue maintenance. Response: part of the permanent operating rules committee noted in Corrective Action No. 7.
- Establish a formal governance process for the Subway Rule Book that considers all track users and fosters continuous improvement, as well as provides authoritative interpretations and effective enforcement of all rules. Response: part of the permanent operating rules committee noted in Corrective Action No. 7.
Peter Pavlovski is missed by all who knew him. The Pavlovski family has asked for privacy, and thanks all media for respecting their wishes.
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