Rail transportation safety recommendation R15-02
Reassessment of the response to TSB Recommendation R15-02
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 R15-02 (December 2015)
Structural deformation can be beneficial during a collision as energy is absorbed and dissipated that would otherwise be transmitted directly to the occupants. The basic principle of crash energy management is to ensure that, during a collision, the unoccupied spaces deform before the occupied spaces. Survivability is influenced by how well the impact is absorbed by features of the vehicle and directed away from the occupants. Any structural damage of the container should not reduce the size of the survivable volume or open it up to the elements to the point where it compromises occupant survivability.
TC, through its Motor Vehicle Safety Directorate, sets safety standards for the design, construction and importation of motor vehicles in Canada. These standards are known as the Canada Motor Vehicle Safety Standards (CMVSS) and are governed by the Motor Vehicle Safety Act and the Motor Vehicle Transport Act through the Motor Vehicle Safety Regulations. The Motor Vehicle Safety Regulations specify the requirements respecting safety for motor vehicles and related components. Pursuant to the regulations, the CMVSS identify the prescribed tests required for the certification of vehicles of various weight categories.
The CMVSS requirements vary according to the weight and type of vehicle. The heaviest vehicle weight category includes tractor-trailers that transport commodities and most transit and interprovincial buses that can transport up to 100 passengers. While these vehicles must meet a baseline of essential safety criteria (brakes, steering, etc.) and there are some vehicle safety standards that apply only to this weight category, these vehicles are generally subject to the fewest safety standards. The ADL E500 buses were designed in accordance with, and were fully compliant with, the legislative requirements of the Federal Motor Vehicle Safety Standards (FMVSS) in the United States and the CMVSS, as well as all applicable state and provincial requirements.
In this occurrence, 4 of the 6 fatally injured occupants were seated in the front row on the upper deck of the ADL E500 bus, which was an area that was structurally compromised during the accident. During the accident, the framing of the upper deck and lower deck floor was torn away. The failure of the bus structure ultimately resulted in the driver, the driver station and seat as well as 8 passengers and 4 passenger seats on the upper deck being ejected from the bus. Although the ADL E500 met all regulatory requirements, the front-end framings were not designed to provide any impact protection for upper deck occupants seated in the front row, and there was no front bumper, nor were these features required by the CMVSS.
During the investigation, other bus designs were reviewed for comparison. The following observations were made:
- Passengers positioned behind the yellow line – Passengers standing on a single-deck bus and passengers standing on the lower deck of a double-decker bus are required to be behind the yellow line located on the floor just behind the driver's station.
- In this accident, although a number of passengers on the lower deck were injured, only 1 passenger standing behind the yellow line sustained fatal injuries. In comparison, all 4 passengers seated in the front row of the upper deck, a location that was directly above the driver station and forward of the yellow line, sustained fatal injuries. Therefore, under the same circumstances, it is less likely that passengers on a single-deck bus would have been exposed to an area that was compromised by the collision.
- School bus – School bus design includes elements that are meant to reduce the effects of a collision. School buses must meet rollover protection standards. They also have a raised underframe, increased body strength, full-length horizontal impact rails and interior compartmentalization. TSB Railway Investigation Report R13W0083 indicated that school buses have an increased ability to withstand an impact and to protect occupants during a vehicle accident.
Vehicles imported to Canada must conform to the applicable CMVSS for the type of vehicle. The manufacturer is responsible for conducting all tests required to meet the CMVSS and for providing copies of the test results to TC. TC reviews the test results and provides approval for importation. Otherwise, there is no formal inspection or risk assessment of the vehicle required prior to delivery, regardless of the vehicle design features.
In contrast, the APTA has developed guidelines for the procurement of transit buses to help transit agencies prepare contracts that contain all necessary provisions and incorporate best available practices. The principal crashworthiness requirements in the APTA guidelines pertaining to transit buses include the following considerations (among others):
- Technical specification (TS) TS 23.2 requires that a bus be designed such that, in the event of a rollover or side impact, its structure is sufficiently robust to maintain a survivable volume with only small permanent deformations allowed.
- TS 70.1 requires the installation of bumpers to provide impact protection to the front and rear of the bus.
- The technical specifications also include static and dynamic strength requirements for passenger seating and seat back handholds to minimize the potential for occupant injuries.
The APTA guidelines include crashworthiness requirements that exceed the requirements specified by the CMVSS and FMVSS. Federal regulations do not require compliance with the more stringent APTA guidelines.
Additionally, in a letter from the National Transportation Safety Board (NTSB) to the NHTSA,Footnote 1 the NTSB outlined the findings from its special investigation,Footnote 2 which examined bus issues and evaluated the FMVSS that govern bus design. The NTSB was concerned that bus passengers may not be adequately protected in collisions. The investigation determined that, while standards within the FMVSS exist for large school buses relating to passenger seating, crash protection and body joint strength, there were no similar standards that applied to other types of large buses, such as motorcoach or transit buses.
The CMVSS contain no requirements for frontal impact, side impact, rollover or crush protection for vehicles with a gross vehicle weight rating (GVWR) in excess of 11 793 kg (26 000 pounds), which includes most transit buses. As a result, buses in this weight category can have different structural features that may not adequately protect the travelling public. Considering the consequences of this accident, the Board recommends that
the Department of Transport develop and implement crashworthiness standards for commercial passenger buses to reduce the risk of injury.
Transportation Safety Recommendation R15-02
Transport Canada's response to Recommendation R15-02(February 2016)
Transport Canada acknowledges the recommendation.
TC also recognizes that extremely high forces were involved in the collision that are beyond reasonable expectations of structural integrity for any road vehicle.
Transport Canada will evaluate the existing crashworthiness of commercial passenger buses by undertaking a review of accident data from urban centers around the world, including this case, to identify leading risks. Should this analysis identify suitable opportunities for possible standards to improve crash safety on buses, it could then be used to guide the implementation of a crashworthiness test program at the Motor Vehicle Test Center. If appropriate, guidelines for possible future standards could be prepared in consultation with stakeholders and published. If suitable opportunities for new standards are not identified during the process, a report on the analysis will be provided.
It is important to note that the United States does not currently have any structural crashworthiness standards in place for large commercial passenger buses. The United Nations vehicle safety regulations deal only with structural crashworthiness requirements during a bus roll over-type collision. Similar to the existing United States regulation, Canada expects to propose regulatory requirements for the installation of seat belts on many types of commercial buses. Any potential standard would only apply to new vehicles and as such would need to have a positive cost benefit analysis to be considered for a mandatory requirement.
TSB assessment of Transport Canada's response to Recommendation R15-02 (March 2016)
Transport Canada has acknowledged this recommendation.
TC will conduct a review of accident data from urban centers around the world to evaluate the existing crashworthiness of commercial passenger buses. If the data analysis supports suitable opportunities for standards to improve crash safety on buses, TC indicates the analysis could be used to guide the implementation of a crashworthiness test program, possibly leading to the development of guidelines for future standards in consultation with stakeholders.
The Board notes that TC will be examining accident data from around the world to identify leading risks for commercial passenger buses. Beyond this commitment, there are no explicit plans for the development and implementation of crashworthiness standards for commercial passenger buses to reduce the risk to passengers. Furthermore, no specific timeline has been provided for the planned review and analysis.
Therefore, the Board assesses the response to Recommendation R15-02 to be Satisfactory in Part.
Transport Canada's response to Recommendation R15-02 (February 2017)
TC is conducting a literature review that is expected to be completed by spring 2017. The analysis will help guide any crashworthiness test program.
The crashworthiness test program is contingent on acquiring a bus shell, either in part or in whole. TC has searched extensively to acquire such a shell, but has not yet been successful. TC is in discussions with industry to explore an approach, where industry could provide structural expertise, fabrication of test bucks, modifications and oversight of testing as required. It is possible that this could include both commuter bus test bucks, as well as transit bus test bucks.
The test buck structure(s) will be incrementally modified (strengthened) and subjected to acceleration pulses. The effect of incrementally strengthening the structure will be evaluated with respect to unrestrained occupant protection. Following completion of the test matrix and analysis of the data, a report on the findings and next steps will be prepared.
The 3 year project is planned as follows:
- Year 1: Acquisition;
- Year 2: Construction/modification of sled buck preliminary testing; and
- Year 3: Test completion, data analysis, report preparation.
In addition, TC has issued a Canada Gazette, Part I publication to propose regulatory requirements for Electronic Stability Control on most truck tractors and buses with a Gross Vehicle Weight Rating (GVWR) greater than 11,793 kilograms (26,000 pounds). TC has received comments following the Part 1 publication and is now preparing the Part 2 submission.
TC is also preparing a Canada Gazette, Part I publication to propose regulatory requirements for the installation of seat belts on many types of commercial buses.
TSB reassessment of Transport Canada's response to Recommendation R15-02 (March 2017)
TC is conducting a literature review on bus crashworthiness that is expected to be completed by spring 2017. Following this literature review, TC will initiate a crashworthiness test program to be completed over 3 years. This project has been planned as follows:
- Year 1 – Acquisition of a bus shell (either in part or in whole).
- Year 2 - Construction/modification of sled buck preliminary testing.
- Year 3 - Test completion, data analysis, and report preparation.
In the short term, TC has initiated a number of regulatory changes that are aimed at improving the safety of bus passengers. These potential regulatory changes include
- the requirement to have electronic stability control on most truck tractors and buses with a gross vehicle weight rating (GVWR) greater than 11 793 kg (26 000 pounds); and
- the installation of seat belts on many types of commercial buses.
The Board notes that TC will be completing its literature review on bus crashworthiness shortly, and has initiated a number of regulatory changes to improve the safety of bus passengers. The Board looks forward to the initiation and completion of the crashworthiness test program, which will include a report on the findings and next steps.
The Board reassesses the response to Recommendation R15-02 as having Satisfactory Intent.
Transport Canada's response to Recommendation R15-02 (January 2018)
The literature review was completed in March 2017. The analysis will help guide any crashworthiness test program. The review has found that current literature focuses primarily on seat belts and compartmentalization in school buses. There is less research on the structural integrity of other types of buses (transit, intercity, motor coaches), particularly as it pertains to occupant protection.
TC has searched extensively to acquire a bus shell, but has not been successful. TC has had discussions with industry to explore an approach, where industry could provide structural expertise, fabrication of test bucks, modifications and oversight of testing as required. It is possible that this could include both commuter bus test bucks as well as transit bus test bucks. Test bucks would be used for repeated exploratory testing on a decelerative sled. Tender documents are being prepared to proceed with a competitive tender process, with a target to award a contract by the 4th quarter of 2018.
TC published a Canada Gazette, Part I, publication that proposed regulatory requirements for the installation of seat belts on many types of commercial buses. Issued in the Canada Gazette, Part I, on 18 March 2017. A Canada Gazette, Part II, is being prepared and publication is planned for 2018. It is expected that seat belts will improve bus occupant safety in severe bus collisions, especially in rollovers. In addition, introducing requirements for seat belts that are optionally installed on school buses would ensure that lap-only seat belts cannot be installed and that all seat belts that are optionally installed are installed correctly. In certain collisions, lap-only belts in school buses can increase injury risk compared to existing compartmentalization features.
An amendment to add section 136 – Electronic Stability Control (ESC) Systems for Heavy Vehicles, to the Motor Vehicle Safety Regulations was published in the Canada Gazette, Part II, on 14 June 2017. The standard requires mandatory fitting of ESC systems on most truck tractors and buses with a gross vehicle weight rating greater than 11,793 kilograms. As of December 2017, most new truck tractors will require ESC technology. Most school buses and inter-city buses will follow in June 2018. While an ESC standard is not for crashworthiness, it is nevertheless an important safety measure for crash avoidance. Rollover and loss-of-control crashes involving heavy vehicles are a serious safety issue. Requiring ESC systems will help reduce the occurrence of rollovers and assist the driver in maintaining directional control of the vehicle during, for example, emergency maneuvers (swerving or braking to avoid an obstacle) or cornering on slippery surfaces. The buses targeted with this standard include motor coaches; which exhibited the majority of fatalities in collisions that ESC systems are capable of preventing. The Department is also requiring that ESC systems be required for school buses. This measure improves occupant safety by further reducing the potential for collisions involving school buses. Finally, the regulation is also applicable to a range of intercity buses.
TSB reassessment of Transport Canada's response to Recommendation R15-02 (March 2018)
The literature review on bus crashworthiness was completed in March 2017. The review indicated that research on the structural integrity of buses (transit, intercity, motor coaches) is limited, particularly as it pertains to occupant protection.
TC has continued to search for a bus shell, but has not been successful. With the possibility that a bus shell will not be available, TC had discussions with industry to explore an alternate approach. For this revised approach, industry would provide structural expertise, fabrication of test bucks, modifications to the test bucks, and oversight of testing as required. A competitive tender process has been initiated, with the contract to be awarded by late 2018.
TC reviewed its regulatory requirements relating to occupant protection on commercial buses and on school buses, resulting in the following proposed changes:
- In March 2017, TC published proposed regulatory requirements for the installation of seat belts on various types of commercial buses in the Canada Gazette, Part I. The Canada Gazette, Part II, publication is being prepared and is expected to be issued in 2018.
- In June 2017, an amendment to the Motor Vehicle Safety Regulations to add electronic stability control (ESC) systems on heavy vehicles was published in the Canada Gazette, Part II. Effective December 2017, most of the new truck tractors will be required to have the ESC technology. Starting June 2018, most of the new school buses and inter-city buses will also be required to have the ESC technology.
The Board is encouraged that TC has taken a leadership role in the assessment of bus crashworthiness, and that continued progress is being made. The Board is also encouraged that a number of changes have been proposed or implemented to the Motor Vehicle Safety Regulations, resulting in improved occupant safety for commercial buses and school buses.
The Board considers the response to Recommendation R15-02 to show Satisfactory Intent.
Transport Canada’s response to Recommendation R15-02 (February 2019)
Statistics drawn from the National Collision Database show that human error (e.g. speeding, distracted driving, impaired driving) continues to be a major contributing factor in fatal collisions in Canada. In addition, statistics from the National Collision Database indicate that road users outside the bus (e.g. pedestrians, cyclists) are vulnerable to heavy vehicles, including transit buses. Based on this evidence, Transport Canada’s efforts to improve commercial passenger bus safety extend beyond the structure of the bus, and recognizes that potential measures to strengthen the structure of the bus could have unintended, adverse impacts on crash avoidance and vulnerable road users. As such, Transport Canada is addressing the issue of crashworthiness as part of a comprehensive, multi-pronged approach to commercial passenger bus safety that includes measures to support: structural crashworthiness, crash avoidance, human factors (the driver), and road users outside the bus.
- Structural crashworthiness: In 2017, Transport Canada completed its review of accident data from urban centres to support the potential development of a standard for crashworthiness. Building on this review, the Department has worked with industry to develop a comprehensive research plan to examine new technologies to help protect bus passengers in the event of a collision. This includes working with bus manufacturers to develop appropriate and effective ways to enhance the safety of passengers in buses, and the acquisition of a highly specialized, custom-made test device, referred to as a test buck. The acquisition of the test buck is a multi-year and iterative process, given the complex design considerations, and the need to seek out qualified and available bidders through a competitive process. The department continues to work in collaboration with Public Services and Procurement Canada on options to contract this work, with a view to launching the competitive process in fall 2019. Results of these efforts would inform next steps for a possible crashworthiness standard.
In July 2018, in order to improve bus occupant safety in severe collisions, Transport Canada published a final regulation mandating seat belts on commercial passenger buses (e.g. medium and large highway buses). This regulation includes technical requirements for the optional installation of seat belts on school buses.
- Crash avoidance: In June 2017, TC published a regulation to mandate electronic stability control in commercial passenger buses and heavy trucks. These control systems are an important crash avoidance technology that would improve driver control and help prevent rollovers. As of June 2018, commercial passenger buses over 14,969 kg (i.e. motor coaches, highway buses, school buses) must be equipped with electronic stability control. By August 1, 2019, this requirement extends to commercial passenger buses over 11,793 kg.
- Human factors (the driver): On January 21, 2019, the federal/provincial/territorial Council of Ministers Responsible for Transportation and Highway Safety agreed to develop a national standard for entry-level training for commercial drivers, including bus drivers, by January 2020. Transport Canada is exercising a leadership role with respect to this standard, including bringing forward this proposal to the Council of Ministers, and working with provinces/territories to develop the national standard.
Transport Canada is also working with partners to finalize the publication of a regulation on electronic logging devices to help track the hours of commercial drivers (e.g. motor coach drivers) to reduce the risk of driver fatigue. It is anticipated that this regulation will be published in Canada Gazette Part II in Spring 2019.
In addition, the department continues to conduct ongoing assessments of emerging technologies to help mitigate the risk of driver error, such as advanced driver assist systems. This work complements Transport Canada Guidelines to Limit Distraction from Visual Displays in Vehicles, explained further in the Department’s response to Recommendation R15-01, which provides evidence-based guidance to reduce driver distraction through the safe design, installation, and use of in-vehicle visual displays.
- Road users outside the bus: In parallel, recognizing pedestrians and cyclists outside the bus are statistically more vulnerable than those inside the bus, in August 2018, Transport Canada published a report, entitled Safety Measures for Cyclists and Pedestrians around Heavy Vehicles, thatdescribes a series of safety measures to support jurisdictions in better protecting vulnerable road users (e.g. automated enforcement technologies, such as speed and red-light cameras; roadway and cycling infrastructure, such as segregated cycling tracks; and visibility and awareness measures, such as warnings in heavy trucks to detect nearby pedestrians). As part of this initiative, Transport Canada has also launched on-road field trials, in collaboration with municipal partners, to evaluate the effectiveness of enhanced detection/visibility systems on a range of commercial vehicles.
TSB reassessment of Transport Canada’s response to Recommendation R15-02 (March 2019)
Transport Canada (TC) is addressing bus crashworthiness as part of a multi-pronged approach to commercial passenger bus safety that includes measures to support: structural crashworthiness, crash avoidance, human factors (the driver), and road users outside the bus.
In 2018, specific progress and observations were made in 4 areas:
- Structural crashworthiness: TC continued its work with bus manufacturers to develop a comprehensive research plan to examine new technologies to help protect bus passengers in the event of a collision. In collaboration with Public Services and Procurement Canada, TC expects to initiate a competitive process in Fall 2019 to acquire a highly specialized, custom-made test device, referred to as a test buck. Results of these efforts will inform next steps for a possible crashworthiness standard.
In July 2018, to further improve bus occupant safety in severe collisions, TC published its regulation that mandates seat belts on commercial passenger buses. In addition, this regulation includes technical requirements for the optional installation of seat belts on school buses.
- Crash avoidance: In June 2018, the requirement for electronic stability control became mandatory for commercial passenger buses over 14,969 kg (i.e. motor coaches, highway buses, school buses). In August 2019, the requirement for electronic stability control will be extended to commercial passenger buses between 11,793 kg and 14,969 kg.
- Human factors (the driver): In January 2019, the Council of Ministers Responsible for Transportation and Highway Safety agreed that a national standard for entry-level training for commercial drivers (including bus drivers) must be developed by January 2020. Working with the provinces/territories, TC has taken a leadership role to develop this national standard.
TC is finalizing a regulation on electronic logging devices to track the hours of commercial drivers (e.g. motor coach drivers) to help reduce the risk of driver fatigue. This regulation is expected to be published in the Canada Gazette, Part II in Spring 2019. TC is also assessing emerging technologies that help mitigate the risk of driver error, such as advanced driver assist systems.
- Road users outside the bus: In August 2018, recognizing that pedestrians and cyclists outside the bus are statistically more vulnerable than those inside the bus, TC published a report, entitled Safety Measures for Cyclists and Pedestrians around Heavy Vehicles. The report identifies a series of safety measures to help protect vulnerable road users. As part of this initiative, TC has also launched on-road field trials to evaluate the effectiveness of enhanced detection/visibility systems on a range of commercial vehicles.
The Board acknowledges that continued progress is being made as part of TC’s multi-pronged, comprehensive approach to commercial passenger bus safety. However, in light of the recent Humboldt and OC Transpo bus accidents, the Board is concerned by the apparent lack of urgency in TC’s response. The Board believes that the structural crashworthiness assessment work, including the acquisition of a suitable test buck, must be significantly accelerated to allow for the timely development and implementation of crashworthiness standards for commercial passenger buses. The Board considers the response to Recommendation R15-02 as being Satisfactory in Part.
Next TSB action
The TSB will continue to monitor progress on the planned actions, particularly relating to the acquisition of a test buck for examining structural crashworthiness.
This deficiency file is Active.
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