II. SUMMARY OF PRELIMINARY FINDINGS
Staff conducted over twenty inspections from July, 2009 through January, 2011. The inspections covered all areas: mechanical, track, signal, and operations. The results of those inspections are documented in Inspection Reports.2 Staff has compiled a list of findings from its inspections:
A. Track Deterioration at Church and Duboce Streets
The track at Church and Duboce streets has deteriorated and has numerous defects. Staff inspected the track on August 12, 2009, and again on October 20, 2009. The problem is current; RTSS has yet to receive any plan for correction. Alleged violations are to General Order ("GO") 143-B, section 14.05, and as incorporated in section 14.05, the standards in the Code of Federal Regulations, including Gage (49 CFR 213.53), Defective Rails (49 CFR 213.113), Rail Joints (49 CFR 213.121), and Frogs (49 CFR 213.137). These ongoing track violations present a serious public safety risk, and could result in various safety implications, including possible derailments. (See e.g. Staff Report, Photographs and Inspection Reports in Appendix B)
B. Automatic Train Control Inoperative in Sunset Tunnel
The Sunset Tunnel has numerous violations. The Automatic Train Control System ("ATCS") may not regularly operate in the tunnel, which is a violation of GO 127.Section 3.16, which states, "No portion of the automatic train control system shall be abandoned, nor its operation discontinued without the permission of this Commission." The ATCS monitors all trains on a continuous basis, and automatically protects against collisions and derailments due to right of way, excessive speed, track switches, and other causes.
The SFMTA is not following its own regulations regarding speed restrictions in a non-functioning ATCS area (Rule 4.32.2) (see inspection of January 6, 2011, attachment Staff Report, Appendix B). Richard Clark, Director of CPSD, sent a letter to Nathaniel Ford, SFMTA Executive Director and CEO, on January 14, 2011, directing the SFMTA to start following its own regulations and directing SFMTA to inform the Commission regarding its plan to restore the ATCS in the Sunset Tunnel. The SFMTA responded with a letter dated January 18, 2011, stating that the ATCS never functioned in the tunnel; however, the SFMTA did not provide any documentation to verify the claim. The SFMTA has yet to provide a plan for implementation of ATCS in the Sunset Tunnel. These violations of GO 127 and SFMTA's internal rules constitute a serious public safety hazard.
C. Poor Maintenance of Signal and Train Control Equipment at Church Portal
An inspection on June 3-4, 2010, of the Church Portal noted numerous deficiencies including induction-damaged loop cable supports, improperly supported cables, cables rubbing switch rods, junction box problems, and others. A follow-up inspection on January 7, 2011, noted the same deficiencies. These deficiencies potentially pose a public safety threat. (See Staff Report, Appendix B)
D. ATCS Malfunction at the Embarcadero Station
The ATCS functions poorly in the Market Street Tunnel and may not regularly operate at the Embarcadero Station. The SFMTA has delayed replacing the induction loop cable (see inspection dated October 11, 2010, Staff Report, Appendix B). The lack of a properly functioning ATCS may have contributed to an incident on October 1, 2010, in which one light rail vehicle ("LRV") hit another LRV at the Embarcadero Station causing major damage to both LRVs. Both train operators had minor injuries and were transported to the local hospital.
E. Failure to Implement Blue Flag Safety Procedures
SFMTA did not have a blue flag/ blue light procedure in place until January, 2011. The blue flag/light procedure is required to prevent injury to personnel working underneath or around LRV's. When an employee is working under a train, or in a location where moving the train could imperil the employee, that employee places a blue flag or turns on a blue light, which can only be removed by the person who placed it or turned it on. The blue flag procedure is common in Rail Transit Agencies ("RTA"). On May 12, 2010, Muni issued a bulletin to Muni operations professionals implementing blue flag/ blue light procedures. In September, 2010, a Muni employee became concerned because the blue light/ blue flag procedure was not used and the employee made a Good Faith Challenge and brought the situation to the attention of Staff.3 On December 7, Muni issued a memorandum to "All Rail Maintenance and Operations Personnel", directing that the blue flag/ blue light procedures should be followed at all times. On December 14, Staff observed SFMTA maintenance employees working on LRV's without a blue flag or blue light. This is a preliminary finding of a violation of SFMTA's own internal safety policy. (See e.g. Staff Report, Appendix B)
F. Failure to Complete Corrective Action Plans
The last Triennial Audit of the SFMTA occurred in October 2008. Of the 49 Corrective Action Plans ("CAP") created by the SFMTA, 17 remain open. Several of these are significant and relate to the SFMTA's track inspection program and the documentation of that program. In several recent meetings with Staff, the SFMTA has not been able to provide the status of pending CAP's for Staff review. (See Staff Report, Appendix A4).
G. Failure to Respond to Inspection Reports or Submit Corrective Action Plans
Staff inspections of the SFMTA between July 17, 2009, and January, 2011, document various material problems with the SFMTA. Of the 29 inspections requiring SFMTA responses within 30 days, 26 responses and CAPs have not yet been received. (See Staff Report, Appendix B).
H. Failure to Provide Incident Reports
GO 164 D requires the SFMTA to submit final accident investigation reports within 60 calendar days of the accident. To date, there are 8 SFMTA accident investigation reports outstanding from 2009, (some of which are over 13 months late) and 25 from 2010. Each of these late reports is a violation of GO 164-D. (See Staff Report, Appendix C).
2 Due to the voluminous nature of the Inspection Reports, only key documents will be attached to this OII and staff report. The inspections reports in their entirety are available upon request.
3 The employee's name has been redacted from the report.
4 Due to their volume, if the appendices to the Staff Report are not attached to this OII, they are available upon request.
