FINAL REPORT PRIVILEGED & CONFIDENTIAL 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 #9, (LRV 116-110) AND PEDESTRIAN ACCIDENT AT MAIN STREET AND WALKER, RED LINE, ON MONDAY, JULY 22, 2013. DESCRIPTION OF OCCURRENCE On Monday, July 22, 2013 at approximately 8:09AM, Train #9 (LRV south 116-110 north) was traveling southbound (Track #2) on Main Street, passing through the intersection at Walker; A pedestrian mounted on her bicycle, that had just exited off the northbound train, went to the north end of the platform and turned left (westbound) from the station platform and entered the track way while Train #9 was passing through. The Train Operator sounded the horn; however contact was made, trapping the pedestrian between the train and the platform between the ‘B’ truck of LRV 116 and the second set of doors. The pedestrian was declared deceased at the scene of the accident. INJURIES The Train Operator was transported to St. Joseph Hospital for observation. She was released the same day. FATALITIES The pedestrian, Vivian Ziwei Guan, age 20, was declared deceased at the scene. PROPERTY DAMAGE There was no damage to the LRV. Labor costs for post-accident inspection were $385.15. The pedestrian’s bicycle was totaled - $200. STREET CHARACTERISTICS Main Street runs north and south with one lane of vehicular traffic in either direction with no parking on either side of the street. There is no southbound lane of traffic south of the intersection so that all traffic on Main Street headed southbound must turn right on to Walker. Walker Street runs one-way westbound with four lanes for vehicular traffic. Parking is allowed of both sides of the street. The intersection of Main and Walker is controlled by traffic signals with “No Left-Turn” signs posted for vehicular traffic traveling on Main Street northbound and “Right Turn Only” signs for southbound traffic. Pedestrian signals are used to cross the street and trackway on the north and south sides of the street. On the southwest corner of the intersection, the sidewalk and platform are only separated by the southbound track (Track #2) since there is no southbound street in this portion of the intersection. The south side pedestrian signals allow access to and from the north end of Main St. Sq. NB platform. At this platform, a fence runs down the west side of the platform to the crosswalk to keep people on the platform from entering the southbound track before the crosswalk. Due to recent construction, a new interlocking signal has been placed in the middle of the north side of the crosswalk, and the previous “Stop, FINAL REPORT PRIVILEGED & CONFIDENTIAL MAIN AND WALKER Red Line Train #9 and Pedestrian 07-22-2013 Page 2 Look, Listen” sign (18” h x 12” w) and “Rail Shuttle 700” sign (17” h x 11” w) were moved 43” to the west On the back side is a “Do Not Enter” sign (18’ h x 18” w) for southbound vehicular traffic (see picture 8). The top of this pole is 5’ from the top of the curb. TRACK CHARACTERISTICS The track at this area is level, tangent, and located at grade and embedded in concrete, with two tracks, running northbound and southbound. Authorized train speed at this location is 30 MPH. SPEED AND SIGNAL RESTRICTIONS Train movement is governed by bar signal indicators, with the signal head for both directions on the north side of the street. ENVIRONMENTAL CONDITIONS The temperature was approximately 80° Fahrenheit, and weather conditions were clear. The lighting was adequate for the conditions. CIRCUMSTANCES The Train Operator (PR# 19436) was unable to answer any questions in a Post-Accident interview attempted the day of the accident. She completed her written statement two days following the accident. Data and video download from the LRV showed that Train #2 entered the intersection of Main & Walker with a flashing vertical bar signal at approximately 22 MPH. Rule 3063 b. states the indication of a flashing vertical bar signal to an Operator is “prepare to stop at signal if within braking distance.” The train was approximately mid-block once the signal began to flash giving the Operator about 125 feet of braking distance. A train at this speed needs approximately 120 feet of braking distance, so the Operator did not violate this rule. The pedestrian/bicyclist entered the crosswalk, against the signal (picture 12) after SB Train #2 had already entered the intersection (see pictures 1- 3). Pictures show that the pedestrian/cyclist did not appear to see the train until just prior to contact. CAUSE This incident was a result of the pedestrian failure to obey pedestrian signals and be aware of her surroundings. CONTRIBUTING FACTORS The pedestrian exited the Northbound train #12 (LRV 108-113) behind several other patrons and began walking north. She mounted her bicycle while still on the platform and continued northbound behind five (5) other people. Three (3) of the people remained in the crosswalk as the pedestrian/cyclist turned left in front of the train and was struck. Based on video evidence from LRV 116 and a later recreation of the scene during the time prior to the accident (pictures 9 & 10), as the southbound train entered the intersection, the FINAL REPORT PRIVILEGED & CONFIDENTIAL MAIN AND WALKER Red Line Train #9 and Pedestrian 07-22-13 Page 3 pedestrian would have been able to see the train (see pictures 1, 10 & 11) showing that neither the signs nor the other pedestrians would have significantly obstructed her view of the southbound train. Video download of the northbound train (LRV 108) shows the headlights for LRV 116 were working properly approaching the intersection, but the railroad light (the light on top of the train) was not on (see picture 13). Rule 4083 of the METRORail Rules and Procedures for Rail Operations reads “Train Operators must use the high beam and railroad light during operation except in the Yard. The Operator must dim headlights or extinguish the railroad light 500 feet prior to approaching oncoming trains or when the safety of the public or employees so requires.” As SB Train #9 was passing NB train #12 at this point, the Operator of SB Train #9 was in compliance with the rule. The video download from LRV 116 also shows that there were no obstructions preventing the pedestrian/bicyclist from seeing the crosswalk signal for her direction of travel. DRUG AND ALCOHOL TESTING The operator of Train #9 LRV 116-110 was drug tested due the incident meeting the requirements of the FTA threshold. The drug and alcohol test results were negative. ACTION TAKEN Train #9, LRV 116-110, was removed from service and inspected by Rail Vehicle Maintenance. No defects were found to the train that would have contributed to the accident. System Safety observed the traffic and pedestrian signals at Main & Walker after the accident. All signals appeared to be working normally at the time. RECOMMENDATIONS The LRV-Pedestrian incident was ruled non-preventable by the Safety Department. CORRECTIVE ACTION PLAN During post-accident investigation several items were noted by emergency responders and the Safety Department. The first emergency responders on scene did not know where the lift points on the LRV were located. Despite training sessions with HFD Heavy Rescue and on-going training with HFD, not all firefighters have had a chance to get necessary training. Therefore, installation of lift point stickers on the LRVs will show any emergency responder where to lift the train safely. This is to be accomplished by LRV Maintenance by the end of October. A second issue was HFD trying to determine who METROs On-Scene Coordinator (OSC) was. METRORail utilizes one person at the scene to coordinate efforts and communication between the Train Control Center, MOW, and emergency responders. In major incidents, METRO may have multiple personnel on location, making it difficult for emergency responders to know who METRO’s OSC is. Therefore, the OSC should wear a different colored vest to distinguish him/her from the rest of METRO FINAL REPORT PRIVILEGED & CONFIDENTIAL MAIN AND WALKER Red Line Train #9 and Pedestrian 07-22-13 Page 5 personnel on location. Finally, although riding a bicycle on the platform is not an infraction, the size of the platform along with the ramp on both ends makes riding a bicycle in this area a hazard to other pedestrians. METRO should implement some public service announcements to avoid riding the bicycle on the platform. PICTURES 1. Southbound train entering intersection of Main & Walker. Pedestrian/cyclist’s helmet can be seen behind the individual in the striped shirt as she is coming north down the middle of the platform. 2. Location of train as pedestrian/bicyclist begins to enter the crosswalk. FINAL REPORT PRIVILEGED & CONFIDENTIAL MAIN AND WALKER Red Line Train #9 and Pedestrian 07-22-13 Page 11 SYSTEM PERFORMANCE INVESTIGATION/TESTING Video and data downloads were taken from LRVs 116 and 110. Video showed the Train Operator entered the intersection on a flashing vertical bar signal travelling at approximately 22 MPH. Video was also taken from Train #12 LRV 108–113, which was the NB train the pedestrian rode from Herman Park/Rice U. to Main St. Sq. Based on the speed of the train (22MPH) at the time the pedestrian entered the intersection, the train was travelling 32 feet/second. At that speed, the stopping distance of the train on dry rail and with normal braking is between 88 -119 feet depending on use of maximum brake or full service brake (see Attachments D). The video shows as the pedestrian proceeded into the crosswalk the train had already entered the intersection and was approximately 64 feet from the pedestrian. The download shows the Operator initially put the train in maximum brake, went to full service brake, and then back to maximum brake. However due to such a short distance between the pedestrian and the train when the pedestrian entered the crosswalk, the Train Operator would not have been able to stop the train to avoid contact. Train Operator #19436 was hired by METRO in July 1999 and qualified as a Train Operator on August 20, 2004. She had completed her most recent Train Operator re-qualification on July 12, 2012. She completed her Defensive Driving Course on August 20, 2012. During her time as an Operator she had been involved in 10 other accidents; all of them classified as non-preventable. Only one of these accidents had been in the past 12 months: on March 12, 2013 a bicyclist had gone around the crossing gates in the down position at Fannin & I-610 Feeder Road and rode into the side of the train as it passed. On July 22, 2013 Operator #19436 was working run 70017/14, reporting to the Station Office at 7:08AM and departing on her first trip NB from Fannin South at 7:23AM with Train #8. The Operator had just had two consecutive days off on Saturday July 20th and Sunday July 21st. Operator #19436 had previously submitted her resignation to METRO on July 15, 2013 to be effective on July 26, 2013 (see Attachment A). There were no special instructions for the area of Main and Walker at the time of the incident (see Attachment B). Construction was being done on the building at the southwest corner of Main and Rusk one block to the north and a fence had been installed for approximately 150 -160 feet from Rusk Street going south. A dumpster and construction debris were located in the lane of southbound traffic and the street was blocked off between Rusk and Walker. This fence or construction activity did not interfere in any way at the accident scene. As SB Tr #8 passes the construction area a man can be seen standing in the middle of the southbound lane of traffic in the general area of the north side crosswalk at Main and Walker. Simultaneously, NB Tr#12, the one in which the pedestrian/cyclist has just deboarded, passes by on the opposite track. At this moment, the Train Operator for SB Tr#9 sounds the whistle, though it cannot be determined for what reason. This occurs eight (8) seconds prior to contact with the pedestrian where the train is approximately 100 -150 feet from entering the intersection at Main and Walker. Maintenance history for LRV 116 was reviewed from the past 12 months (see Attachment E). LRV 116 had returned to service in November 2012 after returning from the Siemens plant in Sacramento, CA for repairs due to damages caused in a LRV-Dump truck accident on October 4, 2011. LRV 116 had been involved in FINAL REPORT PRIVILEGED & CONFIDENTIAL MAIN AND WALKER Red Line Train #9 and Pedestrian 07-22-13 Page 12 two (2) other accidents since it returned; the first on January 3, 2013 and the second on July 10, 2013. The LRV had sustained some damage to the truck skirt in the first accident and damage to the coupler cover, side skirt, coupler frame, and coupler in the second accident. Repairs had been made to the LRV after each accident and prior to its return to revenue service. Maintenance records for LRV 110 A basic signals inspection for Main & Walker was done by City of Houston. All signals (traffic, pedestrian, and bar) were working properly and no defects were found. The latest conflict monitor test was obtained from the City of Houston (see Attachment D). Gary G. McCullum, Rail Safety Officer Investigated By Walter Heinrich, Rail Safety Manager Approved By Corrective Action Plan for LRV Pedestrian Accident July 22, 2013 DATE 7/22/2013 7/22/2013 7/22/2013 7/22/2013 SAFETY OFFICER LOCATION DEFICIENCY CORRECTIVE ACTION G. McCullum ROC Emergency responders do not know where lift points are on LRV Emergency responders need to be able to quickly identify METROs OnScene Coordinator People riding bicycles on the platform are a hazard to other pedestrians. Signs at the ends of platforms need to be in a uniform location to avoid possible line of sight issues. Install lift point stickers on the outside of LRVs where HFD can lift the train METROs On-Scene Coordinators to wear an orange vest. G. McCullum ROC G. McCullum ROC G. McCullum ROC Safety message advising passengers not to ride their bicycles on the platform. Move signs to the middle of the crosswalk to eliminate any possible line of sight issues. RESPONSIBLE DEPARTMENT/ CONTACT PERSON COST DATE TO BE COMPLETED STATUS AND DATE VERIFICATION AND REMARKS LRV Maintenance/ Stephen Land ~ $200 October 31, 2013 Completed October 9, 2013. Blue lift stickers placed at all lifting points Operations/ Eddie Espinosa ~ $200 October 31, 2013 Completed August 29, 2013. Orange vest provided in all Transportation Field Supervisory units December 31, 2013 Completed 8/18/2015 Safety message created and is playing on all station platforms December 31, 2013 Completed December 9, 2013 Signs moved onto interlocking signal in the middle. Safety/ Walter Heinrich Facilities Maintenance $0