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Originally Posted by Express691
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The report seems pretty clear on the sequence of events and that the cause of the actual collision of the two trains was human error, both on the part of train 40 and the staff at the OMC.
How I read this is that due to safety steps being missed in the manual driving process, the driver of train 40 activated the train in the wrong direction (backwards) while simultaneously, the OMC lifted an MRR (manual route reservation) that would have held train 81 at KLCC station. The end result is a perfect storm, as train 40's driver was reversing the train from the console on the other side (and thus had no way of even spotting the oncoming train 81), train 81 was blind to the oncoming train 40 because of the OMC's deliberate lifting of the MRR, and the OMC was blind to train 40's position because it was not on the map and they had simply assumed that train 40's driver had moved the train in the right direction.
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That said, the manual driving of train 40 in the first place was triggered
by both the failure of the main VOBC (vehicle onboard computer)
as well as a backup VOBC (interesting that their trains actually have a backup?). From what I read the procedure the driver had to follow was to drive to a side track, where he could perform troubleshooting and perform the reboot of the train whilst mainline service continued uninterrupted. This is actually better than how we used to handle train time-outs (like in the 2014 ATC meltdowns, when the system essentially remained completely down until all of the timed-out trains could be rebooted on the mainline).
At any rate what I also see is that the KJL does not have an auto-restart system for their trains (which we also did not have when our SkyTrain went through the 2014 ATC meltdowns, resulting in the recommendation to have one installed). While the 23 recommendations are mostly procedural and won't necessarily directly lead to the installation of one, recommendation 21 might lead them to looking into it.
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Anyway I want to add, but there is an eerie similarity between the KL incident and an incident on the Toronto subway system that I read about, in which a train being driven in manual from a tail track nearly collided with another in-service train using the newly installed ATC. The lessons from both incidents are that you have to be extremely careful when mixing automatic operation and manual driving (or avoid it altogether).
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Video captures moment two TTC subway trains narrowly avoided collision last year
A new video is shining light on just how close two TTC subway trains came to colliding in a near-miss incident that could have had a disastrous outcome.
In video of the incident obtained by CTV News Toronto, the view from the camera at the front of one train shows it coming to a stop just before another train zooms by on the track that the first train was about to merge onto.
One of the trains had been southbound at Osgoode station, but had been ordered to turn around in order to provide supplementary northbound service. At that point, the operator switched from automatic to manual control in order to navigate a section of railway used to connect to the northbound track.
The operator did not see the other train approaching from behind, but slammed on the brakes after being notified by a guard stationed at the rear of the train.
According to the TTC, the two trains may have come less than a metre apart during the incident.
While the TTC’s Automatic Train Control system is meant to monitor the position of trains at all times, the system was blind to the one vehicle when it switched to manual control.
TTC spokesperson Stuart Green said the driver missed a red signal that told him to stop.
https://www.cp24.com/news/video-captures...ly-avoided-collision-last-year-1.5460474
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