The Long Island Rail Road knew for more than three decades that the gap between trains and platforms posed a serious threat to passengers, injuring hundreds of riders in terrifying falls.
The railroad knew that Patricia Freeman fell into a gap at Garden City station in July 2004, fracturing a hand, three ribs and a bone in her spine.
It knew that Melissa Kalbacher slipped into a gap at Hunters Point station in Queens in January 1998, tearing the skin off her right shin.
It knew that Mark Daniels plunged into a gap at Hicksville in 1985, crushing his pelvis.
Since 1995, the LIRR has logged more than 800 gap incidents at stations from Penn to Bridgehampton, according to records obtained and analyzed by Newsday. The falls have involved toddlers and senior citizens, regular commuters and occasional riders, the disabled and the able-bodied. During that period, gap falls have comprised an increasing percentage of rider accidents.
And Thursday, LIRR officials revealed that an estimated 38 percent of its platforms have problem gaps.
Yet until recently the railroad's efforts to prevent falls amounted to little more than "Watch the Gap" warnings posted inside train cars, at a few stations and in safety brochures.
The long history of gap falls took a deadly turn in August, when Natalie Smead, 18, a Minnesota teenager whose blood-alcohol level was nearly three times the legal limit for driving, fell through a gap at the Woodside station and crawled into the path of an oncoming train. In ensuing days, Newsday measured and reported the size of gaps across the system, including one in Syosset that was found to be 15 inches wide.
Only then did the railroad launch its first systematic attempt to fix the gap problem. That effort, which they announced two months later, used relatively simple methods -- such as tacking wooden boards onto platform edges -- that top LIRR officials admit they could have employed years ago.
"This was nothing new," state Sen. Dean Skelos (R-Rockville Centre), the Senate's deputy majority leader, said of the gaps. "Injuries were occurring -- nothing fatal until now, but when you have continuous injuries ... I just believe that more significant steps should have been taken sooner."
Smead's death, the railroad's first gap-related fatality, brought into sharp, public focus a problem that has generated more than 30 years' worth of rider complaints and lawsuits but little government oversight or regulation.
"Here's a situation that was just totally neglected for 30 years until Natalie died," said attorney Bob Sullivan, who is representing the Smeads in a $5-million lawsuit against the LIRR. "Shame on every LIRR official for the last 30 years."
A Newsday analysis of railroad records shows that, except for 2002, gap falls were the leading cause of passenger injuries in the 5 1/2 years prior to Smead's Aug. 5 death. The analysis revealed 374 gap incidents from January 2001 through last July.
Looking back, the gap "was not high on the list of things going on," said Charles W. Hoppe, the LIRR president from 1990 to 1994. "Maybe it should have been."
Gerry Bringmann, chairman of the LIRR Commuters Council, an advisory group, said that when the council asked about gap incidents, LIRR officials told the panel that the falls were an inevitable part of running the nation's largest and busiest commuter railroad.
"The impression we always got from the railroad," Bringmann said, "is that, 'It's just one of those things that's going to happen.'"
In the wake of Smead's death, the railroad's past failure to address the gap problem strikes a raw nerve for riders injured in such falls.
The LIRR "had knowledge of a dangerous situation and did nothing about it," said Lori Wright, one of three people who fell through the gap at the Syosset station on the same day in January 1996.
Railroad officials say they have long recognized the hazard of platform gaps, noting that some space is necessary for the safe passage of trains. But they say that until Smead's death, they believed that rider education programs were enough to mitigate the danger.
In recent months, the railroad has launched an aggressive campaign to reduce gaps at several stations by moving tracks, shifting platforms and installing inexpensive wooden boards. The LIRR also has expanded its education programs, including posting a gap safety video on its Web site.
LIRR officials point out that overall, the railroad is safer for passengers than it was a decade ago; the number of total rider accidents has dropped 50 percent since then.
"I remember at different safety meetings ... we discussed the issue of the gap at length," said Acting LIRR President Ray Kenny. "They were for the most part, overwhelmingly, minor incidents. I don't know if we could have foreseen the accident that happened at Woodside."
A team of Newsday reporters spent five months investigating gap incidents and the LIRR's handling of them, reviewing thousands of documents obtained under the state Freedom of Information law, and conducting scores of interviews.
Among the findings:
Since the early '90s, gap falls have consistently ranked as one of the top three causes of customer injuries on annual LIRR safety reports. Newsday found 882 gap incidents on the LIRR since 1995, but that total likely is higher because the railroad does not count all falls into the gap as "gap accidents."
The LIRR has had more gap incidents per year than Metro-North Railroad in all but one of the last 10 years. It has had more annual gap incidents than New Jersey Transit since at least 2000. The LIRR's rate of gap falls per million riders also exceeds that of the two other rail lines.
The inspector general of the LIRR's parent agency, the Metropolitan Transportation Authority, issued a report in 1987 detailing gap dangers on Metro-North Railroad. Yet neither the report nor the resulting changes made at Metro-North were shared with the LIRR, its sister commuter rail, LIRR officials said.
Two weeks before Smead died, the MTA objected to a federal proposal to limit gaps to 10 inches on straight platforms and 13 inches on curved platforms -- even though the agency said it could meet those standards at most LIRR and Metro-North stations, according to an MTA letter to the U.S. Department of Transportation.
Government oversight agencies do not track gap incidents and have never mandated an enforceable maximum width for platform gaps. Instead, they have focused almost exclusively on allowing enough room for trains to pass through stations.
WHY GAPS EXIST
The problem of gaps emerged when railroads began raising platforms to the height of train doors in the early 1900s -- a practice that expanded in the '50s and '60s. Historically, passengers climbed stairs from low platforms to board trains.
But as railroads converted platforms to improve efficiency and accessibility, they faced a dilemma: Gaps were necessary for trains to pass safely through stations but could also pose a hazard to riders if they were too wide.
All rail lines, including the LIRR, regularly measure the distance from the center of the tracks to the platform edge. But until Smead was killed, the LIRR did not keep records of those measurements and did not use them to calculate gaps. LIRR officials say they will now measure platform gaps systemwide every year.
What and when LIRR officials knew
Gap falls have sparked lawsuits against the LIRR and the MTA since at least 1970, when a 72-year-old Manhattan woman slipped into a gap at the Valley Stream station, suffered "debilitating injuries" and tried to sue for $75,000. Rose Zully's lawsuit was dismissed for procedural reasons.
In total, Newsday found 62 gap injury suits against the LIRR, including those of Mark Daniels, Patricia Freeman and Melissa Kalbacher. Daniels, who suffered a crushed pelvis and massive internal bleeding in 1985, sued for $2 million. He alleged that the railroad knowingly permitted a dangerous condition to exist and settled his case for an undisclosed amount. Kalbacher, who fell in 1998, settled for $20,000, and Freeman's case about her 2004 accident is still pending.
"Did the LIRR drop the ball in dealing with the gap issue?" said Bringmann, the commuters council president. "Long-term, over the years? Yes, they did."
In 1987, an MTA inspector general report on the dangers of wide platform gaps also could have flagged LIRR officials to the problem.
The report advised Metro-North to make identifying and fixing dangerous gaps a safety and budget priority. Shortly after the study began, Metro-North began measuring and narrowing gaps in its system.
But while officials from the MTA, Metro-North and the LIRR met at quarterly safety meetings, this information never was shared with the LIRR, LIRR officials say.
As a result of the inspector general study, Metro-North also began tracking its gap incidents. The LIRR began doing so in the early 1990s.
Gap falls soon emerged as one of the top three causes of customer accidents, according to annual LIRR safety updates presented to MTA board members on the LIRR/LI Bus Committee. In 1996, they ranked No. 1.
Still, MTA board members say that the annual totals of gap incidents weren't high enough to draw much attention. Between 1995 to 2005, the number of gap falls reported in safety updates ranged from 55 to 90 per year, except for 2002, when it dropped to 23, officials say.
"It never reached the point where it was so outlandish that it clearly reached the highest priority," said Mitchell Pally, a member of the board's LIRR/LI Bus Committee since 2005 who has seen those breakdowns at committee meetings. He noted that the monthly safety reports do not specify the severity of customer injuries.
Jose Fernandez, LIRR vice president for safety and security, referring to his department's analysis of accident statistics, said the number of gap falls raised no red flags.
"We didn't see anything that just stood out," he said.
LACK OF OVERSIGHT
The Federal Railroad Administration, which requires commuter railroads to report accidents that cause serious injury or death, tracks accidents involving reptiles, bee stings and spider bites. But it doesn't have a category for gap falls.
Consequently, even the administration task force that began studying the problem after Smead's death so far has been unable to compile reliable national statistics on gap incidents.
"As for why ... [gap falls] is not a category, when I asked around, the answer was, 'We don't know,'" said administration spokeswoman DeDe Cordell.
LIRR officials don't have an accurate count of gap falls on their system, either -- despite keeping tabs on such falls in its internal accident database. The railroad's safety department does not always classify gap falls as such in its incident database, the Newsday review found. For example, when a passenger slips on ice or debris, then falls into the gap, the accident is classified by the first event and not as a gap fall.
Experts say that physical conditions, particularly the sharpness of a curve, dictate how large a gap must be -- so any mandated gap maximum would have to allow for exceptions.
The only law currently limiting the width of platform gaps is the federal Americans with Disabilities Act, which sets a 3-inch maximum at platforms built after 1991. But, according to a Federal Railroad Administration report on Americans with Disabilities Act gap requirements, that standard is "probably impossible to meet" because that small distance doesn't allow for safe passage of trains.
Most commuter railroads, including the LIRR, comply with the disabilities act through the use of bridge plates -- metal ramps that crews can extend from the train door to the platform.
Federal officials did not propose a more feasible gap maximum until last February, 15 years after the disabilities act was enacted. The proposed change -- which could be adopted later this year -- includes a maximum gap at new stations of 10 inches on straight tracks and 13 inches on curved tracks.
In July, the MTA, erroneously thinking the restriction would apply to existing stations, objected.
Elliot G. Sander, who took over this month as the MTA's new executive director and chief executive, said while officials will "review what transpired in the past," their primary focus will be on future solutions.
"The LIRR and MTA are conducting a comprehensive review of the gap issues," Sander said, "and we are committed to developing a menu of best practices that will enhance safety."
WHAT DID THE LIRR DO?
The LIRR has been monitoring gap incidents and presenting the numbers to MTA board members in regular safety reports since at least the early 1990s -- about the same time it launched its first "Watch the Gap" campaign.
That effort, which included fliers and train decals, was launched in 1992 and modeled after the London Underground's "Mind the Gap" program, though it never reached the success of its counterpart across the Atlantic.
For years, it was the LIRR's primary strategy for preventing gap falls.
But unlike the Underground's campaign, which was so aggressive it has become a part of England's popular culture, the LIRR's rider education program was limited in scope: a mention in a passenger brochure or during a school safety program. Decals on train doors. "Watch the Gap" signs at a few stations. Occasional train announcements.
The railroad's efforts before Smead's death occasionally stretched beyond education, addressing problem gaps at a handful of stations. For example, at Syosset, the railroad assigned a conductor to help riders board trains during the morning rush hour.
"Obviously, they [LIRR officials] were hopeful ... that the education campaign on its own could take care of the problem," Pally said. "And obviously, it did not."
Fernandez, the LIRR safety chief, defended the railroad's response to gap incidents over the years, noting that the LIRR has experimented with edge boards and platform lighting.
"I believe we did what we could and we did the best we could," Fernandez said. "We just continue to push forward and try to fix what we can."
DEATH SPARKS ACTION
In the months after Smead died, the railroad stepped up its education efforts and made physical changes to tracks or platforms at stations with problem gaps.
"Now on the train they say, 'Watch the Gap,' and I want to laugh," said Melissa Kalbacher of Manhattan, formerly of St. James, who injured her knee in a gap fall at the Hunters Point station in 1998. "They never used to say that. It's really a shame they had to wait [until Smead died]."
Since August, the railroad has realigned at least 25 tracks at 17 stations, including Woodside's Track 3, where Smead fell.
The LIRR also has raised or shifted platforms to narrow gaps at six stations.
Until recently, track realignment -- in which a machine moves tracks that have shifted over time -- was not used specifically to narrow gaps, officials say.
The railroad also has added platform conductors at five more stations and installed wooden edge boards at four stations to narrow the gaps.
"What they're doing now," Bringmann said, "you have to ask, 'Then why the hell didn't they do it sooner?'"
These techniques reduce gaps but don't eliminate the problem, railroad officials say, adding that stations with sharp curves will require more costly solutions.
LIRR officials, who since August have considered a range of possible gap fixes, say they have narrowed their options: reducing the railroad's standard distance between platforms and tracks, installing mechanical gap fillers on sharply curved platforms, and widening the doorsteps on trains.
Railroad officials say they have not yet determined how much the LIRR has already spent, or will spend this year, closing gaps.
The MTA is expected to submit 2007 budget amendments to the State Legislature within the next month.
"We're working together closely ... with our best people to mitigate this problem moving forward," said Kenny, the acting LIRR president.
Several longtime LIRR employees say the railroad is an easy scapegoat for a difficult problem.
Gary Lockel, 56, of East Islip, an engineer who retired in October after 33 years, said, "I think some people are just getting on the bandwagon. Everybody's running to their lawyer. It's like getting hit by lightning to fall through the crack."
Doug Willox, 54, an engineer who retired to North Carolina after 31 years at the LIRR, said he had witnessed only one gap fall during his career. It happened at Woodside.
"It's an accident, that's all," he said. "It's just a matter of people being more careful. They're trying to blame the railroad, when they should just look in the mirror and blame themselves."
A state probe into Smead's death found that she contributed to her own death because she was drunk and scrambled underneath the platform and into the path of a train arriving on the opposite track.
State officials measured the gap at the spot where they believe Smead fell and found it to be between 7 7/8 and 81/2 inches. Elsewhere along the same platform, Newsday found gaps as wide as 11 inches.
In addition to the state investigation, the National Transportation Safety Board is investigating Smead's death. As part of the probe, LIRR officials took systemwide platform gap measurements for the first time. The results indicate that 100 of the railroad's 262 platforms at passenger stations have gaps that need some kind of improvement, officials said. That figure includes platforms where work already has been done. Newsday obtained the gap measurements at 40 LIRR stations that reveal a maximum gap of 133/4 inches on straight platforms and a maximum gap of 151/2 inches on curved ones.
By comparison, most gaps on Metro-North fall between 5 and 7 inches. However, Metro-North has several on curved platforms stretching as wide as 123/4 inches, and on one straight platform, the space reaches a gaping 153/4 inches.
A broader state probe into the gap issue on both the LIRR and Metro-North Railroad is expected to conclude this spring and likely will include recommendations for both .railroads.
The NTSB investigation into Smead's death and the LIRR's gap problem could continue for several months.
And a Federal Railroad Administration task force studying the issue on a national scale could recommend new regulations sometime this year.
"Sometimes, I guess, an incident will drive ," said Fernandez, who said his department is participating in the task force. "There used to be an old saying: Safety rules are written in blood."
LIVES FOREVER CHANGED
For some of the injured, moving forward hasn't been easy.
Jayne Rothman, 44, of Fresh Meadows, flinches every time she steps onto a subway car or train, though it's been more than 20 years since she fell into a gap at the Hewlett .station.
"The injuries I got from the fall, the physical injuries, have all healed," the homemaker said. "But it was a very traumatic thing. I still have nightmares ... even to this day, just getting on a subway car is difficult."
Recently, Skelos described the railroad's limited response to gap incidents over the years as "benign .neglect."
Patricia Freeman, of Manhattan, who fractured her hand, ribs and spine in a 2004 fall, uses a different word.
"It's a travesty," said Freeman, 64, who wore a back brace for six months. "I think it's human indifference."
The series of stories on the LIRR platform gaps running today through Sunday were reported by JENNIFER BARRIOS, SOPHIA CHANG, MICHAEL EBERT, REID J. EPSTEIN, JENNIFER SINCO KELLEHER, EDEN LAIKIN, HERBERT LOWE, JOSEPH MALLIA, JENNIFER MALONEY, LUIS PEREZ, and KARLA SCHUSTER.