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Reassessment of the response to TSB recommendation R15-03

 Recommendation R15-03
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Vehicle event data recorders

Background

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 enroute 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 Board concluded its investigation and released report R13T0192 on 02 December 2015.

TSB Recommendation R15-03 (December 2015)

The ADL double-decker buses were equipped with a video monitor that provides the driver with interior views and exterior views of the bus. However, the system monitoring the video cameras installed on the bus did not have recording enabled, and no video information was recovered from the system.

Each of the rail, air and marine modes of transportation require locomotives and many commercial aircraft and vessels to be equipped with event data recorders (EDRs) that record a number of specified elements. In contrast, the Canada Motor Vehicle Safety Standards (CMVSS) contain no requirements for buses (including school, transit and inter-city) to be equipped with an on-board crashworthy EDR. While nothing precludes an operator from installing such technology on its fleet, OC Transpo had no such requirement. As a result, the occurrence bus was not equipped with a crashworthy EDR (i.e. black box) to record and store vehicle operation data that occurred prior to and during the accident sequence. Consequently, 8 electronic units that contained non-volatile memory (NVM) were recovered and analysed.

Of the 8 units recovered, only the engine control module (ECM) retained useful data. The ECM is programmed to automatically record a sudden deceleration event when the bus decelerates at greater than 9.0 mph/s (14.5 km/h/s). Had the bus decelerated at less than 9.0 mph/s (14.5 km/h/s), the ECM would have contained no data at all. While, in this case, the recovered ECM data were useful, when compared to locomotive event recorder (LER) data, the ECM data lacked sufficient detail to conduct a meaningful analysis. Specifically,

Consequently, a detailed braking analysis had to be performed to determine event timing, braking distance and amount of braking force applied by the bus during the accident. The complexity of this work added a number of months to the investigation process. In comparison, comprehensive data from the LER were available for review the next day. The LER data clearly identified the operating parameters of the train and actions of the train crew, which permitted investigators to make informed decisions as to the direction of the investigation and turn their attention to the condition and operation of the bus.

In the United States, the National Transportation Safety Board (NTSB) has recommended EDRs for buses since 1999. While progress has been made, the use of EDRs remains voluntary for roadway vehicles, and the NTSB has classified the related safety recommendations as “Open—Unacceptable Response” because the United States National Highway Traffic Safety Administration (NHTSA) has not required the use of EDRs on buses.

Through years of experience with EDRs in the air, rail and marine modes of transportation, the TSB, the NTSB and the transportation industry have learned a great deal about the effective use of recording technology. Establishing industry standards for recording in these modes has been critical to effective implementation of EDRs by ensuring consistency in the recorded data in standardized formats.

Railway companies routinely use LER data in conjunction with operator (driver) proficiency testing to identify potential areas of improvement within the context of a railway company's safety management system (SMS).

EDRs have been commonly used by over 100 United States jurisdictions to manage school bus fleets. Studies have determined that, when integrated into a company's safety program, the review of EDR data has led to operational safety improvements for vehicle fleets. A sampling and review of EDR data can identify emerging driver trends, and modifications to company training and/or employee mentoring can be made to improve safety accordingly. Such reviews can also be used to identify and reinforce positive and safe driver behaviour. This demonstrates that EDR information can be used in a non-punitive way as a tool for monitoring driver behaviour and performance in conjunction with a transportation company's safety program that can further reduce risk and improve safety before an accident occurs.

Although accidents involving transit buses at level crossings are rare, they are considered to be high-risk events due to the number of passengers transported in each bus and the potential for injury to the travelling public. When these accidents occur, it is imperative that all investigators have access to real-time recorded data that are consistent and meaningful to quickly identify safety deficiencies and prevent recurrence. Understanding driver behaviour and identifying the related human factors are critical to understanding why accidents happen.

All safety, regulatory, law enforcement and company accident investigations benefit from the efficient, timely and accurate collection, assimilation and analysis of available information. In many cases, EDRs provide and validate much of this valuable information. Early recovery of the information can also result in more timely communication of safety deficiencies and accident reports to industry, regulators and the public, which in turn can result in the implementation of measures to prevent a recurrence. Considering that today's vehicles are capable of supporting crashworthy technology that has the capacity to record safety-critical information that enables safety improvements as well as comprehensive and timely accident investigation, the Board recommends that

the Department of Transport require commercial passenger buses to be equipped with dedicated, crashworthy, event data recorders.
TSB Recommendation R15-03

Transport Canada's response to Recommendation R15-03 (February 2016)

Transport Canada acknowledges the recommendation.

There are no United States or United Nations safety regulations requiring EDRs on large commercial vehicles of any type. At the same time, Transport Canada will commit to scan current EDR technologies available for commercial passenger buses. This research will look at vehicle‑based systems, engine-based systems as well as global positioning systems developed both by original equipment manufacturers and after-market suppliers. TC will review available international commercial vehicle EDR standards and recommended practices. Transport Canada will also evaluate the feasibility of developing a commercial passenger bus EDR standard by undertaking a review of technical and scientific reports/papers and validation studies on the accuracy, reliability and limitations of commercial vehicle EDRs. The results of this work would help to determine the need for standards and guide TC on how to proceed. Such work could produce useful guidelines for the installation of such equipment.

TSB assessment of Transport Canada's response to Recommendation R15-03 (March 2016)

Transport Canada has acknowledged this recommendation.

TC will initiate research on EDR technologies, including vehicle-based systems, engine-based systems as well as global positioning systems developed both by original equipment manufacturers and after-market suppliers. After reviewing the results of the research, TC will evaluate the feasibility of developing an EDR standard for commercial passenger buses. This work will help determine the need for standards and could lead to guidelines for the installation of such equipment. 

The Board is encouraged that TC will initiate research to help determine the need for standards and/or guidelines for the installation of EDRs for commercial passenger buses.  However, this work will take time, and no specific timeline has been provided. In addition, beyond this commitment, there are no explicit plans for the development of EDR standards for commercial passenger buses.

Therefore, the Board assesses the response to Recommendation R15-03 as being Satisfactory in Part.

Transport Canada's response to Recommendation R15-03 (February 2017)

TC will research current EDR technologies available for heavy commercial vehicles, document current EDR standards and recommended practices, undertake a thorough literature review of commercial vehicle EDRs, review any existing national or international standards and evaluate the feasibility of developing a commercial passenger bus EDR standard. 

TC has posted the Request for Proposal (RFP) to hire a consultant to do the research. The bid period has closed and a contract has been awarded.

In addition, recognizing that it is important to develop expertise and operational procedures within TC for commercial vehicle EDRs, TC staff (a collision investigator and a defect investigator) have recently taken further training in “Accessing and Interpreting Heavy Vehicle Event Data Recorders”.

TSB reassessment of Transport Canada's response to Recommendation R15-03 (March 2017)

TC recently hired a consultant to conduct research on EDR technologies. This work will include researching current EDR technologies for heavy commercial vehicles; documenting current EDR standards and recommended practices; undertaking a literature review of existing commercial vehicle EDRs; reviewing any existing national or international standards; and evaluating the feasibility of developing a commercial passenger bus EDR standard.

The Board is encouraged that TC has initiated research to help determine the need for standards and/or guidelines for the installation of EDRs for commercial passenger buses. TC has also invested in the development of in-house expertise by providing selected staff with specialized training. However, no explicit plans have yet been established for follow-up work, including the development of EDR standards for commercial passenger buses.

Therefore, the Board reassesses the response to Recommendation R15-03 as being Satisfactory in Part.

Transport Canada's response to Recommendation R15-03 (February 2018)

There are two components to the work that will be conducted as part of this recommendation:

An environmental scan of technical and scientific reports/papers and validation studies on the accuracy, reliability and limitations of commercial vehicle EDRs has been completed and submitted to Transport Canada. Many publications from the environmental scan were subject to Copyright Protection Laws; as such, the Department undertook to purchase the documents of interest. There are only a few outstanding items that need to be purchased.

A report with the highlights (observations and conclusion) compiled from the environmental scan of technical and scientific reports/papers and validation studies identified has been submitted to TC. The report is undergoing final review and formatting.

A three-day face-to-face meeting with Mecanica Scientific Services (the contractor) was held the first week of December. The summary report of the facts, based on analysis of the scientific reports/papers and validation studies was reviewed and final editing is being done.

A DRAFT summary report of all commercial vehicle-based systems, engine-based systems as well as global positioning systems developed both by original equipment manufacturers and after-market suppliers is currently being developed. This includes equipment requirements, operational requirements and technical specifications.

Interviews with key government and industry stakeholders are currently being formalized in terms of questionnaires and protocols. It is anticipated that some of these discussions will take place in Washington in late January during the SAE Government/Industry meetings. 

Also it is worthy of noting that the SAE Truck and Bus Event Data Recorder Committee, which has been inactive since June of 2010, has been re-activated to review SAE J2728 (Heavy Vehicle Event Data Recorder [HVEDR] Standard - Tier 1), as well as further development of standards on Truck and Bus EDR. The re-activation of the committee is in large part due to a feasibility study that was launched by Transport Canada. Transport Canada is an active member of the committee.

TSB reassessment of Transport Canada's response to Recommendation R15-03 (March 2018)

TC will research current EDR technologies available for heavy commercial vehicles, document current EDR standards and recommended practices, undertake a thorough literature review of commercial vehicle EDRs, review any existing national or international standards and evaluate the feasibility of developing a commercial passenger bus EDR standard. The status of the work (to-date) includes:

The Truck and Bus Event Data Recorder Committee (Society of Automotive Engineers) was re-activated to review the SAE J2728 standard (Heavy Vehicle Event Data Recorder [HVEDR] Standard - Tier 1), and to further develop standards for Truck and Bus EDRs. The re-activation of the committee was in large part due to TC initiating the feasibility study to develop a commercial passenger bus EDR standard. Transport Canada is an active member of the Committee.

The Board is encouraged that the environmental scan of technical and scientific reports/papers and validation studies identified has been completed and that the Truck and Bus Event Data Recorder Committee (Society of Automotive Engineers) has been re-activated to assist with this work. However, no explicit commitments or timelines have been established for the development of EDR standards for commercial passenger buses.

Therefore, the Board assesses the response to Recommendation R15-03 as being Satisfactory in Part.

Transport Canada's response to Recommendation R15-03 (February 2019)

Transport Canada continues to research current event data recorder (EDR) technologies available for heavy commercial vehicles, document current EDR standards and recommended practices, undertake a thorough literature review of commercial vehicle EDRs, review any existing national or international standards, and evaluate the feasibility of developing a commercial passenger bus EDR standard. The Department has advanced these efforts as follows:

TSB reassessment of Transport Canada's response to Recommendation R15-03 (March 2019)

In 2018, Transport Canada (TC) continued its work on event data recorder (EDR) technologies for heavy commercial vehicles. This work included documenting EDR standards and recommended practices, conducting a literature review of commercial vehicle EDRs, reviewing national and international standards, and evaluating the feasibility of developing a commercial passenger bus EDR standard.

Specific progress and observations on Heavy Vehicle Event Data Recorders (HVEDR) were made in the following areas:

Due to the adoption of SAE J2728 by industry, TC considers that a review and update of this standard will be the most effective course of action. In January 2019, the SAE J2728 committee met to continue its review of the existing standard, with consideration to standardize certain data elements to assist with crash reconstruction and to add additional features to monitor the automated driving systems. TC participated in the meeting and will continue to be an active member of this committee.

The Board is encouraged that a course of action has been identified and that the SAE committee (which includes TC participation) is actively reviewing the standard, with the intent to standardize and update certain areas of the standard. However, the timeline for completing the next steps has not yet been established. The Board assesses the response to Recommendation R15-03 as having Satisfactory Intent.

Transport Canada’s response to Recommendation R15-03 (December 2019)

Transport Canada continues its work on heavy vehicle event data recorder (HVEDR) standards development. Specifically:

The Truck and Bus Event Data Recorder Committee (Society of Automotive Engineers) was re-activated in early 2017 to review the SAE J2728 standard (HVEDR] Standard - Tier 1), and to further develop standards for Truck and Bus EDRs. The re-activation of the committee was in large part due to Transport Canada’s initiation of a feasibility study to develop a commercial passenger bus EDR standard. Transport Canada is a member of this Committee.

Since Transport Canada’s last progress update, a proposed standard has been developed. On November 20, 2019, the SAE J2728 committee tabled a standard, which sets out data elements and event triggers for recording of event data relevant to collision investigations for heavy vehicles, and provides design and performance recommendations needed to develop baseline HVEDR capabilities. This standard is currently in “ballot status”, awaiting approvals. The next meeting of the SAE J2728 committee is scheduled to take place in early 2020.

Looking ahead, Transport Canada will seek international consensus of a baseline HVEDR standard at the April 2020 session of the United Nations’ Working party on General Safety Provisions.

TSB reassessment of Transport Canada’s response to Recommendation R15-03 (February 2020)

On November 20, 2019, the SAE J2728 committee (of which Transport Canada (TC) is a member) tabled a proposed standard for heavy vehicle event data recorders (HVEDR). This standard sets out the data elements and the event triggers for the recording of data relevant for collision investigations involving heavy vehicles. This standard is in “ballot status,” awaiting approval by the SAE J2728 committee. The next committee meeting is scheduled in early 2020.

At the April 2020 session of the United Nations’ Working party on General Safety Provisions, TC will seek international consensus of a baseline HVEDR standard.

The Board is encouraged that a proposed standard has been developed and tabled at the SAE committee and that TC is seeking international consensus for a baseline HVEDR standard. The Board assesses the response to Recommendation R15-03 as having Satisfactory Intent.

Transport Canada’s response to Recommendation R15-03 (January 2021)

Transport Canada has been working with the Society of Automotive Engineers Truck and Bus Event Data Recorder Committee to advance the adoption of the standard for Event Data Recorders (EDR) on commercial passenger buses. The standard was published on June 9, 2020 and includes data elements and event triggers for the recording of event data relevant to crash investigations. Looking ahead, Transport Canada is supporting the review and update of data extraction and hardware requirements.

In addition, Transport Canada has identified the United Nations’ Working Party on General Safety Provisions to collaborate on its proposal to establish international consensus on a baseline standard for Heavy Duty Vehicle EDRs. The next meeting is scheduled for April 12-16, 2021, at which time Transport Canada intends to provide the group with an overview of its progress on fleet adoption for heavy duty commercial vehicle EDR standards and encourage continued discussion and harmonization at the international level.

TSB reassessment of Transport Canada’s response to Recommendation R15-03 (March 2021)

The Truck and Bus Event Data Recorder Committee (Society of Automotive Engineers (SAE)) published standard J2728 (Heavy Vehicle Event Data Recorder [HVEDR] Standard – Tier 1) on 09 June 2020, which includes data elements and event triggers for the recording of event data relevant to crash investigations. Transport Canada (TC) is supporting the review and update of data extraction and hardware requirements.

TC is now working toward an international consensus on a baseline standard for heavy-duty vehicle event data recorders. At the next meeting of the United Nations’ Working Party on General Safety Provisions in April 2021, TC will be presenting an overview of its progress on fleet adoption of HVEDR standards.

The Board is encouraged by the publication of the SAE standard on HVEDR. However, the timeline for the completion of next steps to introduce HVEDR to Canadian commercial passenger vehicles has not yet been established and there is no clear workplan for the roll-out of planned changes to the Canada Motor Vehicle Safety Standards (CMVSS) indicated in the response.

The Board considers the response to Recommendation R15-03 as being Unable to Assess.

Transport Canada’s response to Recommendation R15-03 (November 2021)

Transport Canada continues to play a leadership role in encouraging international consensus on a baseline standard for Heavy Duty Vehicle Event Data Recorders (EDRs). In keeping with this objective, Transport Canada presented a report on the feasibility of equipping Heavy Duty Vehicle EDRs in commercial passenger buses at the April 12-16, 2021 meeting of the United Nations’ Working Party on General Safety Provisions (UNECE WP.29 GRSG-EDR Committee).Footnote 1 In particular, the report summarized Canadian research of Heavy Duty Vehicle EDR and international development of EDR technology and standards, and concluded that a Heavy Duty Vehicle EDR regulation can and should be developed.

Transport Canada has also shared its report and detailed research findings at the September 22, 2021 meeting of the Society of Automotive Engineers (SAE)’s J2728 Truck and Bus Event Data Recorder (EDR) CommitteeFootnote 2 where Canada is strongly advocating for the development and adoption of the standard for EDRs on commercial passenger buses, building on the current edition of the SAE J2728 standard which was published on November 1st, 2020.

Looking ahead, Transport Canada is developing industry best practices for Heavy Duty Vehicle EDRs as a path towards standardization, with guidelines to be published by fall 2022. These guidelines will form the basis of ongoing discussions with key stakeholders to encourage harmonization at the international level, including the U.S. National Highway Traffic Safety Administration, SAE’s J2728 Truck and Bus EDR Committee, and the UNECE WP.29 GRSG-EDR Committee.

TSB reassessment of Transport Canada’s response to Recommendation R15-03 (March 2022)

Transport Canada (TC) presented a report on the feasibility of equipping Heavy Duty Vehicle Event Data Recorders (EDRs) in commercial passenger buses at the 12-16 April 2021 meeting of the United Nations’ Working Party on General Safety Provisions and at the 22 September 2021 meeting of the Society of Automotive Engineers (SAE)’s J2728 Truck and Bus Event Data Recorder Committee.

While the report findings conclude that Heavy Vehicle EDR (HVEDR) regulations can and should be developed, it does not provide an update on the progress about the adoption of HVEDR standards in Canada.

As a path towards standardization, TC is developing industry best practices for HVEDRs, with guidelines to be published by fall 2022. However, no timeline has been provided for any planned changes to the Canada Motor Vehicle Safety Standards (CMVSS).

The Board considers the response to Recommendation R15-03 as being Satisfactory in Part.

Next TSB action

The TSB will monitor progress on the planned activities. However, the Board is concerned that no timelines for the completion of next steps to introduce HVEDRs to Canadian commercial passenger vehicles has yet been established, and there is no clear workplan for the roll-out of planned changes to the CMVSS.

This deficiency file is Active.