FEDERAL INVESTIGATORS have concluded that a short circuit on a Red Line train set off a chain of events in April 2022 that allowed a passenger trying to exit the vehicle at Broadway Station to get caught in the door and dragged to his death as the subway car accelerated and pulled away from the station.
A National Transportation Safety Board report issued on Tuesday and dated April 12 found that the train operator did not comply with all procedures before pulling away from the station, but said the primary cause of Robinson Lalin’s death was a series of wire strands in the lead subway car that touched a mounting screw, completing a short circuit.
Normally, the doors of the subway car would not shut if they were obstructed and the train would not accelerate. But investigators said the short circuit in the train’s lead car bypassed a circuit governing the train door in the second car, allowing Lalin to get caught in the door as the subway began to move. Once the subway reached 3 miles per hour, the doors locked into position, trapping him, the report said.
“As the train accelerated to depart the station, the passenger ran alongside the train with his upper body pinched between the doors. The train did not stop, and the passenger collided with a wall at the end of the platform and was killed,” the report said.
Video surveillance indicated the driver of the train stuck her head out of the lead subway car and visually inspected the station platform, but then pulled her head back in before the pilot lights above the doors had turned off. Pilot lights light up when railcar doors are open and turn off when they close.
The National Transportation Safety Board said train operators are required to make sure all pilot lights are turned off before they pull their head back into the cab and take off. “Investigators also identified a 19-foot blind spot in the [train operator] camera view that included the middle doors of the second railcar in the train consist. The NTSB determined that, had the train operator been using the [train operator] monitor to check whether the platform was clear before departing the station, it was unlikely that she would have seen the accident passenger stuck in the doors,” the report said.
The driver passed toxicology tests after the incident, which occurred just after midnight on April 10. The driver had a handful of disciplinary actions listed in her file, including “for an incident that involved a previous door failure” in 2019, attendance issues in 2020, and failure to stop “for a double red signal” in 2021.
The death of Lalin at Broadway Station prompted the Federal Transit Administration three days later to inform the T that it was going to assume a safety oversight role at the transit authority. On June 15, 2022, the FTA issued a series of safety directives to the MBTA, which the agency is continuing to address.
Lalin’s family filed a wrongful death suit against the MBTA in March.
According to the safety board report, the MBTA’s fleet preventative maintenance inspection procedures did not previously include an inspection of the various door circuits. Now they do, and tests are required to make sure the subway does not move forward if the doors are in an open position. The MBTA has also implemented procedures to make sure that “protruding wires do not unintentionally complete a short circuit.”
The 10-page report said the problem discovered with the Red Line train has not been found on any other cars in the fleet. It also said the T now regularly inspects the location of cameras used by subway train drivers to inspect the platform to remove blind spots.
The Federal Transit Administration in October 2022 issued a safety advisory directing all rail transit agencies “to evaluate the sufficiency of railcar passenger door inspection and function testing procedures,” according to the report.