Rail transportation safety investigation R13T0192

The occurrence

On 18 September 2013, at about 0832 Eastern Daylight Time, westward VIA Rail Canada Inc. (VIA) passenger train No. 51 departed from the VIA Ottawa Station on time and proceeded en route to Toronto. At 0847:27, OC Transpo double-decker bus No. 8017 departed from the Fallowfield Station on the OC Transpo bus Transitway. At 0848:06, while proceeding at about 43 mph, the train entered the OC Transpo Transitway crossing, located at Mile 3.30 of VIA’s Smiths Falls Subdivision. At the time, the crossing lights, bells and gates were activated. The northbound bus was travelling at about 5 mph with the brakes applied when it struck the train. As a result of the collision, the front of the bus was torn off. The train, comprising 1 locomotive and 4 passenger cars, derailed but remained upright. Among the bus occupants, there were 6 fatalities and 9 serious injuries, and about 25 minor injuries were reported. No VIA crew members or VIA passengers were injured.

The investigation

Event recorders

On the day of the accident, investigators obtained downloads from the crossing signal bungalow and the locomotive event recorder (LER) to evaluate the operation of the crossing protection and the train. The bus tires and brakes were visually examined and documented in place. The bus did not have a single event recorder to store vehicle performance and operation data (i.e. black box). However, there were a number of electronic units which contained non-volatile-memory (NVM). These included the anti-lock braking system/anti-slip regulation (ABS/ASR) control module, the central controller, the transmission control module (TCM), the heating-ventilation and air conditioning (HVAC) system memory, the automatic fare recording Presto units, the Intelligent Vehicle Network (IVN) system, Global Positioning System (GPS) data from the City of Ottawa and the Engine Control Module (ECM). The bus battery was disconnected and the engine compartment was sealed to preserve any recorded data. The bus was then transported to a secure location for further examination.

Re-enactment

On 28 September 2013, the TSB conducted an accident re-enactment on the Transitway. The re-enactment was photo and video documented from the bus driver’s station. It was conducted at approximately the same time as the accident and under similar environmental conditions. A few days later, additional testing was conducted at the crossing to record the time it took for various bus types to travel over the crossing after stopping at the north approach.

Sequence of events

A detailed sequence of events was compiled from various sources including the train, the crossing signals, the bus and video cameras at the OC Transpo Fallowfield Station. Some event times for activities that occurred onboard the bus were approximated based on multiple witness accounts of what transpired.

All available data from the electronic units recovered from the bus and containing NVM was downloaded and examined at the TSB Engineering Laboratory. Only the Engine Control Module (ECM) contained any information relevant to the operation of the bus just prior to the accident. However, the information lacked sufficient detail to conduct a meaningful analysis and further work was required to calculate speed at the time of the collision, braking force and the related stopping distances.

Bus braking system

A detailed teardown and examination of the bus braking system was completed. A braking analysis was performed to determine event timing, speed at the time of impact, braking distance and amount of brake force applied to a loaded bus during the accident scenario. The analysis incorporated measurements and observations made on-site and detailed engineering calculations based on ECM data, brake system reaction time, and brake performance charts from both the bus certification tests and manufacturer tests.

Traffic studies and speed testing

Traffic studies were conducted on Woodroffe Avenue, the Transitway and Fallowfield Road. The TSB conducted speed testing in the vicinity of the crossing for vehicles using the Transitway.

Ergonomic study

TSB Human Performance staff conducted an ergonomic study of the driver’s station for each of the bus designs operated by OC Transpo.

Information sharing

As part of data collection and information sharing, the following activities have been ongoing:

• In accordance with an existing Memorandum of Understanding, the TSB and the Coroner have been sharing information in support of each other’s ongoing investigations.
• Numerous interviews have been conducted with survivors, witnesses, OC Transpo staff and City of Ottawa personnel. The TSB continues to conduct interviews as necessary.
• TSB specialists have remained in contact with the next of kin of the victims and have provided them with updates on progress.

What we know

The following is a summary of facts as determined by the investigation so far.

Information known shortly after the accident:

• The bell was activated, but no train horn was sounded due to an existing municipal ban.
• The crew applied the emergency brakes 2 seconds prior to the accident.
• The train was travelling at 47 mph when it was struck by the bus.
• At the time of the accident, the crossing Active Warning Device (AWD) protection operated as intended with no malfunctions.The gates had been horizontal for 26 seconds prior to the accident.
• TSB has not identified any issues with the operation of the train, the operation of the crossing signals or the condition of the track.

Since then:

Bus Operator

• The Coroner’s investigation determined that there was no medical illness involved in the driver’s death and toxicology testing showed no evidence of drugs or alcohol.

Maintenance

• A series of mandatory certification tests had been conducted to verify compliance with the Canada Motor Vehicle Safety Standards (CMVSS). The bus met or exceeded all CMVSS criteria for operation in Canada.
• Upon delivery of the bus, a Ministry of Transportation of Ontario inspection was performed with no exceptions noted.
• The bus was maintained in accordance with the operator’s approved maintenance program.

Braking

• There were no reported brake defects on the occurrence bus.
• There were no mechanical discrepancies identified that would preclude normal operation of the bus air brake system.
• The initial application of the bus brakes occurred when the bus was travelling at a speed of 67.6 km/h (42 mph), which exceeded the posted speed limit of 60 km/h (37.3 mph).
• Full braking force was not initially applied.
• The bus was located 116.8 ft (35.6 m) south of the point of collision when braking was initiated.
• The bus was travelling between 6.4 - 7.7 km/h (4 and 4.8 mph) when the collision occurred.
• TSB calculations indicated that, had the bus been travelling at the posted speed limit (60 km/h) and all other factors remained the same, the stopping distance for the bus would have been 29.5 m (96.8 ft) which would be 6.1 m (20 ft) before the point of collision.

Ergonomic Study

• Within the driver workstation, a small video monitor (6” (15 cm) wide by 3 ¾” (10 cm) high) is located on the left side of a forward panel above the driver seat which creates a significant upwards viewing angle for the driver.
• OC Transpo drivers are instructed not to stare at the video monitor while driving.
• At station stops, OC Transpo drivers are required to view the monitor before departing to ensure that upper deck passengers are seated. If passengers are seen standing on the upper deck, drivers are required to announce that standing is not permitted on the upper deck.
• To find available seating after boarding a double decker bus, some passengers may be moving or standing on the upper deck after the bus is in motion. Under these conditions, to monitor the upper deck, a driver will need to periodically glance at the screen while the bus is in motion. This situation can lead to a driver being visually distracted from the driving task.

Next steps

As the investigation continues, the TSB will:

• undertake further assessment of crossing and roadway alignment including a review of previous grade separation studies;
• review the studies relating to buses stopping at railway crossings;
• continue to analyze what may have influenced driver behaviour and information processing;
• gather and analyze information related to OC Transpo transit operations and bus driver training; and
• conduct a crashworthiness assessment of the bus.

Safety communications

Safety Recommendations

Safety Advisory Letters

Media materials

News releases

Backgrounders

Speeches

Deployment notice

Video