OTTAWA – Driving distractions, speed and roadway configuration were among 15 factors that led to a fatal 2013 collision in Ottawa between a city bus and a Via Rail train, the Transportation Safety Board concluded in its final report on the crash.
Removing just one of these contributing factors could have meant the difference between tragedy and any other day on the capital’s busy transitway, lead investigator Rob Johnston said in releasing the report on Wednesday.
But combined, they proved deadly.
“Given the same circumstances, this accident could have happened to just about any driver,” said Johnston.
Six people on board, including the driver, were killed when the double-decker OC Transpo bus slammed into Via No. 51 on the morning of Sept 18, 2013. No one on the train was hurt.
Some of the 83 passengers screamed “stop, stop” as they saw the bus headed toward the oncoming train at a level crossing, but the bus driver was likely distracted by an on-board video monitor and passenger conversations, the report said.
“It is likely that the driver was distracted, both visually and cognitively, in the seconds before the crash,” said TSB chairwoman Kathy Fox.
“The video monitor above the driver’s seat was relatively small and the individual quadrants were even smaller still.”
OC Transpo double-decker bus drivers are required to monitor the upper deck to ensure no passengers are standing while the bus is moving. The four-way split-screen video monitor also allows the driver to view the stairwell, side doors and exterior of the bus.
It’s a visual distraction that needs to be addressed, said Fox.
“Even changing the view and moving the screen to an angle more aligned with the driver’s line of sight doesn’t change the fact that a driver cannot watch it and the road at the same time,” she said.
The board had already concluded that the bus was in good mechanical shape, the brakes were working and there were no drugs or alcohol involved.
However, the bus was speeding in the seconds before the crash, travelling at 67.6 kilometres an hour in an area where the posted limit was 60, the report said. The driver also did not initially apply the full force of the brakes, although that was standard protocol for stopping the double-decker buses, the report said.
The board made five recommendations Wednesday that could affect not only Ottawa transit, but also bus-train interactions in cities across the country.
It called for:
— New guidelines from Transport Canada on the installation and use of in-vehicle video display monitors.
— New crashworthiness standards to reduce the risk of injury in commercial bus crashes.
— A requirement that commercial passenger buses be equipped with event data recorders, similar to the so-called “black boxes” found in commercial airliners.
— New guidance from Transport Canada as to when municipal and other transit authorities should consider installing underpasses or overpasses instead of level train crossings.
— Having Ottawa reconsider the need for grade separations at two of the city’s level crossings.
In its initial response to the report, the city said it and Via Rail will jointly study the need, feasibility and cost of grade separations at those crossing, as well as two others.
It also said it would provide an official response to the TSB’s recommendation within 90 days.
Transport Minister Marc Garneau said his department will also review the report.
Follow @tpedwell on Twitter