Ottawa, Ontario, 24 September 2014
THE OCCURRENCE
At 0832 EDT on 18 September 2013, VIA Rail passenger train No. 51 departed Ottawa Station and proceeded westward en route to Toronto. At 0847, OC Transpo double decker Bus No. 8017 (the bus) departed OC Transpo Fallowfield Station on the OC Transpo Bus Transitway (Transitway). At 0848, while proceeding at about 47 mph, the train entered the Transitway crossing located at Mile 3.30 of VIA Rail’s Smiths Falls Subdivision (the crossing) and was struck by the northbound bus. As a result of the collision, the front of the bus was sheared off. The train, comprised of 1 locomotive and 4 passenger coaches, derailed but remained upright. No VIA crew members or passengers were injured. Among the bus occupants, there were 6 fatalities, 8 serious injuries and approximately 25 minor injuries.
The accident bus is an Enviro 500 (E500) double decker model designed and manufactured by Alexander Dennis Limited (ADL) in the United Kingdom. It was delivered to OC Transpo in September 2012.
WORK COMPLETED TO DATE
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). [1] 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. This work was completed by May 2014. 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 in June 2014. 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. This work was completed in August 2014.
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 (MOU), 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.
- 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.
- 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.
- 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, an Ministry of Transportation of Ontario (MTO) inspection was performed on 21 September 2012, with no exceptions noted.
- The bus was maintained in accordance with the operator’s approved maintenance program.
- 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, the stopping distance for a bus travelling at the posted speed limit (60 km/h) with all other factors remaining the same, would have been 29.5 m (96.8 ft) which would be 6.1 m (20 ft) before the point of collision.
- Within the driver workstation of the ADL double decker buses, 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.
COMMUNICATION OF SAFETY DEFICIENCIES
New
Today, the TSB issued two new safety advisory letters (RSA 10/14, RSA 12/14) to the City of Otttawa on: distracted driving, and bus speed on the Transitway at the VIA Rail level crossing.
With respect to distracted driving, given the importance of minimizing driver distraction, the City of Ottawa may wish to review the procedural/operational aspects related to the use of the video monitors on OC Transpo double decker buses to ensure that safe bus operation is always maintained.
With respect to bus speed on the Transitway, the City of Ottawa may wish to implement additional measures to monitor and control bus speed, particularly in the vicinity of railway crossings.
Previous actions
Following the identification of safety issues in the September 2013 TSB accident re-enactment, the City of Ottawa:
- Reduced the speed on the Transitway in the area of the crossing from 60 km/h to 50 km/h.
- Cleared the trees and brush that obscured the crossing.
- Removed the sign adjacent the Transitway which obscured the crossing lights.
- Installed an advance warning light for the northbound lane approaching the crossing.
For VIA Rail:
- Although still visible for northbound traffic, 2 of the crossing lights were slightly misaligned.
The misalignment was corrected and all 142 VIA public crossings were subsequently inspected (Alexandria, Beachburg, Smiths Falls and Chatham Subdivisions). A total of 20 lights were corrected at 12 crossings.
On 25 February 2014, the TSB issued 2 Rail Safety Advisory Letters (RSA 01/14, RSA 02/14) to the City of Ottawa, following a review of a number of reported incidents that occurred at the crossing. While such incidents are not normally reportable to the TSB, the team followed up on them as part of its ongoing investigation.
The TSB documented 4 incidents in which OC Transpo buses traversed the crossing while the lights were activated but the gates had not yet come down.The TSB advised that vehicle drivers should slow down when approaching a railway crossing, look both ways, be prepared to stop and yield the right of way to a train. It further suggested that the City of Ottawa ensure that buses can stop safely in advance of an activated railway crossing signal. On 28 February 2014, in response, OC Transpo issued Bulletin No. 050/14, entitled Safety at Railway Crossings to all operators (drivers), Transit Supervisors and Dispatchers. On 02 May 2014, OC Transpo and the Amalgamated Transit Union (ATU) jointly issued a handout, entitled Railroad Crossings, Important Information for all Operators, to all drivers.
Additionally, the TSB documented an incident where the crossing protection remained activated in fail-safe mode following a malfunction and 3 OC Transpo buses subsequently traversed the crossing while AWD protection was activated. The TSB suggested that OC Transpo and VIA Rail may wish to develop and implement Standard Operating Procedures to ensure safe operations when unusual activations or malfunctions of crossing automated protection occur. The City of Ottawa and VIA Rail have since implemented procedures to respond to these types of occurrences.
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.
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This information is factual in nature and does not contain any analysis. Analysis of the accident and the findings of the Board will be part of the accident report. The investigation is ongoing.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
TSB Media Relations
819-994-8053
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[1] 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).
