Feds issue final report on dragging death of Red Line passenger

Local News

The NTSB identified three factors that contributed to Robinson Lalin’s death — a train car door malfunction, a camera monitor’s blind spot, and a train operator’s failure to follow standard departure procedures.

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Last spring, 39-year-old Red Line passenger Robinson Lalin was dragged to his death when his upper body was trapped between the doors of a train car as it left Broadway Station.

After investigating the incident and the MBTA‘s practices for over a year, federal transit officials have released their final report on what caused Lalin’s death on April 10, 2022.

The National Transportation Safety Board (NTSB) identified three factors that contributed to Lalin’s death — a train car door malfunction, a camera monitor’s blind spot, and a train operator’s failure to follow standard departure procedures.

The train car door malfunction

The NTSB reaffirmed the finding from its preliminary report that the main cause of Lalin’s death was a safety mechanism malfunction that allowed the train to begin moving while a car door was open. The safety mechanism would normally have prevented this from happening.

The train car was designed so that when any door is open, the electrical circuit that allows the train to move would be incomplete, preventing the train from moving, the report said.

However, in this particular car, protruding wires on the master controller panel were touching a mounting screw. The report said that this accidentally created a short circuit, allowing the car to leave the station without all its doors closed.

This type of Red Line car also has a safety mechanism which causes its doors to keep opening and closing when obstructed, the report said. But when the train car reaches 3 miles per hour, the doors lock in place as far closed as the obstruction allows.

On April 11, 2022, the train car that trapped Lalin quickly reached 3 miles per hour once it started moving, the report said. Lalin’s upper body then became stuck in between the car doors, and he was unable to free himself.

After the malfunction was discovered, the MBTA checked all Red Line cars within 72 hours to see if they had the same issue, but found no others with the malfunction, the report said. It has also since modified the master controller panel on these cars so that screws are electrically isolated.

Still, the report said, before the accident, checking whether a train could move when car doors were still open was not part of the MBTA inspections. This has since been added to the list of safety features checked during inspections.

The camera monitor blind spot and the train operator

Another safety issue federal investigators discovered was that the camera monitor used by the train operator had a 19-foot blind spot that kept her from being able to see the car door which was malfunctioning, as well as that car’s pilot light, the report said.

After the accident, the MBTA audited the placement and alignments of its cameras, and now checks them twice daily to ensure functionality and clarity, the report said.

Additionally, security video from the accident showed that the train operator did not follow proper departure procedure, the report said.

The operator stuck her head out the window of the operating cab to check if the train’s car doors were open and that the train’s pilot lights were off, as is procedure, the report said.

But instead of waiting to see that the train’s pilot lights were off and that all doors were closed before leaving the station, she pulled her head back in the cab, pressed a button to close the doors, and took off, the report said.

The operator, who’d worked for the MBTA since 2018, underwent a toxicology screen after the accident. The screen did not find any drugs or alcohol in her system, the report said.

But, federal investigators did find that in 2019, she faced disciplinary action for an incident that involved a door failure, and that in 2021, she was disciplined for failing to stop for a double red light.

The MBTA placed the operator on unpaid leave in June 2022. An MBTA spokesperson confirmed to Boston.com Tuesday that she no longer works for the MBTA.

What’s happened since Lalin’s death

In December 2022, The Boston Globe discovered that the Red Line fleet that the train car that killed Lalin belonged to is over 50 years old and was originally set to be retired in 1994. That retirement date has been pushed back nine times, the Globe reported.

The NTSB report said the MBTA has committed to retiring the fleet by March 2024, but the transit authority is still facing a lawsuit filed by Lalin’s family.

After the accident, the Federal Transit Administration (FTA) conducted an in-depth safety inspection of the MBTA, eventually issuing their second scathing report in less than five years.

The MBTA took action to meet the FTA’s safety directives, even resorting to dramatically cutting service last summer, but more safety issues followed, such as the infamous Orange Line fire. By the end of the summer, the MBTA was forced to close the entire Orange Line for 30 days to do repairs.

In 2023, the MBTA hired a new general manager and chief safety officer, both of whom were considered key hires for the transit authority. But even after they took office, in May, the FTA once again came down on the MBTA, saying that its plan to improve worker safety after four near-fatal incidents was insufficient.

The MBTA’s response to the NTSB report

“The MBTA acknowledges the release of the National Transportation Safety Board’s final report, is closely reviewing the final report, and expresses its appreciation for the NTSB’s diligent work on the circumstances surrounding the tragic death of Robinson Lalin at Broadway Station,” the MBTA said in a statement Tuesday.

After the incident, the MBTA said, it tested all cars on all lines to see if any other cars were experiencing the door safety malfunction, but found none. Additionally, it said, the malfunction has not been detected in any cars since it began regularly testing for it.

The MBTA said it has also conducted safety audits of camera monitors, mirrors, signage, platform lighting, and cameras on all but the Green Line since the incident and replaced 31 of 55 monitors, including at Broadway Station.

Red Line cars are inspected every 8,500 miles, amounting to around four to six inspections a year, the MBTA said. The transit authority also said it’s nearly doubled the size of its safety department in the last three years and expanded its responsibilities.

“The safety and well-being of every MBTA rider is of the utmost importance,” the transit authority said in the statement. “The MBTA has been working aggressively to improve safety at all levels and has been advancing safety-related objectives with billions of dollars in infrastructure and vehicle investments in recent years.”