Associated links (R13T0192)
Kathy Fox
Chair, Transportation Safety Board of Canada
and
Rob Johnston
Investigator-in-Charge, Transportation Safety Board of Canada
Ottawa, Ontario, 2 December 2015
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Kathy Fox
Good morning, and thank you for coming today.
On the morning of September 18, 2013, an OC Transpo double-decker bus collided with a VIA Rail passenger train just a few hundred metres from the Fallowfield bus station in south Ottawa. Six people died, including the bus driver, and dozens more were injured.
The TSB's investigation was complex, and we left no stone unturned. Mr. Rob Johnston, the Investigator-in-Charge, is going to walk you through exactly what we learned, explaining how events unfolded that morning and, more importantly, why. After that, I'll talk about the five recommendations the TSB is issuing today. These deal with the installation and use of in-vehicle video displays; crashworthiness standards and data recorders for commercial passenger buses; and grade separation at busy railway crossings, both here in Ottawa and across Canada.
But before turning it over to Rob, to help illustrate the multiple factors involved in this accident, and to show how they influenced one another, we have created a short video that reconstructs the sequence of events leading to the accident in real time.
Rob Johnston
Good morning.
Before we go any further, I'd like to be clear that this accident goes far beyond the actions of any one individual. In fact, given the same circumstances, this accident could have happened to just about any driver. As such, I'd like to highlight a few things that we learned:
- There was no evidence of any drugs, alcohol or fatigue, nor did any medical issue affect the driver's performance.
- The automated flashing lights, bells and gates at the crossings operated as designed. In fact, they were active for about 49 seconds before the bus struck the train.
- The operation of the train met company and regulatory requirements and it was slowing down as it approached the VIA Fallowfield Station.
- The bus was well maintained, and the brakes were fully operational.
So the key question became “why didn't the bus stop in time?”
Ultimately, we identified multiple factors that played a role in this accident. The elimination of any one of these may have reduced the severity of the outcome, or even prevented it from happening.
Broadly speaking, these factors included: speed, company practices, driving distractions, and the configuration of the Transitway.
For example, the posted speed limit on the bus's approach to the crossing was 60 km/h, increasing to 90 km/h after the crossing. Because it was common for drivers to use the section after the crossing to make up time—which OC Transpo enforcement did not prevent—and because the driver did not expect to encounter a train, the bus was accelerated beyond the posted speed limit, by 7.6 km/h. This increased stopping distance.
With respect to company practices, we found that the driver did not initially fully apply the brakes. This was consistent with company driver training, which focused on smooth braking, to reduce the risk of passenger injury.
- There were also a number of driving distractions, both visual and cognitive.
- The visual distraction was the use of an on-board video monitor, located above and to the left of the driver. The company required drivers to check the monitor at station stops and while the bus was in service. This took the driver's eyes off the road, a risk that the company did not effectively manage.
- The cognitive distractions included the heavier workload of negotiating the left-hand curve, the nearby passenger conversations about upper deck seating, and the perceived need to make a no-standing on upper deck announcement—all at a critical time in the driving sequence.
With regards to the Transitway's configuration … this entire accident unfolded in just 39 seconds from the time the bus left the station—but the really critical window was significantly smaller. While travelling at 67.6 km/h—and considering that the driver's view of the crossing was obstructed and there was no active advance warning sign interconnected with the railway signals to warn of the train's approach—there was a window of only a few seconds to identify that the crossing signals were activated, to apply the brakes, and to stop the bus. Any distraction during this critical time would pose a significant challenge, for any driver.
So how do we prevent such an accident from happening again?
I'm now going to turn things back over to the Chair who will outline the rationale behind the five recommendations we are issuing today.
Kathy Fox
Thank you, Rob.
Since the accident, a number of steps have been taken to make the area around the Transitway crossing—and the adjacent Woodroffe and Fallowfield crossings—safer. But more must still be done to lower the risks.
As our investigation determined, it is likely that the driver was distracted—visually and cognitively—in the seconds before the crash. The video monitor above the driver's seat was relatively small, and the individual quadrants on the screen were smaller still. Even changing the view and moving the screen to an angle more aligned with the driver's line of sight doesn't change the fact that a driver cannot watch it and the road at the same time. Although Ontario has a provincial distracted-driving law, that law contains exemptions that allow drivers of certain commercial vehicles—including buses—to use video screens while in motion. It's time that changed. We are calling on Transport Canada to work with provincial authorities to reduce the risk for all vehicles, with guidelines on the placement and use of in-vehicle video monitors to reduce the risk of driver distraction.
For our second recommendation, we want to see the development and implementation of crashworthiness standards for commercial passenger buses. The Canada Motor Vehicle Safety Standards set out minimum design and safety standards for vehicles. In this case, the bus met all applicable federal safety standards. Yet unlike automobiles and school buses, there were no requirements for impact, rollover, or crush protection. A more robust, crashworthy design may have reduced the damage to the bus and prevented loss of life in this accident.
Our third recommendation deals with the need to equip commercial passenger buses with a dedicated event data recorder, or “black box.” In this case, we were fortunate to get any information from the various bus electronic modules. There was little that was initially useful and, as a result, months of work was added while investigators sought other sources of information and performed additional complex analyses.
As the TSB has said on numerous occasions, timely access to accurate data is invaluable in helping us to more fully understand an accident's causes and contributing factors. The event recorders on locomotives, and on many airplanes and ships, have been benefiting all investigators for years and can also help companies better manage their operations.
Our final two recommendations deal with the issue of grade separation for railway crossings—that is, separating rail and road traffic by an overpass or underpass.
This is something that the City of Ottawa first considered for the area about a decade ago but ultimately set aside in favor of the current arrangement of flashing lights, bells, and gates. That decision was based on various population-growth assumptions, engineering considerations, and public-consultation.
Traffic was also considered—specifically, the number of vehicles multiplied by the number of trains in a day, something known in the industry as “cross-product.” Although a cross-product of 200,000 is the common threshold for considering grade separation, there are, in fact, no federal regulations or guidelines stipulating this. Just to put that in perspective, by 2013, the cross-product at the Fallowfield and Woodroffe crossings respectively had risen to double—and more than triple—that threshold.
It's time to take action. With so many buses, cars and trains passing along these roads every day—and a population that continues to increase—Transport Canada needs to provide specific, detailed guidance on when roads and railways should be grade-separated. Moreover, we want the City of Ottawa to reconsider the need for grade separation at the Woodroffe Avenue, Transitway, and Fallowfield Road crossings.
Every day, vehicles and trains interact at thousands of railway crossings across Canada. The number of crossing accidents is too high; that's why this issue is on the TSB's Watchlist. Whether it's a busy street or a country road, people need to understand that crossing safety is a shared responsibility. Drivers always need to approach a crossing as if a train were coming. Operators, road authorities, regulators, and bus manufacturers also have a role in making vehicles and crossings safer. The recommendations we make today will go a long way toward reducing the risks, not only here in Ottawa, but across Canada.
Thank you.