Inspection Detail

Inspection: 1438519.015 - San Francisco Bay Area Rapid Transit District

Inspection Information - Office: American Canyon District Office

Investigation Summary

At 10:32 p.m. on October 15, 2019, an employee was working for a commuter rail system as a train operator. She had worked for her employer for 23 years. A transportation supervisor oversaw train operators working in the yard. He was at the facility at the time of the incident. The employee was building a consist. She was coupling a B2 car, #1647, to another car, #1734, with the inter-car closure doors open at the lead end of car #1647. She did not to slow the car and come to a complete stop before proceeding to couple to car #1734. She fell forward between the cars. She was caught between the two rail cars during their coupling. Her right leg was crushed. She was transported to and admitted for treatment at a medical center. Her right leg was amputated just below the knee. An in-car video showed the train operator did not follow the rules documented in the employer's Train Operator Manual (TOM). Specifically, she was standing in the opening of the inter-car closure doors while they were opened greater than 6 inches (150 mm) at the lead end of the car while the rail car was in motion (TOM rule 208). She did not reduce speed to less than 5 mph (8 kph) when at least one car length short of the coupling point and then make a complete stop at least 5 feet (1.5 meters) from the car being coupled. After that, she was to get the cars as close as possible without coupling at a speed not to exceed 2 mph (3 kph) and then stop again. Then, she was to visually verify the proper alignment of the coupler pins before coupling the cars (TOM rule 306). The employer reported the incident to the Division on at approximately 12:27 a.m. on October 16, 2019, within two hours of the event and in compliance with the Division's reporting requirements. On October 17, 2019, the division held an opening conference with the employer. During the inspection walkthrough in the rail yard, two CSHOs accompanied by an employer representative observed four couplings not complying with TOM rule 306.

Keywords: Amputated, Amputation, Caught Between, Couplings, Crushed, Door, Emergency Response, Fall, Fall From Elevation, Guardrail, I2P2, Leg, Railroad, Railroad Car, Surgical Amputation, Training, Work Rules