NTSB blames operator error, Muni for West Portal crash 

The July 2009 Muni train crash at the West Portal station that injured 48 people was the result of operator error and lax oversight by agency officials, according to a long-awaited federal report released Thursday.

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While improperly running his train in manual mode near the West Portal exit of the Twin Peaks Tunnel, Muni operator Henry Gray suffered a medical condition and passed out, causing his two-car L-Taraval train to smash into a one-car K-Ingleside train that was parked at the station’s boarding platform.

Of the 48 people hurt that day, 27 sustained serious injuries, including a broken neck and orbital fracture suffered by passenger Kit Fong Ma, who was recently awarded $475,000 from Muni for her injuries. Passenger Karen Smith, who received $320,000 for her injuries, suffered nerve and musculature damage to her back and legs.

Since Gray’s train was still in the Twin Peaks Tunnel, it should have been operating under automatic control, with the speed and velocity dictated by Muni’s central command. However, Gray was in manual mode — meaning the train was under his control — a controversial time-saving maneuver that had been informally practiced and accepted by both Muni management and operators, according to an accident report released Thursday by the National Transportation Safety Board, a federal oversight body.

While the West Portal accident was the result of operator error, Muni contributed to the crash due to its “failure to monitor and enforce the requirement that the operator wait until reaching the platform before changing the operating mode of the train,” the report said.

Peter Knudson, a spokesman for the NTSB, said the federal group is not a regulatory body so it cannot fine or penalize local transit operators for violations.

Paul Rose, a spokesman for the San Francisco Municipal Transportation Agency, which operates Muni, said the department has no qualms with the NTSB report and has gone through great lengths to prevent such incidents from happening again.

He said the SFMTA added street supervisors to monitor movements at key transition points, directed its central command center to shut down trains if they’re in unauthorized manual modes and provide constant reminders to its operators about the potential disciplinary measures they could face for switching into manual mode too early.

Since the July 18, 2009, accident, the number of “cutouts” — switching early from automatic to manual mode — has dropped dramatically at the West Portal station. According to the NTSB report, about 2,500 monthly trips — 40 percent of all arrivals at the West Portal station — were done in manual mode before the accident. After Muni clamped down on that practice, the number of cutouts dropped to 11 the month after the accident.

Overall, the West Portal accident cost the SFMTA nearly $7 million — $4.5 million in vehicular damage and $2.4 million in injury lawsuits. Gray, a 30-year veteran of the agency, is no longer with the SFMTA, although the terms of his exit have not been released.

According to the NTSB report, Gray suffered from a narrow heart valve, which caused the blackout. Since the accident, Rose said the SFMTA requires more rigorous medical tests before an operator can be cleared for duty.

wreisman@sfexaminer.com

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