Safety communications for the investigation into the September 2013 collision between an OC Transpo bus and a VIA Rail train in Ottawa, Ontario
On the morning of September 18, 2013, an OC Transpo double-decker bus collided with a VIA Rail train in Ottawa, Ontario. Six people died, including the bus driver, and about 34 more were injured.
The Canadian Transportation Accident Investigation and Safety Board Act specifically provides for the Board to make recommendations to address systemic safety deficiencies posing significant risks to the transportation system and, therefore, warranting the attention of regulators and industry. Under the Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies.
Recommendations issued on 02 December 2015
Distracted driving guidelines
Despite jurisdictional issues, it is important for Transport Canada (TC) to take a leadership role and develop a framework that provides consistent guidance to both the industry and provinces to address the emerging issues related to distracted driving. The Board considers this framework to be an important element in mitigating the associated risks, particularly with regards to railway crossing safety.
In order to minimize any potential distraction while driving a vehicle, 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 R15-01
The Canada Motor Vehicle Safety Standards (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.TSB Recommendation R15-02
Vehicle event data recorders
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, event data recorders 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
Grade separation guidelines
It is recognized that federal guidelines are generally not enforceable, particularly in other jurisdictions. However, the Board considers that guidance similar to that contained in the United States Department of Transportation Federal Highway Administration Railroad-Highway Grade Crossing Handbook would be a useful framework that provides consistent guidance on issues related to grade separation for the industry as well as federal, provincial and municipal road authorities.
Since Canada has no such guidelines for grade separation, the Board recommends that
The Department of Transport provide specific guidance as to when grade separation should be considered.TSB Recommendation R15-04
Grade separation of Woodroffe Avenue, the Transitway, and Fallowfield Road
Grade separation projects usually involve multiple jurisdictions with funding provided by the railways, the respective road authority and the federal government. The decision to proceed with level crossings was based on known risk factors in 2004. Since that time, changes have occurred in the risk factors such as area population, number of trains, train speed, the number of vehicles, the resulting cross-product and the average number of vehicle occupants. These risk factors will continue to increase with further urban and potential railway development in the area with a commensurate risk that existing level crossing protection may no longer be adequate.
Therefore, the Board recommends that
The City of Ottawa reconsider the need for grade separations at the Woodroffe Avenue, Transitway, and Fallowfield Road level crossings.TSB Recommendation R15-05
TSB safety concerns
Safety concerns are expressed in final investigation reports. A safety concern focusses on an identified unsafe condition for which there is insufficient evidence to validate a systemic safety deficiency, but the risks it poses warrant highlighting. A safety concern provides a marker to the industry and the regulator that the Board has insufficient information to make a recommendation, but that as more data and analysis become available, the Board will return to this unsafe condition if it is not redressed.
Safety concerns issued on 02 December 2015
It is recognized that requirements for a bus to stop at a railway crossing falls under provincial, municipal, and in some cases, transportation company jurisdiction. However, the studies used to support decision-making made on this issue are out of date, incomplete and limited in scope. The absence of good guidance can lead to ill-advised or misinformed decisions that could in turn result in wasted investments that do not effectively mitigate the safety risks and that give people a false level of confidence in the safety of particular practices. Under these circumstances, more up-to-date guidance, based on research and science, would be useful for all jurisdictions.
The Board is concerned that, given there is no recent comprehensive study that specifically deals with the risks associated with all buses stopping at all railway crossings, decision-makers may not make the best choices possible to ensure an adequate level of safety.
Safety advisory letters
Safety advisory letters are concerned with safety deficiencies that pose low to medium risks, and used to inform regulatory or industry stakeholders of unsafe conditions. A safety advisory letter suggests remedial action to reduce risks to safety.
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