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Findings of the investigation into the September 2013 collision between an OC Transpo bus and a VIA Rail train in Ottawa, Ontario

Findings as to causes and contributing factors

  1. Although the crossing protection was activated, the bus did not stop as required and struck the train as the train entered the crossing.
  2. Locomotive VIA 915's lead truck followed the main track while its rear truck derailed on the Transitway crossing when the locomotive was contacted by the bus chassis. Then, the rear truck of locomotive VIA 915, along with the lead truck of the first car (VIA 3455), took a diverging route into the VIA Rail Canada Inc. siding.
  3. As locomotive VIA 915 and car VIA 3455 jackknifed, the lateral restraint capacity of both tracks was exceeded as the rail on both tracks spread out of gauge and rolled to the field side, resulting in the derailment of the remaining passenger cars.
  4. As it was common for drivers to use the section of the Transitway immediately following the crossing to make up time, and because the driver did not expect to encounter a train, the bus was accelerated beyond the posted speed limit.
  5. The bus speed of 42 mph (67.6 km/h) exceeded the posted speed limit of 60 km/h by 7.6 km/h just prior to the initial brake application, which increased the stopping distance required.
  6. The driver did not initially fully apply the brakes, which increased the bus stopping distance.
  7. OC Transpo's training on brake application, which focused on smooth braking to minimize passenger discomfort, may have contributed to the driver not initially applying maximum braking force in an emergency situation.
  8. OC Transpo speed monitoring and enforcement activities on the Transitway in the vicinity of the crossing were not sufficient to prevent drivers from exceeding posted speed limits when approaching the crossing, in contravention of recommended safe driving practices.
  9. The driver was likely visually distracted by looking at the video monitor during the critical driving sequence of negotiating the left-hand curve and approaching the crossing.
  10. Conversations between the driver and a passenger and among passengers near the driver, as well as the perceived need to make an announcement to passengers standing on the upper deck, created a situation where the driver was likely cognitively distracted in the seconds before the accident.
  11. OC Transpo did not identify or mitigate the risks arising from driver attention being inappropriately directed at the video monitor when the bus was in motion and from the need to make announcements if passengers were observed standing on the upper deck.
  12. The trees, shrubs, foliage and roadway signage on the Transitway right-of-way, as well as the bus front corner and window pillars, obstructed the driver's view of the activated automatic warning devices until the bus was 122.5 m (402 feet) from the crossing, a distance that was slightly less than the recommended stopping sight distance of 130 m (426.5 feet).
  13. In addition to distractions that likely influenced the driver, the additional driver workload associated with negotiating the left-hand curve on approach to the crossing likely decreased the driver's ability to detect the activated automatic warning devices.
  14. Although the crossing automatic warning devices (AWDs) had been activated before the bus departed from the station, the view of the activated AWDs was obstructed and there was no active advance warning of the train's approach available to the driver.
  15. Although not required by regulation, a more robust front structure and crash energy management design may have reduced the damage to the bus and prevented the loss of a protective shell for the occupants.

Findings as to risk

  1. If officials tasked with the enforcement of traffic violations on the Transitway are not provided adequate enforcement tools, there is an increased risk for a related vehicle accident to occur.
  2. If mitigating strategies are not put in place to address driver distraction, bus drivers may not always remain focused on the driving task and on the roadway ahead, increasing the risk of a roadway accident.
  3. If active advance warning signs interconnected with railway crossing signals are not installed on roadways with a significant curve near a crossing or at locations with inadequate stopping sight distances, drivers may not have sufficient time to react to an approaching train, increasing the risk of a crossing accident.
  4. If the stopping sight distance is not periodically checked by road authorities, especially along roadways with trees and other growing vegetation, the view of the crossing from the roadway may become obstructed over time, increasing the risk of a crossing accident.
  5. If vehicle safety standards for transit buses do not include requirements for enhanced crashworthiness, there is an increased risk of injury to vehicle occupants in the event of an accident.
  6. If buses are not equipped with crashworthy event data recorders, the circumstances and factors contributing to a bus accident may not be fully understood and appropriate safety action may not be implemented, increasing the risk that other similar bus accidents will occur.
  7. If bus companies do not have access to or do not use available technology and event data recorder data for proactive safety analysis, there is an increased risk that opportunities to improve operational safety will not be identified.
  8. If the need for grade separation is not periodically reconsidered, changes in the risk factors may not be identified in a timely manner, increasing the risk that existing crossing protection may no longer be adequate to address increases in train and roadway vehicle traffic.
  9. For grade crossings that require increased driver workload, if vehicle drivers do not fully understand crossing automatic warning device protection, interconnected traffic signals, visual cues, approach signage and roadway markings, the risk of a crossing accident is increased.
  10. If there are no guidelines established for when a grade separation should be constructed, level crossings with elevated risk factors can remain in place, increasing the risk of a crossing accident.
  11. If there is no clear guidance to determine whether buses should stop at railway crossings even when the automatic warning devices are not activated, there is a risk that railway crossing safety may not be optimized.
  12. If staff tasked with managing drivers and reviewing driver abstracts do not fully understand the company's driver performance monitoring process, unsafe driving behaviours may not be identified and addressed in a timely manner, increasing the risk of roadway accidents.
  13. If driver accident and incident data are not available and reviewed by the training staff, existing or emerging driver deficiencies may continue unchecked, increasing the risk that the requisite training will not be modified to correct unsafe practices.
  14. If bus transit companies do not consider the factors that may influence driver behaviour, the drivers may engage in unsafe practices, increasing the risk of accidents.
  15. If bus drivers do not receive targeted railway crossing safety education, and if driver compliance with the rules of the road is not actively enforced, railway crossing safety will not be optimized, increasing the risk of a crossing accident.
  16. If vehicle drivers are repeatedly exposed to unwanted crossing automatic warning device (AWD) activations, there is an increased risk that drivers will develop an expectation that no train is present at the crossing when the AWDs are activated and may circumvent the crossing protection.
  17. If railway electronic log time stamps are not synchronized, operational analysis of safety-critical data may be difficult, increasing the risk of delays in the analysis and of misinterpretation of the data.

Other findings

  1. The automatic warning device crossing protection for both the Woodroffe Avenue and the Transitway crossings operated as designed with no malfunctions.
  2. The ADL E500 double-decker bus met or exceeded all required air brake system criteria for operation in Canada. There was no indication of any pre-accident conditions or deficiencies with the air brake system mechanical and pneumatic components that would have precluded normal operation of the brake systems.
  3. While it was possible to construct roadway overpass grade separations for Woodroffe Avenue, the Transitway and Fallowfield Road, the need to reopen the environmental assessments, the possible loss of Millennium funding and the clear preference for the roadway underpass alternative demonstrated by both the public and the National Capital Commission limited the grade separation options considered by the City of Ottawa in 2004.
  4. From a distance of 100 feet (30.5 m), a high-level emergency passenger train horn would have been barely audible to a driver and may not have prompted a response even if the horn had been activated at the time of the accident, whereas a freight train horn would have been inaudible to a driver.
  5. Although the north-side back LED lights (short) of the Transitway crossing were slightly misaligned, they were intended for vehicles stopped at the crossing, and the misalignment likely did not play a role in this accident.
  6. The emergency response was well coordinated between the attending agencies with appropriate and effective measures taken to protect the site and to ensure passenger and public safety.
  7. A review of a series of unwanted automatic warning device activations of the Barrhaven crossings in early 2014 determined that, although disruptive, there was no systematic failure of the crossing protection system, and the parties involved (Transport Canada, VIA Rail Canada Inc. and the City of Ottawa) took appropriate steps to resolve the issues.
  8. The driver was fully qualified and fit for duty at the time of the accident.
  9. There was no medical illness involved and there were no traces of drugs or alcohol in the driver's system.
  10. Although the driver had a red-green colour vision defect, it was unlikely that this colour vision defect played a role in the accident as the driver had near-to-normal brightness sensitivity to the red flashing lights at the crossing.
  11. The driver's sunglasses enhanced the conspicuity of the crossing signal lights and did not play a role in the accident.
  12. As the driver was not experiencing any significant ongoing pain or discomfort and he had full range of motion for at least 18 months preceding the accident, the driver's previous neck injury did not play a role in the accident.
  13. Although the driver had Type 2 diabetes, it had been managed appropriately and there was no indication that the disease played a role in the accident.
  14. Based on the review of the driver's work-rest history and related sleep patterns, driver fatigue did not likely play a role in the accident.
  15. The crossing gate and its lights were not very conspicuous from a distance, nor were they designed to be.
  16. As the stationary vehicles at the adjacent crossing on Woodroffe Avenue were obstructed by trees, shrubs and foliage on the Transitway right-of-way, they were not conspicuous enough to alert the driver to the activated crossing protection.
  17. The relatively similar approach speeds of the bus and of the train toward the crossing likely made it difficult for the driver's peripheral vision to detect the presence of the train.
  18. The sound level of the bells would not likely have been detected above the ambient noise levels within the bus.