Tom Dedes was one of those people. A 50-year-old TTC track worker with 18 years experience, he made his living working on the transit system after most of the city had gone to sleep.

In the early hours of Oct. 1, 2017, he and his crew were at the TTC’s McCowan yard loading a rail car with equipment for a track maintenance job on the Scarborough RT.

The operator of the car got the signal to proceed and, in accordance with procedure, sounded his horn twice to alert the crew, according to a police report. He advanced the car slowly, moving at about 1 km/h. The operator didn’t get far before he heard screaming, and a warning bell telling him to stop.

The TTC later said the rail car took a turn in the track the rear end swung out and hit Dedes, pinning him against a truck. According to the police report, the force of the impact “pushed the truck upwards onto its two wheels, with the victim in between both vehicles.”

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Dedes’ pelvis was crushed and he suffered serious internal injuries. He survived the initial trauma, but died in hospital eight days later.

Dedes was the third TTC track worker to be killed on the job between 2007 and 2017. The circumstances of each accident were different, but all three involved rail cars, and all occurred during the night shift when TTC workers face what one transit agency report described as a “race against time” to carry out their duties.

Separate Ontario ministry of labour investigations into two of the deaths — that of Dedes, as well as the 2007 fatal accident that killed a worker named Tony Almeida — found the TTC had failed to take every precaution necessary for the protection of workers, and the province laid workplace safety charges against the transit agency in those cases. In the third, the 2012 death of Peter Pavlovski, the ministry found a more minor violation of workplace safety legislation but decided not to recommend charges.

The TTC pled guilty and paid a $250,000 fine in the Almeida case. The Dedes case is still before the courts. The TTC has said it will respond “appropriately” to the charges, but hasn’t said whether it will fight them.

A Star investigation into the fatalities that included examining previously unpublished ministry of labour reports found the ministry concluded in 2013 that the TTC wasn’t adequately tracking potentially dangerous “near miss” incidents at track level, and the province’s investigator wrote that there was a “code of silence” among unionized transit employees that discouraged them from reporting unsafe situations for fear of getting coworkers in trouble.

Years after those safety concerns were raised, there is indication the TTC hasn’t fully addressed them, and as recently as last year sources say officials at the agency were alarmed by a lack of compliance with basic safety procedures. Meanwhile, the time constraints faced by overnight track crews have only become tighter as the aging subway is in greater need of repair.

Stuart Green, a spokesperson for the transit agency, said the TTC does everything possible to protect employees, and does not believe there is a culture of secrecy in its workforce.

He said the agency has “numerous protocols and policies in place” to keep workers safe, including providing them with extensive training and protective equipment, holding monthly safety talks, conducting safety briefings “each and every time” workers go into the system, and performing frequent site visits to ensure all policies are followed. He said crews are not assigned more work than is manageable on a night shift.

“Safety is paramount in all we do,” he said.

The union, while conceding that it sometimes seeks to protect individual members from discipline, said it encourages workers to report safety hazards and works with management to address them.

The deaths of Almeida, Pavlovski and Dedes have been devastating for their loved ones, with some saying the charges have led them to question whether the accidents could have been prevented.

It’s a question that haunts Dedes’s brother, George.

George Dedes had a mental breakdown about six months after Tom’s death. He said he’s lost 60 pounds and is in counselling.

“I still can’t deal with Tom’s passing,” George said. “We don’t want to see other people going through what we’re going through.”

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On a recent Thursday morning, a crew of 28 men (almost all track workers are male) was dispatched to the eastbound section of tunnel between Dufferin and Ossington stations to replace a worn-out “stringer,” a 390-foot section of rail.

The tunnel was dim, lined with grime, and lit by sparsely placed fluorescent bulbs near the ceiling, as well as a handful of portable lights brought by the crew. On this unusually warm October night, it was hot underground, and at times the sound of hammering and sawing made it difficult to converse in anything below a shout.

While in many ways the subway has modernized, much of the work it requires is still performed the way it would have been on a railroad 100 years ago. To replace the rail, the men knock out the metal clips that fasten it to the tunnel floor using sledgehammers, and then use tonglike devices called “carryalls” to hoist it out of place.

A stringer weighs about 13,000 pounds, and has to be lifted in sections. On each section, the workers lined up shoulder-to-shoulder on either side of the rail, each one grasping one end of a carryall. One worker stood at the head of the line and shouted “Are you ready?!”

“Yeah!” the men hollered back.

“Are you ready?!”

“Yeah!”

On the count of “One, two, three!” they heaved the rail out of its ties. After the entire stringer had been removed, workers lifted the replacement rail into place.

The track crews have little time to do their work. On weeknights trains start to go off-duty from “revenue service” at around 1:30 a.m. and head back to yards across the network, before being sent out again around 5 a.m.

Overnight crews access job sites on work cars that travel the same track as the subways, and it’s a complicated task to co-ordinate the incoming passenger trains with the outgoing work cars. Crews often have little more than three hours to get to their site, finish the assigned job, and head back to the yard.

“There’s a lot of things that are competing. Track time is precious. You don’t get a lot of it. You can’t waste it,” said Jim Ross, the TTC’s acting chief operating officer, in an interview. Ross was appointed to the role in April, but has spent 20 years at the TTC, starting as a subway operator.

The amount of work that needs to be done in those precious hours has only grown in recent years, both because the aging system requires more maintenance, and as a result of major new projects like the installation of the automatic train control signalling system. TTC officials say that a decade-and-a-half ago they used to set up about 15 work zones each night, but now need to co-ordinate 30 to 40.

“There’s a lot of hazards in the tunnel,” Ross said. “To allow for any kind of wiggle room on work methods and procedures is not acceptable. You have to stay focused on: this is a dangerous job.”

Ross was in Dedes hospital room shortly before the worker died, and said that his passing has spurred him to double down on improving safety at the TTC.

“For me, that was a very focusing moment,” Ross said. He said he is always looking for ways to improve safety. “The best question to ask is, what else can we be doing?”

For the past decade, the deadliest hazard for TTC track workers has been the work cars they travel on. The TTC has about 80 of the vehicles, which can weigh at least 118,000 pounds.

On Apr. 23, 2007, Almeida, a 38-year-old equipment operator, was killed while driving a three-car work train. At around 4:35 a.m., he and an 11-member crew were returning to Greenwood yard at the end of an overnight asbestos abatement shift on Line 1, when a scaffold extension on the car ahead of the one Almeida was operating snagged on the side of the tunnel.

According to a previously unpublished October 2007 ministry of labour report, a redacted copy of which the Star obtained through a freedom of information request, the contact caused the scaffold to rise out of its mounting, and then flip into the operating cab of Almeida’s car, “causing crushing damage” to the operator.

At around 4:44 a.m. on Sept. 14, 2012, Pavlovski, an experienced 49-year-old TTC roadmaster, was killed when he was struck by a work car while performing an inspection on track north of Yorkdale station. Pavlovski was on a section of track that hadn’t been designated a work zone, according to the TTC, and neither transit control nor the crews on duty knew he was there.

Each of the three deaths sparked investigations by both the TTC and the ministry of labour. The TTC released its reports about Almeida and Pavlovski. The Star obtained redacted copies of the ministry of labour reports on those two incidents through a freedom of information request. Neither the TTC nor the ministry has yet released their investigations into Dedes’ death.

In Almeida’s case, the ministry determined the TTC didn’t have proper rail car inspection procedures in place. Following his death, the agency took the type of work car he was driving out of service until they could be made safer, hired a consultant firm to improve its workplace safety culture, and implemented a drug testing policy (Almeida was found to have had cannabis in his system, although that wasn’t identified as a primary cause of the accident).

The findings of the ministry’s investigation into Pavlovski’s death are heavily redacted in the version obtained by the Star. But the TTC’s investigation determined a primary cause of the accident was Pavlovski’s failure to notify his colleagues he was on an unprotected stretch of track.

However, the ministry investigator concluded the TTC had violated the Occupational Health and Safety Act as the headlights on the work car that struck him were misaligned and weak, illuminating an area just six metres in front of the car. Charges weren’t recommended in part because the investigator found lighting wasn’t the main cause of death.

After Pavlovski’s death, the TTC revised its work area warning system to better protect track workers.

Both the ministry and TTC investigations into Pavlovski’s death raised wider concerns about safety culture at the transit agency, including what they described as inadequate reporting and tracking of so-called “near miss” incidents — cases in which there was the potential for serious injury but no one was actually harmed.

The TTC report, released in 2013, said the agency did a good job of tracking serious accidents, but placed less focus on near misses, meaning there was “incomplete information available to supervisors and workers to assess the actual risk of (employee) behaviour,” such as accessing tracks without permission.

The ministry investigator wrote that in the course of examining the incident that killed Pavlovski, he became aware of at least four other “near miss incidents” involving track level workers, three of which occurred in the three months after Pavlovski’s death. They included an incident in December 2012 in which a train unexpectedly entered a work zone near Islington station.

“It is highly unlikely that these incidents almost never occurred prior to the incident (Pavlovski’s death) and only now is there a sudden increase in near miss incident frequency,” he wrote.

The ministry report charged there was a “code of silence” among TTC workers that dissuaded them from reporting near misses and other safety risks. The investigator attributed the culture of silence to the fact that “TTC workers are all part of large unionized environment,” which meant “there may be a reluctance on the part of a union worker to report violations of another fellow union member, for fear of reprisal.”

“Only a co-ordinated effort between the union leadership, members and the TTC management could hope to overcome the code of silence,” the report warned, calling the TTC’s “insufficient” tracking and analyzing of near miss data “not acceptable.”

TTC spokesperson Green said the agency is unaware of any “code of silence” among employees.

“It is certainly not something that we believe is taking place now, nor we would condone such a thing,” he said in a statement this month, adding “we want and expect all incidents to be reported and there are numerous ways that employees can anonymously report if they feel they need to do so.”

Green said all safety incidents, including near misses, “are to be reported to the appropriate supervisor as required,” and the reporting, recording, investigation and corrective action on individual incidents are dealt with at the department level.

The leader of the largest TTC workers union acknowledged the union often prefers members not identify fellow employees who violate safety rules to management.

“We normally encourage them to report it to us, so that we can correct the problem and thus not have a member disciplined,” said Frank Grimaldi, president of Amalgamated Transit Union Local 113.

“We would approach management and not mention anybody’s name, but mention that we have a problem in this area, (and discuss) what steps are we going to take to ensure it doesn’t happen again.”

TTC’s acting COO Ross said management does “everything that we can to encourage” workers to report safety violations, but acknowledged “there may be reluctance” among employees.

“The worker may choose to deal with it on his own … Maybe they work it out between the two of them and that worker is satisfied that that’s been addressed,” he said, adding: “There’s no way of knowing if they all get reported.”

Although the TTC has made safety improvements after individual near misses, other transit agencies have done more to track such incidents.

According to a report cited by the ministry of labour in the Pavlovski investigation, New York City Transit created an annual report to provide detailed analysis of the different types of near miss incidents, their causes and potential solutions, allowing the agency to identify and address trends.

“We do not do anything like that, that I’m aware of,” Ross told the Star. “We don’t have good safety data.”

He said the agency is implementing a software upgrade next year that will allow the agency to better track safety incidents.

Green said the new software will ensure “all reported incidents will be better managed from start to finish” and allow for “for further corrective action” beyond addressing individual incidents.

Another concern the TTC investigations raised was the time pressure that track workers are under.

The TTC report on Pavlovski’s death noted that taking shortcuts that violated policy was a “fact of life” for track workers because it “consumes precious time” to get permission from transit control to perform tasks like an unscheduled inspection.

“The context is one of a chronic race against time to complete work within a short window of opportunity at night,” the report said.

Five years earlier, the TTC’s investigation into Almeida’s death had also flagged the short work window as a safety concern, and recommended the agency look into expanding it to give workers more time.

While the TTC now relies more heavily on weekend subway closures to get work done, a decade after the Almeida report the regular overnight work window hasn’t been expanded. In fact, the only change to the work window over the past decade is that it’s gotten shorter on weekends, as a result of the TTC now opening an hour earlier on Sundays, a change made in 2016.

Next year the agency plans to start selectively closing sections of the subway early on weeknights to allow crews more time.

Grimaldi said many union members have raised concerns about TTC management scheduling “more work than is possible to be done” on overnight shifts.

But Green said overnight track work “is scheduled so that only what is manageable is planned.”

***

Both TTC workers and members of management who spoke to the Star agree that the focus on safety has improved since Ross took over as acting chief operating officer.

In the months before Ross became acting COO, top agency officials became alarmed by a number of incidents that suggested basic safety procedures were not being followed. According to TTC sources, they included at least one instance when power had not been cut in a work zone where track workers were performing their duties.

One source said that, prior to Ross being appointed, monthly safety meetings the agency is supposed to hold with workers weren’t happening. A TTC safety check conducted in the spring of 2017 found just one third of track workers were wearing proper protective equipment.

Recent changes Ross has instituted include adding another layer of senior supervision on overnight shifts, and increasing the number of safety audits. A safety audit this summer found the number of workers wearing proper protective equipment had increased to 90 per cent.