NEW YORK STATE PUBLIC TRANSPORTATION SAFETY BOARD RAIL SAFETY SECTION CASE #7623

INVESTIGATION OF A MULTIPLE INJURY ACCIDENT INVOLVING THE MTA - TRANSIT AT YORK STREET STATION, BROOKLYN, NEW YORK ON JULY 19, 2003

SYNOPSIS On Saturday July 19, 2003 at approximately 3 :08 a.m., a smoky electrical fire erupted in a high voltage trolley lead under the second to last car of a southbound NYCT "F" train. The fire resulted in the discharge of approximately one hundred forty passengers from the train to the station platform at York Street in Brooklyn, NY. Some of the passengers were directed to the south end of the station platform away from a smoke condition that blocked the station's only exit to the street. As the smoke condition intensified, the discharged passengers were forced to evacuate the station platform onto the roadbed and adjoining bench wall where they were eventually led by transit employees through the tunnel to emergency exit #264 located approximately 1000 feet south of the station. One hundred twenty-nine people required medical treatment, mostly for smoke inhalation and/or other minor injuries. Fifty-seven passengers were transported to area hospitals for additional treatment. The Public Transportation Safety Board staff finds that the probable cause of this accident was an electrical fire under car #6133 caused by a failure of a soldered trolley cable connection to the terminal stud resulting in a direct electrical short to ground. Contributing to the severity of the accident was the failure of the Control Center Desk Superintendent to ascertain information in a timely manner thereby underestimating the severity of the situation. Also contributing to the severity of this accident was the improper use of the emergency ventilation fan system by the Control Center Desk Superintendent and the System Operator. INVESTIGATION

Accident Scene : York Street Station is located on the NYCT's 6th Avenue "F" line and has only one station access point which is located at the north end of the center island platform. Access to and egress from the station is obtained by descending down a set of stairs and a long sloping ramp to the platform. Emergency exit #264 is located 1000 feet south of the station, approximately 28 feet below street level . The emergency exit egresses at the corner of Tillary and Jay Streets in Brooklyn.

The Accident: At approximately 3 :08 a.m., a southbound 2 :03 a.m. "F" train consisting of eight R-46 type cars departed East Broadway Station in headed for York Street Station in Brooklyn via the Rutgers Street tube. An NYCT employee riding in the seventh car of the train (#6133) stated that she heard a small explosion during the trip and observed a glow coming from under the train as it traveled through the tunnel between stations. The glow was the result of an electrical fire caused by a failure of a soldered trolley cable connection to a terminal stud that connected it to the shoe beam fuse assembly. A post accident inspection of the equipment by NYCT personnel revealed that the trolley lead was fused to the vertical shock absorber on the number #2 truck of car #6133 .

The southbound "F" train arrived in York Street on track B-1 at approximately 3 :10 a.m. and made a normal station stop . The conductor attempted several times to close the doors, but they kept cycling open because a New York City Police Officer, who saw smoke issuing from under one of the rear cars, was preventing the doors from closing. The train operator, concerned about the delay, radioed the conductor to find out why the train doors were being held open. The conductor, now aware of the smoke issuing from under the rear of the train, informed the train operator of the smoke and fire condition. The train operator reported the fire under car #6133 to the Control Center at approximately 3 :12 a.m. The Control Center Desk Superintendent on duty instructed the train operator to open the 600 volt circuit breaker on that car to isolate what he assumed was a traction motor problem.

In the meantime, smoke was now filling the air at the north end of the station. NYC Police who were on scene advised the conductor to discharge the train. As the fire and smoke condition began to escalate, the passengers were directed to the clear air at the south end of the station platform, away from the smoke . The police and train crew stated in post accident interviews that they were unaware that there was not a second exit at the south side of the station. Some passengers who gathered at the south end of the station platform in an area that was clear of smoke began to immediately descend to the road bed walking south towards the Jay Street Station away from the increasing smoke. At 3 :16 a.m., the NYC Police on scene requested that the Control Center remove all third rail power in the area. The Control Center Desk Superintendent was willing to remove the third rail power from track B-1 immediately, but would not remove power from track B-2 until all northbound "F" trains were located and safely stopped . At 3 :17 a.m., circuit breaker 14E2 tripped which de-energized track B-1 from Madison Street to Livingston Street. The outage went un-noticed by the System Operator and therefore was not communicated to the Control Center Desk Superintendent until 3 :36 a. m.

While the remaining passengers were assembling in the clear air on the south end of the platform, the 2 :46 a.m. northbound "F" train entered York Street Station. The Control Center Desk Superintendent had ordered all southbound F trains to stop and hold their positions, but he failed to do the same for northbound service . Because of this oversight, the 2 :46 "F" train was allowed to enter into a known smoke condition. The train operator, seeing the smoke at the north end of the platform, stopped his train with only the first five cars berthed at the platform. The train operator reported seeing the smoke and fire coming from the southbound train and that the smoke was about half way down the platform. He could not see the north end of the station through the smoke. Until now, the smoke stayed mostly at the north end of the station. However, when the northbound train entered the station, it stirred up the air and forced the smoke to move towards the passengers standing at the south end of the platform. At approximately 3 :16 a.m., the train operator of the southbound "F" train twice attempted to contact the Control Center Desk Superintendent to inform him that a northbound train was entering the station, but both attempts were not answered by the Control Center Desk Supervisor who did not hear the train operators' radio calls because he was 2 talking to the northbound train operator who was reporting smoke in his cab . The passengers on the platform began pounding on the doors of the train demanding to be let in. Because the train was not fully berth in the station, the conductor of the northbound train refused to open the car doors. He attempted to call the train operator on the public address system to ask whether or not he should open the doors and pick up the passengers, but his calls went unanswered .

Meanwhile, the train operator of the northbound train reported to the Control Center that he was having trouble breathing because the thick smoke had reached his train and was enveloping his cab. The Control Center Desk Superintendent instructed the northbound train operator not to open his doors and to get the train out of the station. NYCT Rules and Regulations Manual, Rule 56(d), instructs train operators to make an effort to get their trains out of any smoke area unless it's unsafe to do so. The train operator informed his conductor that they were going to leave the station without picking up the passengers and left the station at approximately 3 :18 a.m. This angered the stranded passengers and as the northbound train exited the station, the smoke was pushed closer to them. Once the northbound train left the station, the Control Center began making the required delay of service announcements, which lasted for thirty seconds. The train operator of the southbound train tried to call the Control Center at the conclusion of this announcement at 3 :19 a.m., but the Control Center was making calls for supervisors and emergency response officer to report to the Control Center. When these transmissions were over at 3 :20 a.m., the Control Center made another delay announcement which lasted approximately forty seconds . The Control Center then contacted the northbound train which was now at the East Broadway Station in Manhattan trying to air the smoke out of the train. At 3 :20 a.m., the Control Center radioed the southbound train and inquired ifFDNY was on scene, and, learning that the fire department was on scene, the Control Center's attention was again diverted away from the southbound train to the developing smoke condition reported at the East Broadway Station. By the time the Control Center re-contacted the southbound train about three minutes later at 3 :26 a.m., smoke was enveloping the passengers at the south end of the platform. During this exchange, neither the Control Center Desk Superintendent nor anyone within the Control Center attempted to check on the severity of the fire and smoke or the whereabouts of the passengers. Consequently, the Superintendent was unaware of the rapidly deteriorating conditions at the station.

Evacuation: On the evening of the accident, a maintenance supervisor and a group of track workers were conducting track inspections south of York Street Station when the supervisor noted that the train was not leaving the station in a timely manner. As the supervisor walked toward the station, he encountered a small group of passengers who were walking southbound in the tunnel away from the platform. They told the maintenance supervisor of the smoke and fire condition in the station. The supervisor advised the passengers of how dangerous it was to be walking in the tunnel because third rail power was still on, and directed them to follow him back to the station. Upon reaching the station and assessing the situation, the supervisor used a wayside emergency alarm box at the south end of the station to telephone the Control Center to report the smoke and fire, and that he found four passengers walking on the roadbed south of the station. The maintenance supervisor requested that third rail power be removed from all tracks south of York Street Station. The call was recorded at the Control Center as coming in at 3 :21 a.m. even though the power was already removed from track B-1 at 3 :17 a.m. when circuit breaker 14E2 tripped.

3 The smoke condition at the south end of the platform was so severe that visibility was reduced to a few feet. The passengers were panicking but the NYCT employees brought order to the evacuation . The maintenance supervisor, with the aid of his crew, NYC Police, and the conductor of the disabled train, escorted the passengers towards emergency exit #264; some by walking between the running rails as employees guided them from the front, side and rear, while others used the west bench wall, walking with one hand on the hand rail and the other on the shoulder of the person in front of them. When the passengers reached the emergency exit, they were directed up the stairs to the street where they were met by NYPD, FDNY, EMS, and other NYCT employees who were assembled and waiting to render assistance as needed. The FDNY reported the evacuation was completed at approximately 3 :45 a.m. The elapsed time of the evacuation, from the time the maintenance supervisor reached the station platform until the customers exited to the street, was approximately twenty-three minutes.

Fan Plant Operation: At approximately 3 :23 a.m., nine minutes after the first report of fire and smoke to the Control Center, the Control Center Desk Superintendent instructed the system operator to activate the York Street fans (#6378 and #6379) on ventilation supply mode and the Rutgers Slip fans (#6375 and #6376) on ventilation exhaust mode . It takes from two to three minutes for the fans to come up to operating speed. The York Street fans, located north of the York Street Station in Brooklyn, were set in ventilation supply mode and came up to speed at 3 :27 a.m. Since the York Street Fan Plant is located north of the York Street Station, the fans, when activated on ventilation supply mode, blew the smoke towards the passengers assembled at the south end of the station platform. The smoke was also blown into the tunnel south of York Street, making the evacuation route more hazardous. To further complicate matters, the system operator initially activated the wrong fan plant to ventilation exhaust mode. Instead of activating the Rutgers Slip fans, he instead activated the Bleeker Street fans to the north. This allowed some of the smoke in the Rutgers Tube to be pulled past the Rutgers Slip fans a distance of approximately 4,500 feet causing a smoke condition and eventual evacuation of the East Broadway Station in Manhattan. The East Broadway Station was evacuated using the normal exits at approximately 3 :32 a.m. There were no reported injuries or incidents as a result of the East Broadway Station evacuation. At approximately 3 :29 a.m. the system operator realized his error and switched the ventilation operation over to the Rutgers Slip fans . The Rutgers Slip fans came up to full speed in ventilation exhaust mode at 3 :32 a.m. Although there are a total of six different modes of operation for each fan, the Control Center Desk Superintendent did not specify which mode of operation was needed, other than the direction of the air. Before executing the order, the System Operator should have repeated the instructions back to the Control Center Desk Superintendent to clarify the order. The Control Center Desk Superintendent did not follow up after requesting activation of the fans as to the extent of the smoke condition by requesting an update from someone on scene until 3 :39 a.m., sixteen minutes after fan plant activation. This is a violation of NYCT Policy/Instruction #10.32.3 which states, in part, that the Desk Superintendent "will gather and evaluate data pertaining to the extent and intensity of the fire/smoke condition" and notify the appropriate authorities "of the extent and intensity of the fire/smoke condition". The smoke situation did not become dangerous for the passengers at the south end of the platform until the Desk Superintendent erroneously requested the York Street fan plant be activated in ventilation supply mode, which blew the smoke south toward the customers. 4 Injuries:

A triage area was set up by NYC Emergency Medical Service personnel on street level at the corner of Jay and Tillary Streets. There were a total of one-hundred twenty-nine persons requiring medical treatment as a result of smoke inhalation and/or minor injuries. The more severely injured were transported to area hospitals. Forty-four passengers were taken to Brooklyn Hospital and thirteen passengers were taken to Bellevue Hospital. The remaining passengers were treated at the scene and released. Among the aided were seven NYC police personnel, two NYC Fire Department personnel and seven Transit employees.

Electrical Fire Damage : FDNY reported that the fires were extinguished on cars #6133 and #6132 at 4:01 a. m. The electrical fire began under of the seventh car of the consist, car #6133, as it traveled through the Rutgers tube between the East Broadway and York Street Stations . The initiating event was a high voltage arcing condition involving the high voltage trolley lead from the knife switch box, grounding itself to the vertical shock absorber on the #2 truck of car #6133 . A post accident inspection of the equipment by NYCT personnel revealed that the trolley lead was fused to the vertical shock absorber on the number #2 truck. This most likely was the result of a failure of a soldered cable connection to the terminal stud that connected it to the shoe beam fuse assembly. A second fire of less intensity started due to an electrical short circuit on the #1 shoe beam of the #1 truck of car #6133 . The fire spread to the cables and conduit on the #2 truck, and to the fiberglass end bonnets of cars #6133 and #6132 . Car #6133 was last inspected on June 4, 2003 and revealed no preexisting conditions that could have led to this incident. The cars were shopped at the NYCT's Coney Island Maintenance Facility for post accident inspections on July 19, 2003 . The inspection revealed that the #2 truck of car #6133 was severely damaged by fire and that the #1 truck showed signs of being damaged by an explosion and a less severe fire. The exterior fiberglass end bonnets on cars #6133 and #6132 were also severely damaged by fire as well. The damage to the track and third rail consisted of three broken insulators and three third rail protection boards that were burnt. A five foot section of contact rail and a thirty-nine foot section of running rail had to be replaced because of warping due to the extreme heat of the fire.

New York City Transit Findings : The NYCT Office of System Safety analyzed all the information gathered in this case and made the following observations: The Control Center Desk Superintendent did not follow up on or further inquire about the severity of the fire, the location of the smoke and its density, thereby under estimating the severity of the situation. The Control Center Desk Superintendent did not inquire about the location or the conditions of the passengers; nor did he use the fire safety system computer. The Desk Superintendent instead used the printed version to reference things such as third rail diagrams which restricted his ability to gather vital information to help with his decision making. Police on scene directed passengers to the south end of the platform, away from the fire, and the only station exit. There are no signs informing the public that this station has only one exit. Some of the Police, NYCT employees and passengers interviewed after the accident stated that they assumed that there was a second exit at the other end of the platform. The Control Center Desk Superintendent incorrectly ordered the fan plant operator to turn the fan plant at York Street to supply mode and the fan plant at the Rutgers St. to exhaust mode. This fan arrangement caused smoke to be blown toward the passengers at the south end of the platform instead of away from the passengers. After ordering the fan plants to be turned on the desk superintendent never checked on the operation of ventilation with the train operator or conductor on scene that violates NYCT Policy 10.32.3 . During the length of the crisis, the Console Train Dispatchers kept making delay announcements to passengers on other trains. These announcements lasted for over 30 seconds at a time. The train operators, and conductors of both trains involved in this incident both reported having difficulties in communications during this event. The passengers who were evacuating south on track B-1 towards the emergency exit came to an area where track B-1 converges with track A-3, and they run together parallel to the emergency exit. The desk superintendent failed to stop service on track A-3 . This meant that the passengers were walking next to live tracks with train service still running during the evacuation.

Follow Up :

The Office of System Safety instructed the Department of Car Equipment (DCE) to conduct an immediate inspection campaign of all the high voltage trolley leads and connectors on the R-44 and R-46 fleets to determine if there are any similar defects; repair and replace any defective components as necessary; and to document the findings. This campaign was completed on July 28, 2003, and no defects were reported . A more detailed inspection was then conducted to include all high voltage connections and shoe beam assemblies . This inspection examined for improperly dressed cabling, loose connections, broken strands, and chafed insulation. The expanded inspection was reported complete on November 20, 2003 ; again with no defects found.

As a result of the NYCT's internal investigation into the circumstances surrounding this accident, the NYCT's Office of System Safety issued several recommendations to the Department ofRapid Transit Operation, Department of Car Equipment, Department of Maintenance of Way, Department of Subways and the Department of Stations. The recommendations covered three major areas of concern: training, fan operations, and communications.

The Office of System Safety recommended that the Department of Subways develop procedures for Control Center personnel to gather and provide more detailed information on passenger conditions and the location where passengers are being discharged or evacuated. They should develop a standard checklist to be used by Control Center personnel and the desk superintendents as a guide in acquiring detailed information upon which to make crucial decisions.

Additionally, all Control Center personnel should be re-instructed on how to comply with Policy/Instruction 10 .32 .3, "Procedures for Response to Emergencies," Procedures, Section O, "Emergency Procedures Manual: Fan Operation", which states, in part : "It is of the utmost importance that the Desk Superintendent receive feedback from the train crew or supervisory personnel on the scene as to the condition of the fire/smoke, customers/employees after the fans have been activated." Desk superintendents and Control Center personnel are evaluated by the Control Center General Superintendent twice yearly. Desk superintendents and Control Center personnel will be reinstructed with an emphasis on these polices as part of their routine training, which occurs every year.

OSS also recommended that the Control Center develop a training course outline for the posting of Desk Superintendent's to ensure that all receive the same information during training including a checklist for specific tasks that the Desk Superintendent must be trained in and demonstrate proficiency in, which will be reviewed by the Control Center General Superintendent during the review of the Desk Superintendent. Similar training should be developed for Control Center personnel.

CONCLUSION

The Public Transportation Safety Board staff finds that the probable cause of this accident was an electrical fire under car #6133 caused by a failure of a soldered trolley cable connection to the terminal stud resulting in a direct electrical short to ground. Contributing to the severity of the accident was the failure of the Control Center Desk Superintendent to ascertain information in a timely manner thereby underestimating the severity of the situation. Also contributing to the severity of this accident was the improper use of the emergency ventilation fan system by the Control Center Desk Superintendent and the System Operator.

RECOMMENDATIONS

Based on the findings developed during this investigation, the Public Transportation Safety Board staff makes the following draft recommendations. The New York City Transit. . . . .

7623-1 . . . . .Rapid Transit Operations and Office of Maintenance of Way Departments should review all the actions taken by employees involved in this accident and take appropriate action to correct deficiencies and assess accountability . 7623-2 . . . . .Training Department should develop a structured training syllabus available for the Desk Superintendent to ensure that they all receive the same information during initial training. The training syllabus must include, but not be limited to, training on the control and operation of ventilation fans; in-depth initial training on the Fire Safety system; and the fan operation book. Training should also ensure that the Desk Superintendents are scheduled for retraining on a regular basis . 7623-3 . . . . .Division of Subways should develop streamlined emergency checklists, that treat every smoke and fire condition reported to the Control Center as severe and life threatening, to aid employees and superintendents in information gathering and decision making. Once the Desk Superintendent ascertains enough information from employees or emergency personal on scene, he may then downgrade the situation. These check lists

should include, but not be limited to, a fire and smoke rating system to clearly identify different levels of smoke and fire conditions from minor visibility obstruction to life threatening. 7623-4 . . . . . Division of Stations should identify all the stations with similar characteristics as York Street and provide signage noting the locations of single exit areas, as well as "No Exit" signs to prevent passengers from being directed to areas with no station exits in future emergencies. Additionally, the Office of System Safety should use this information to develop site specific evacuation instructions to assist the Control Center in handling incidents within these stations. This information should be made available to all NYC service personal working in or around the subway system and should contain, but not be limited to, station layouts, any special requirements, and emergency evacuation procedures.

7623-5 ...... Rapid Transit Operations should modify Policy Instruction 1 .202 "Train Announcements" to allow employees in the Control Center more discretion in making train announcements as well as allowing for abbreviated announcements and a greater duration between announcements during life threatening situations .

PROPERTY RESPONSE

On May 21, 2004, the NYCT responded to the draft recommendations proposed in Draft PTSB Case #7623 which were issued to the NYCT on April 13, 2004. Their response to each of the five draft recommendations follows.

PTSB Draft Recommendation 7623-1 - "Rapid Transit Operations and Office of Maintenance of Way Departments should review all actions taken by employees involved in this accident and take appropriate action to correct deficiencies and assess accountability ."

The NYCT responded that as a result of the York Street incident, all Department of Subways Control Center personnel took part in a critique of the incident. The personnel who were directly involved in the incident were critiqued on appropriate actions to be taken, specifically on what was done correctly and what actions need further improvement. The System Operator involved in the incident was reinstructed in the Rapid Transit Operations and Division of Electrical Systems communications protocols.

PTSB Draft Recommendation 7623-2 - "Training Department should develop a structured training syllabus available for the Desk Superintendent to ensure that they all receive the same information during initial training. The training syllabus must include, but not be limited to, training on the control and operation of ventilation fans; in-depth initial training on the Fire Safety System; and the fan operation book. Training should also ensure that the Desk Superintendents are scheduled for retraining on a regular basis."

The NYCT responded that Human Resources, Subways Operations Training developed a structured training syllabus for Desk Superintendents to ensure that they all receive the same information during training. Additionally, Desk Superintendents are scheduled for annual refresher training. The two-day training syllabus for Desk Superintendents includes such items as console 8 simulations; incident review; control center administrative procedures; fan/fan plant modes of operation; power operations; general order operations; fire safety system operations; and computer systems

PTSB Draft Recommendation 7623-3 - "Division of Subways should develop streamlined emergency checklists that treat every smoke and fire condition reported to the Control Center as severe and life threatening, to aid employees and superintendents in information gathering and decision making. Once the Desk Superintendent ascertains enough information from employees or emergency personnel on scene, he may then downgrade the situation. These checklists should include, but not be limited to, a fire and smoke rating system to clearly identify different levels of smoke and fire conditions from minor visibility obstruction to life threatening."

The NYCT replied that the Department of Subways Control Center currently uses a Fire/Smoke checklist, however, as a result of the York Street incident, the checklist has been revised. The NYCT further replied that they did not agree that every report of Fire/Smoke in the system should be treated as severe and life threatening. They feel that according to current procedures, the Desk Superintendent's job is to obtain information concerning the severity of the condition and makes the appropriate decision. They further feel that the revised checklist will aid in this process. PTSB staff will monitor the NYCT's implementation of the revised checklists to insure compliance to established procedures.

PTSB Draft Recommendation 7623-4 - "Division of Stations should identify all the stations with similar characteristics as York Street and provide signage noting the locations of single exit areas, as well as "No Exit" signs to prevent passengers from being directed to areas with no station exits in future emergencies. Additionally, the Office of System Safety should use this information to develop site specific evacuation instructions to assist the Control Center in handling incidents within these stations. This information should be made available to all NYC service personal working in or around the subway system and should contain, but not be limited to, station layouts, any special requirements, and emergency evacuation procedures." The NYCT replied that Department of Subways has identified and provided the Office of System Safety (O S S) with a list of all stations with similar configurations to that of York Street. This list was submitted to the Division of Rapid Transit Operations and Stations by OSS so that this information can be used when handling incidents. All stations have directional signage to exit the station. However, NYCT agreed to provide additional reflective "No Exit" signage at these stations. In addition, NYCT is going to provide information that identifies single-exit stations on the Fire Safety System and the Control Center model board.

PTSB Draft Recommendation 7623-5 - "Rapid Transit Operations should modify Policy Instruction 1 .202 "Train Announcements" to allow employees in the Control Center more discretion in making train announcements as well as allowing for abbreviated announcements and a greater duration between announcements during life threatening situations."

The NYCT's Department of Subways Control Center agreed that it will allow Desk Superintendents discretion in making train announcements during incidents involving -life threatening" situations . The discretion will impact duration between announcements and 9

abbreviation of announcements as requested in the recommendation.

Prepared by: Robert Maraldo

SUBMITTAL

This report is hereby submitted by Jerry Shook, Director, Rail Safety Bureau, to the Public Transportation Safety Board for further action.

DATED: July 21, 2004 Jerry S , ok, hector Rail S ety Bureau Public Transportation Safety Board