Language selection

Rail transportation safety investigation R13T0192

The TSB has completed this investigation. The report was published on 02 December 2015.

Table of contents

Crossing collision

VIA Rail Canada Inc. passenger train No. 51
OC Transpo double-decker bus No. 8017
Mile 3.30, Smiths Falls Subdivision
Ottawa, Ontario

View final report

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.


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:

What we know

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

Information known shortly after the accident:

Since then:

Bus Operator



Ergonomic Study

Next steps

As the investigation continues, the TSB will:

Safety communications

Safety Recommendations


TSB Recommendation R15-01: The Board recommends that the Department of Transport, in consultation with the provinces, develop comprehensive guidelines for the installation and use of in-vehicle video monitor displays to reduce the risk of driver distraction.


TSB Recommendation R15-02: The Board recommends that the Department of Transport develop and implement crashworthiness standards for commercial passenger buses to reduce the risk of injury.


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


TSB Recommendation R15-04: The Board recommends that the Department of Transport provide specific guidance as to when grade separation should be considered.


TSB Recommendation R15-05: The Board recommends that the City of Ottawa reconsider the need for grade separation at the Woodroffe Avenue, Transitway and Fallowfield Road level crossings.

Safety Advisory Letters


Rail Safety Advisory Letter 12/14: Braking analysis and bus speed approaching crossings


Rail Safety Advisory Letter 10/14: Video monitoring system on OC Transpo double decker buses


Rail Safety Advisory Letter 02/14: Reported malfunction of transitway automatic crossing protection


Rail Safety Advisory Letter 01/14: OC Transpo buses traversing crossings with activated AWD protection

Media materials

News releases


TSB assesses responses to recommendations arising from the 2013 OC Transpo-VIA RAIL accident investigation
Read the news release


TSB issues five recommendations following investigation into September 2013 collision between an OC Transpo bus and a VIA Rail train
Read the news release


Progress update on investigation into fatal 2013 OC Transpo – VIA Rail collision on Ottawa’s Transitway
Read the news release


TSB issues safety advisory letters to the City of Ottawa as part of fatal September 2013 bus–train collision investigation
Read the news release


Update on investigation into OC Transpo - VIA Rail collision in Ottawa
Read the news release


TSB launches investigation into bus-train collision in Ottawa, Ontario
Read the news release




News conference for OC Transpo-VIA Rail (R13T0192): Opening remarks
Kathy Fox, Chair, Transportation Safety Board of Canada
Rob Johnston, Investigator-in-Charge

Deployment notice


Transportation Safety Board of Canada deploys team to the site of a collision between a VIA Rail train and an OC Transpo bus in Ottawa, Ontario

The Transportation Safety Board of Canada (TSB) is deploying a team to the site of a collision between a VIA Rail train and an OC Transpo bus in Ottawa, Ontario. The TSB will gather information and assess the occurrence.



Sequence of events of the crossing collision between VIA Rail Canada Inc. passenger train and OC Transpo double-decker bus (R13T0192)
Watch the video

Investigation information

Map showing the location of the occurrence


Photo of Rob Johnston

Mr. Johnston has been with the Transportation Safety Board of Canada (TSB) since 2001. He was Senior Regional Investigator in Winnipeg until 2004, when he assumed the position of Senior Investigator, Standards and Training Officer at TSB Head Office in Gatineau, Quebec. He became Manager of Central Regional Operations in November 2009, and served as Acting Director of Investigations - Rail/Pipeline for 9 months in 2010– 2011. He now manages a staff of 6 rail/pipeline investigators in Winnipeg, Toronto, and Ottawa, and is responsible for all activities related to rail investigations in TSB's Central Region, which extends from Cornwall, Ontario, to near the Alberta–Saskatchewan border. During his time at the TSB, Mr. Johnston has been Investigator-in-Charge of 20 rail accident investigations, and has provided technical expertise on a number of other investigations. Before joining the TSB, Mr. Johnston worked for Canadian Pacific Railway in Winnipeg from 1984 until 2001, where, as a member of the Train Accident Prevention group, he acquired an extensive background in mechanical operations, failure analysis, and dangerous goods.


  Download high-resolution photos from the TSB Flickr page.

Class of investigation

This is a class 2 investigation. These investigations are complex and involve several safety issues requiring in-depth analysis. Class 2 investigations, which frequently result in recommendations, are generally completed within 600 days. For more information, see the Policy on Occurrence Classification.

TSB investigation process

There are 3 phases to a TSB investigation

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

The TSB is an independent agency that investigates air, marine, pipeline, and rail 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.