Memorandum Dd New York City Transit Date To From Re January 21, 2011 c pen Bianco, Senior Vice President, Department of Subways ce 1699, Vice President, Office of System Safety lechanical Gap Filler Incident, 14" Street / Union Squar 2/10/10 ‘The Office of System Safety conducted an investigation regarding a customer injury that occurred on December 10, 2010 at 14" Street Union Square involving one of the station’s mechanical gap fillers, Please review the attached report and provide a response to the recommendations by February 4, 2011 ce: J, Wincek M. Dettore Attachment: ReportMechanical Gap Filler Incident 14" Street / Union Square December 10, 2010 FINAL REPORT January 21, 2011SYNOPSIS On the evening of December 10, 2010, at approximately 2155 hours, Mr. Michael Dion, a Al year old male customer, fell between gap filler X3 and a southbound express Number “4” Train operating on Track 2 at 14" Street Union/Square Station. Mr. Dion fell into the Bap while the train was berthed at the station platform. As the mechanical gap filler extended, Mr. Dion's abdomen became wedged between the gap filler and the third car of the train. ‘The train crew was initially unaware that Mr. Dion was trapped. An MTA Contractor who was working at the station at the time of the incident was able to bleed air {rom the tank that fed the gap filler, allowing emergency personnel to free Mr. Dion. Once freed, Mr. Dion was removed by Emergency Medical Services to Bellevue Hospital. OSS has determined that Mr. Dion was staggering about the platform and fell into the gap after the train was fully berthed in the station. After Mr. Dion fell into the gap the gap filler extended as'designed (to close the gap) causing Mr. Dion to become caught between the gap filler and the car body. INVESTIGATION Occurrence: On December 10, 2010, at approximately 2155 hours, the 2119 Number “4” Train (consist: 1126-1127-1128-1129-1130-7075-7074-7073-7072-7071) from Woodiawn Avenue to Utica Avenue, made a station stop at 14 StreevUnion Square on the southbound express track (Track 2). According to the Department of Subways (DOS) Train Incident Report, at 2156 hours the Train Operator (I/O), J. Carter, reported to the Rail Control Center (RCC) that there was a report of a customer injury on her train and Conductor (C/R) C. Cumberbatch was investigating, 1/0 Carter reported that she was positioned at the proper car stop marker and that her train was fully in the station, C/R Cumberbatch had been alerted by other customers that the injured customer, Mr. Michael Dion, was trapped by a gap filler. At 2159 hours, C/R Cumberbatch reported to the RCC that Mr. Dion had fallen between the train and the platform gap filler at Car #1128 (3" car). C/R Cumberbatch requested Emergency Medical Services (EMS). The RCC then notified the Division of Car Equipment, Division of Station Operations, Maintenance of Way and the NYC Police Department. Emergency personnel who responded to the scene to free Mr. Dion were initially unable to disable the gap filler. An MTA contractor, J. Setter, who was working at the station at the time of incident, was able to bleed air from the tank that fed the gap filler at approximately 2206 hours. This allowed emergency personnel to free Mr. Dion. Power was removed from Track 2 at 2211 hours and at the crew complied with the RCC’s instructions to secure the train by placing the train’s brakes into emergency at both of their operating positions.Mechanical Gap Filler Incident 14" Street / Union Square - December 10, 2010 2o0f7 TSS Echevarria notified the RCC at 2221 hours that Mr. Dion had been freed from between the train and gap filler. Mr. Dion was then removed to Bellevue Hospital by EMS, Department of Subways (DOS), Signals Section personnel responded to the scene and inspected/tested gap filler X3. They determined that the gap filler was operating as designed and did not malfunction, M, Dettore, Manager from the Office of System Safety, responded to the scene on December 11, 2010, at approximately 0100 hours. At 0337 hours, M. Dettore requested that a test train from Westchester Yard be brought in to test the gap filler X3 with Signal’s personnel. With the test train present, the gap filler was deployed and retracted multiple times. It was determined that the gap filler was operating as designed. Furthermore, the ‘announcements alerting customers to “... stand clear of the moving platforms (gap fillers) as trains enter and leave the station” were also being made. Subsequently track 2 was retumed to service, Service Delivery Interview Statement ‘TO Statement: The T/O, Janice Carter (Pass #137004), operating the 2119 Number “4” Train (Woodlawn Avenue to Utica Avenue), indicated that nobody was on the roadbed and she did not observe Mr. Dion on the platform as the train was entering the station. She was focusing her attention primarily on the roadbed. It was not until shortly after coming to a complete stop that a customer knocked on her window and alerted her to the fact that Mr. Dion was trapped by a gap filler. T/O Carter stated that after Police arrived at the scene, she assisted with controlling the crowd COR Statement The C/R, Comell Cumberbatch (Pass # 191124), on the 2119 Number “4” Train, indicated that he did not observe Mr. Dion on the platform as the train entered the station. C/R Cumberbatch was alerted by customers that Mr. Dion was trapped by a gap filler, after the train had come to a complete stop, and after opening the train doors, Upon observing the injured customer, C/R Cumberbatch immediately notified the Rail Control Center (RCC) and requested Emergency Medical Services. C/R Cumberbatch secured the train by activating the Emergency Brake Valve located at his position, as instructed by the RCC. CIR Cumberbatch also indicated that he observed a Budweiser can beside Mr. Dion and in his opinion, Mr. Dion appeared to be inebriated. Train Service Supe Statement: TSS Americo Echevarria (Pass # 245763) was located at Grand Central when the incident ‘occurred and reported to the scene shortly after Mr. Dion was freed from the gap filler.Mechanical Gap Filler Incident 14" Street / Union Square - December 10, 2010 3of7 Electrical Subdivision, Signals Section Interview Statement: Superintendent, Signals, Division of Electrical Statement Superintendent Joseph Orvieto (Pass #f 669687) arrived at the scene at 0145 hours on December 11, 2010 to relieve Superintendent K, Mitchell, Signals. Prior to his arrival at the scene, Signals personnel tested/inspected the gap filler and perfornied scheduled ‘maintenance on the device. Subsequent to the inspection, it was deterinined that the gap filler was operating as designed and had not malfunctioned. At 0200 hours Superintendent Orvieto met with M. Dettore, Manager from the Office of System Safety and requested a test train to pass through the station along Track 2. At approximately 0315 hours, the test train arrived on Track 2 and stopped at the proper location along the platform. All the gap fillers where operating normally. New York City Police Department (NYPD) Report (Summary): According to the NYPD report, Mr. Dion appeared to be intoxicated at the time of the incident. Witnesses reported seeing him staggering about the platform while holding a can of Budweiser, prior to the train (involved in the incident) entering the station. Mr. Dion ‘was reportedly standing on gap filler X3 as the train entered the station and fell and became caught between the train and the gap filler. The conductor was unaware of the incident and opened the train doors. Shortly afterwards, multiple people alerted the conductor regarding, the situation. The train crew stated that the train did not move once the doors were opened. According to witnesses, Mr. Dion was not the victim of a crime. The Police Supervisor who responded to the incident requested EMS as well as the NYPD"s Emergency Service Unit (ESU), and ordered power removed from Track 2 at 2202 hours. Thé Supervisor called for assistance with crowd control at 2205 hours, and ordered that southbound number “6” trains bypass the station to keep the crowd to a minimum, Al 2254 hours, power was restored to Track 2. At 2302 hours, the train involved in the incident was released and left the station. Electrical Subdivision, Sign: The Signals Section is responsible for inspecting and maintaining the gap fillers at 14° Stree/Union Square Station, Gap fillers are mechanical devices used to bridge the larger than usual gaps between the car body (train doors) and edge of the station platform. ‘The gap fillers are pneumatically operated and controlled by the signal system. ‘The gap fillers are in the retracted position when trains enter or leave the station and are automatically extended when the train has been properly berthed in the station.Mechanical Gap Filler Incident 14" Street / Union Square - December 10, 2010 40f7 As a train enters the station itis detected through track circuits and ultrasonic sensors. An announcement is made when the train is detected advising the passengers to please stand clear of the moving platform as trains enter and leave the station When the train is detected by the track circuits and ultrasonic sensors to be properly berthed in the station, the gap fillers are automatically extended. Once filly extended the platform announcements cease. It should be noted that the time interval between the train berthing at the station and the gap filler fully extending is six seconds. ‘Once all passengers have safely exited/entered the train the conductor closes the doors. As the train moves forward to leave the station, ultrasonic sensors detect train movement, the gap fillers are retracted, and announcements are made advising passengers to stand clear of the moving platform The gap at the location of gap filler X3 ranges from 12 to 13 inches (while the gap filler is in the retracted position). Once the gap filler extends, the gap is reduced to approximately 3 inches. In accordance with NYC Transit’s Department of Subways, Electrical Subdivision (Signals Section) Standard Procedure 7.14.048, gap fillers are tested as follows: * Every 90 days, a Signal Maintainer (S/M) will perform the test, * 90 days is the maximum allowable time between tests, * Atleast every 180 days, a Maintenance Supervisor will monitor the S/M performing atest ‘* When placed in service or when a mechanical and/or electrical component/part of the layout or associated circuit(s) is added, repaired, replaced, or adjusted. In addition to the above mentioned testing, scheduled preventative maintenance is performed on the gap fillers every 30 days. Preventive maintenance requires cleaning, lubrication and draining moisture from the air receiver tanks when necessary. Signals Subdivision’s testing/maintenance records indicate that the subject gap filler was ‘maintained and tested on 10/29/10, 11/19/10 and 12/10/10. In each instance there was no reference to a failure. The maintenance and testing was conducted within the required intervals. It should be noted that on the day of the incident (12/10) gap filler X3 was serviced prior to the incident. Following the incident, gap filler X3 was thoroughly inspected and operated with a test train present. No deficiencies were identified, and it was thereby determined that the subject gap filler was operating as designed at the time of the incident.anical Gap Filler Incident 14" Street / Union Square - December 10, 2010 Sof7 The Event Recorder, which records the movement (extension/retraction) of the gap fillers at 14° Street/Union Square, indicated that on 12/10 at 2153 hours, gap filler X3 did not “Tock up reverse” and continued trying to lock up until 2206 hours (a total of 13 minutes). STATISTICS From January 1, 2006 through December 9, 2010 there were a total of five customer injuries that occurred involving gap fillers at the 14" Street / Union Square Station, + Two of te incidents occurred whereby a customer's leg slipped into the gap between the gap filler and car body prior to the gap filler fully extending, These incidents resulted in the customer's leg becoming caught between the gap filler and car body when the gap filler extended. * One incident occurred whereby a customer was detraining and her leg slipped into the gap between the car body and the gap filler after the gap filler was fully extended, * One incident occurred whereby a customer's leg slipped between the ear body and gap filler. However, there was insufficient information to determine if the gap filler Was extended at the time of the incident. * One incident occurred whereby a customer slipped and fell on the gap filler. The ap filler was fully extended at the time of the incident, and the customer did not fall into the space between the gap filler and the train. KE! DINGS, Based on the information obtained regarding the incident, the following sequence of events occurred: + Signals Subdivision’s testing/maintenance records indicate that the gap filler X3 at 14” Street/Union Square Station was maintained and tested on 10/29/10, 11/19/10 and 12/10/10. The maintenance and testing was conducted within the required intervals. It should be noted that on the day of the incident (12/10) gap filler X3 was serviced prior to the incident. Following the incident, gap filler X3 was, thoroughly inspected and operated with a test train present. No deficiencies were identified, and it was thereby determined that the subject gap filler was operating as designed at the time of the incident.Mechanical Gap Filler Incident 14” Street / Union Square - December 10, 2010 60f7 * Mr. Dion was seen staggering about the platform while holding a can of Budweiser prior to the train entering the station according to the NYPD report. + The 2119 Number “4” Train entered 14" Street Union Square Station on Track 2 and made a normal station stop. * Mr. Dion was standing on gap filler X3 and fell from the platform between gap filler X3 and Car #1128 (3% car). * Gap filler X3 extended as designed and caught Mr. Dion between the gap filler and the train. * Conductor Cumberbatch observed a can of Budweiser beside Mr. Dion and believed Mr. Dion to be inebriated. * The Gap Filler Event Recorder indicated that at 2153 hours, gap filler X3 did not “lock up reverse” and continued trying to lock up until 2206 hours (a total of 13, minutes). + Acontractor, J. Setter, from Fresh Meadow Electric was on the platform and disabled the gap filler. * At2221 hours, TSS Echevarria reported to the RCC that the customer was removed from between the train and gap filler to the platform. At 2225 hours, the customer was taken to Bellevue Hospital for medical treatment. * At 0337 hours, M. Dettore, Manager from the Office of System Safety requested that a test train from Westchester Yard be brought in to test the gap filler with Signal’s personnel. With the test train present, the gap filler was deployed and retracted multiple times. Tt was determined that the device was operating as designed, and Track 2 was subsequently put back in service. CONCLUSION Upon review and consideration of the abovementioned findings OSS has determined that Mr. Dion, was staggering about the platform while holding a can of Budweiser and fell into the gap between a fully berthed train and the gap filler that was in a retracted position at the time. The gap filler then extended as designed, causing Mr. Dion to becomie caught between the car body and gap filler. It should be noted that the train crew followed required operating procedures and the gap filler operated as designed.Mechanical Gap Filler Incident 14" Street / Union Square - December 10, 2010 Tof7 RECOMMENDATIONS 8S recommends the following: Department of Subways ‘+ Investigate the feasibility of modifying the gap filler systems to sense and detect obstructions thus prohibiting deployment of the gap fillers. * Investigate the feasibility of reducing the force required to deploy the gap filler, thus minimizing injury to the customer. ‘+ Investigate a means which would enable the train crew to disengage or retract the gap filler. * Paint/mark gap fillers to wam customers of the moving platform and to stand clear.