The LIRR's parent agency knew that education wasn't enough.
State authorities didn't set a maximum gap width.
Federal officials didn't keep track of gap injuries, even as hundreds of passengers were hurt from falls each year.
And no one fixed the gap.
While the Long Island Rail Road works to reduce its dangerously wide platform gaps in the wake of Natalie Smead's death, a review of authorities who could have intervened reveals a void of oversight and regulation of the number one cause of customer accidents on the nation's busiest commuter railroad.
"Just because we adhere to the law doesn't mean we don't have a problem," said MTA board member Mitchell Pally, who sits on the LIRR/LI Bus Committee. "People are being injured and in one unfortunate circumstance, one girl was killed."
On Aug. 5, Smead slipped through a gap at Woodside station, then crawled under a platform and into the path of an oncoming train.
A state investigation into her death found that the railroad was in compliance with all state and federal laws.
However, government oversight agencies 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.
Federal officials now are considering new regulations that would limit platform gaps at new stations to 10 inches on straight platforms and 13 inches on curved platforms.
While state and federal agencies left platform gaps to the discretion of railroads, the LIRR's parent agency, the Metropolitan Transportation Authority, failed to inform the LIRR about techniques the MTA knew could eliminate a serious hazard to riders.
In 1987, the MTA's Inspector General investigated problem gaps on the Metro-North Railroad after having discovered similar problems on a New York City subway line. The study, which found that gap problems could not be solved by education alone, advised Metro-North to: identify and fix problem gaps and take gaps into consideration in all major construction or repair projects.
Metro-North implemented those recommendations, but the MTA never imposed them on the LIRR, according to Metro-North and LIRR officials.
MTA and LIRR officials also for at least two decades received monthly and annual commuter surveys including many angry passenger complaints about dangerous gaps.
Compiled by the LIRR Commuters Council -- a railroad advisory group -- the reports included comments such as, "Put something at each door so there isn't such a big gap," and, "The gap between the platform and train in Syosset is scary, much too wide."
In November, MTA Chairman Peter Kalikow's testimony before a state Assembly committee underlined the parent agency's underestimation of the gap problem. "Prior to the incident we had, I think it was over the summer, they never reached the serious stage," Kalikow testified.
Yet since the mid-90s, the gap had appeared as one of the top three causes of LIRR customer accidents in annual safety reports the railroad provided to MTA board members sitting on the LIRR/LI Bus Committee.
A review of LIRR accident records shows that, with the exception of 2002, gaps were the number one cause of customer accidents during the 51/2 years before Smead's death.
Kalikow went on to say that, "Where a station is built on a straight piece of track, those platforms are great. When they're built behind a curved piece of track, they're not great."
According to the LIRR's own measurements, gaps on straight platforms stretch up to 13.75 inches -- a space as large as a man's size 15 shoe.
State and federal monitoring
The Federal Railroad Administration is responsible for monitoring all commuter railroads, including tracking rider accidents nationwide.
But while the FRA requires railroads to specify whether customer accidents involved bees, spiders or reptiles, it does not have a category for gap falls. As a result, the administration has no reliable statistics on gap accidents.
"As for why it's not a category, basically when I asked around, the answer was, 'We don't know,'" DeDe Cordell, an FRA spokeswoman, said of the agency not tracking gap falls.
She said that the FRA now is conducting a review of the gap issue.
New York State law does not directly address platform gaps but sets a minimum distance between the center of the tracks and the platform -- allowing for freight trains to pass safely. The corresponding platform gap varies, depending on the width of the train.
"In theory, it does make sense that you would have a maximum gap and make provisions that if you exceed the maximum, you take certain measures," said Gerry Bringmann, chairman of the LIRR Commuters Council. "That kind of legislation only gets passed if you have people pushing for it."
But many railroad experts said regulatory bodies can't set a gap maximum because sharp curves and other obstacles sometimes necessitate very wide spaces.
But if state and federal regulations don't call for maximums, neither do they require railroads to provide assistance for crossing wide spaces.
State officials, citing the continuing investigations, declined to comment on the absence of regulation or the possibility of new policy recommendations.