PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT This report is for improving overall Metro System Safety. It is intended to be for confidential use only. This report is prepared based on the information available to the author at the time of the report. The findings, conclusions and opinions expressed herein are subject to change based upon further investigation and analysis. SUMMARY OF FACTS RELATED TO THE TRAIN #719, (LRV 212S-211N) AND PEDESTRIAN ACCIDENT AT FANNIN STREET AND IH-610 GRADE CROSSING, RED LINE, ON WEDNESDAY, JUNE 10, 2015. DESCRIPTION OF OCCURRENCE On Wednesday, June 10, 2015 at 11:47AM, Train #719 (LRV #212S-211N) was traveling northbound on Fannin St. (Track #1) approaching IH-610 westbound feeder road. A pedestrian walking eastbound north of this gated grade crossing was struck by the front right coupler skirt of LRV #211. He was pronounced deceased at the scene. INJURIES None FATALITIES The pedestrian, Billy Forsythe, age 56, was pronounced deceased at the scene. PROPERTY DAMAGE LRV #211 did not suffer any damage. Cost for electronic downloads and resets: $385.15 LRV #212 did not suffer any damage. Cost for electronic downloads and resets: $385.15. STREET CHARACTERISTICS Fannin Street is a two-way street that runs north and south with two lanes for vehicular traffic. One of the south bound lanes is designated for left turns to the east 610 feeder road. The second lane can turn left or continue south. Parking is not allowed on either side of the street. There are two signalized pedestrian crosswalks at this location. The first one (where the accident occurred) is located on the north side of the westbound feeder road and the second one is located on the south side of the eastbound feeder road. A Hiload detection system is in place on both feeder roads. IH-610 Freeway West Feeder Road is a one-way street that runs west across Fannin Street with three lanes for vehicular traffic. Parking is not allowed on the road. IH-610 Freeway East Feeder Road is a one-way street that runs east across Fannin Street with three lanes for vehicular traffic. Parking is not allowed on the road. Intersection drawing page 10. PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT FANNIN AND IH-610 Red Line Train #719 and Pedestrian 06-10-2015 Page 2 TRACK CHARACTERISTICS The track at this area is protected by automatic grade crossing arms and warning devices. The track is level, tangent, located at grade and in an exclusive right-of-way with two tracks that run north and south. SPEED AND SIGNAL RESTRICTIONS Train movement through the intersection is governed by automatic grade crossing arms and warning devices. Maximum Authorized Speed (MAS) at this location is 40 MPH. ENVIRONMENTAL CONDITIONS The temperature was approximately 88° Fahrenheit with scattered clouds. CIRCUMSTANCES A post incident investigation was conducted with Operator #22013. The Operator stated in substance, but not verbatim that on Wednesday June 10, 2015, at approximately 11:47AM, “I was traveling northbound going under 610 Freeway around 40MPH, when I got to the other side, I noticed a white male walking in the trackway, I used my audible and was braking at the same time, but he never looked my way. The train made contact with him.” Also, footage from the intersection camera showed the victim crossing track #2 and walking diagonally towards track #1 while the gate arms of the westbound feeder at Fannin and IH-610 were down. Footage showed that the victim never acknowledged the presence of the train before he got struck by the front right side of LRV #211. He was thrown onto the street side approximately 13 feet before colliding with a traffic pole at that location. CAUSE This incident was due to the pedestrian jaywalking across the street, not complying with the directions of the traffic control signal at that location and ignoring the railroad crossing gates that were down at the time and the train audibles indicating that a train was on approach. PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT FANNIN AND IH-610 Red Line Train #719 and Pedestrian 06-10-2015 Page 3 CONTRIBUTING FACTORS The victim had been panhandling on the eastbound feeder few hours before the accident. Video footage showed him dangerously walking in the eastbound feeder lanes of traffic with cars going around him. The victim may have been listening to music at the time of the accident. Headphones were found on his body and a small portable radio was recovered nearby. A Fannin and IH-610 Automatic Highway Grade Crossing (AHGC), the bells begin to sound before the gate arms go down and continue to sound while the gates are in transition. Once the gate arms are completely down, the bells stop making the audible sound. The flashing lights on both the Crossbuck and the gate arms remain active. IH-610 support columns create a blind spot for Train Operators as they exit the underpass. This area under IH-610 itself is listed as a ‘No Clearance Zone’ in the Rulebook. Autopsy report is still not available. A City ordinance prohibiting panhandling at this location does not exist. DRUG AND ALCOHOL TESTING The operator of Train #719 was drug tested due the incident meeting the requirements of the FTA threshold. The drug and alcohol test results were negative. ACTION TAKEN MPD established a perimeter around the scene and only authorized personnel were allowed access. Train #719, LRV 212S-211N, was later removed from service and inspected by Rail Vehicle Maintenance. No defects were found to the train that would have contributed to the accident. Train #719 was off-loaded and the passengers on-board at the time were directed to alternate service. Rail service was suspended between Fannin South and Smith Lands stations and a bus bridge was implemented. Once the Medical Examiner retrieved the body of the victim and cleared the scene, the train was released by MPD and Safety personnel and returned to the Rail Operations Center Yard for inspection. PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT FANNIN AND IH-610 Red Line Train #719 and Pedestrian 06-10-2015 Page 4 RECOMMENDATIONS The LRV-Pedestrian incident was ruled non-preventable by the Safety Department. SYSTEM PERFORMANCE INVESTIGATION/TESTING Video and data downloads were taken from LRV 211 and LRV 212. Data downloads showed the Train Operator traveling at 41 MPH for under 2 seconds. The Operator applied Maximum Braking at 41 MPH approximately 176 feet prior to making contact with the individual at approximately 25 MPH. Data downloads also indicated that the Operator was sounding the Horn as the train was traveling through the gated grade crossing. Rule #3132 from the Rulebook states: “Operators must sound the appropriate warning device(s) when approaching a gated grade crossing. The horn will be sounded only in the event of imminent danger or when instructed by Control to use at a specific location. Exception: Horn will be sounded at gate crossing I-610. Based on the event recorder, the Operator was in compliance with this Rule. As prescribed by the Rulebook, the sequence for the Horn warning in approach to a grade crossing until crossing is occupied is (2) two long, (1) one short and (1) one long sounds. The Operator was using this sequence through this crossing. Based on the speed of the train (41MPH) at the time the pedestrian came into the operator view, the train was travelling 60 feet/second. At that speed, the stopping distance of the train on dry rail and with normal braking is roughly 308 - 411 feet depending on use of maximum brake or full service brake and with a margin of error of plus or minus 5 percent (see Attachments D). The downloads showed that the Operator was already applying the Horn as the train was traveling though the crossing and as prescribed by Rule #3132 mentioned above and applied maximum braking 176 feet prior to making contact of the individual. There was evidence of sanding on the tracks from both LRVs. Operator #22013 started his career at METRO started in Bus Operations where he held a Bus Operator position for nearly 10 years before switching to Rail Operations. He was hired as an LRT Operator November 2012, qualified to operate on January 2013 and was recertified after two years on January 2015 (Attachment A). He also completed his Defensive Driving Course on November 29, 2013. For the past year, he has been worked with the Training Department as a Relief Rail Trainer before getting promoted to Relief Rail Supervisor. He was disqualified from these positions but remains a qualified Line Instructor. PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT FANNIN AND IH-610 Red Line Train #719 and Pedestrian 06-10-2015 Page 5 SYSTEM PERFORMANCE INVESTIGATION/TESTING (Continued) The work hours for Operator #22013 were reviewed; work related fatigue does not appear to be a contributing cause for this incident (see Attachment A). On June 10, 2015, Operator #22013 was working run #70011/45 (see Attachment A) reporting to the Station Office at 03:35 AM. His shift consisted of two halves. The first half was between 4:05 AM and 8:17 AM and the second half between 9:17 AM and 1:41 PM with and hour break between the two halves. The accident occurred on the second trip of the second half. Operator #22013 is an Extra Board Operator. His regular days off are Wednesday/Thursday. He worked this same exact run on 6/8/15 and 6/9/15. He worked an extra 4 hours each of these dates for a total of 12 hours a day. He received over 10 hours of rest time between each working day. There were no special instructions for the area of Fannin and IH-610 at the time of the incident (see Attachment C). When LRV #211 returned to the ROC Yard, Rail Safety personnel tested the audible devices as well as the braking systems. All appeared to be working as intended. Also, both LRV’s were inspected by Maintenance with no defects found. Maintenance histories for LRV #211 and LRV #212 were reviewed from since they were delivered on May 2013. The last inspection was performed on LRV#211 on May 25th, 2015. LRV #211 was involved in one previous fatality on March 2nd, 2015 and four previous minor accidents that resulted in no injuries and minor damage. LRV #211 was inspected and repaired after each incident and all components were found to be working properly. Fannin and IH-610 crossing case was inspected by Signals and Communications personnel. All components were performing as intended. PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT FANNIN AND IH-610 Red Line Train #719 and Pedestrian 06-10-2015 Page 10 INTERSECTION DIAGRAM X X Location of Collision PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT FANNIN AND IH-610 Red Line Train #719 and Pedestrian 06-10-2015 Page 11 CORRECTIVE ACTION PLAN Temporary and short term solutions: A temporary speed restriction of 25MPH was implemented on June 10, 2015 following the second fatality at Fannin and IH-610. METRO Police increased their patrols in the area to minimize the presence of panhandlers. Long term and final solutions: Re-configure the bells at Fannin and IH-610 grade crossing so they can continue to produce an audible warning from the time the train is detected on approach to the time the train clears the crossing. Add fencing on the west side of both feeder roads to channelize pedestrians to the desired crossing location and to prevent them from crossing the tracks except at designated locations along with additional signage in the area. Mohammed Boukhriss, Rail Safety Manager Investigated By Walter Heinrich, Director of Safety Approved By PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT Corrective Action Plan for LRV Pedestrian Accident June 10, 2015 DATE 6/10/2015 6/10/2015 SAFETY OFFICER Mohammed Boukhriss Mohammed Boukhriss LOCATION Fannin and IH-610 Fannin and IH-610 DEFICIENCY Grade Crossing bells Fencing CORRECTIVE ACTION Reconfigure the bells at Fannin and IH-610 grade crossing so they can continue to produce an audible warning from the time the train is detected on approach to the time the train clears the crossing. Design a fencing solution for this area and additional signage and pavement markings RESPONSIBLE DEPARTMENT/ CONTACT PERSON Signals and Communication Dwayne Lehnert Safety, Operations and Facilities Maintenance/ Mohammed Boukhriss COST N/A Unknown DATE TO BE COMPLETED STATUS AND DATE June 14, 2015 Closed June 14, 2015 Rail Safety personnel witnessed the test and confirmed the implementation Open Fencing on north side of intersection has been installed. Still under review for underpass. 11/14/2016 - Safety will review fencing needs with EVP and/or PEC. 6/30/2017 VERIFICATION AND REMARKS