Investigation of a Multiple Injury Accident Involving the Mta - New York City Transit at York Street Station, Brooklyn, New York on July 19, 2003
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NEW YORK STATE PUBLIC TRANSPORTATION SAFETY BOARD RAIL SAFETY SECTION CASE #7623 INVESTIGATION OF A MULTIPLE INJURY ACCIDENT INVOLVING THE MTA - NEW YORK CITY 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 Manhattan 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.