Ottawa, Ontario, 24 September 2014
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.
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).Footnote 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.
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.
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.
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 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.
TSB Human Performance staff conducted an ergonomic study of the driver's station for each of the bus designs operated by OC Transpo.
As part of data collection and information sharing, the following activities have been ongoing:
The following is a summary of facts as determined by the investigation so far.
Today, the TSB issued two new safety advisory letters (RSA 10/14, RSA 12/14) to the City of Ottawa 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.
Following the identification of safety issues in the September 2013 TSB accident re-enactment, the City of Ottawa:
For VIA Rail:
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.
As the investigation continues, the TSB will:
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.Error processing SSI file
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).