Investigators examine the scene of an accident involving a bus and a train in Ottawa on Sept. 18, 2013.CHRIS WATTIE/Reuters
The bus driver who crashed his double-decker vehicle into a train two years ago, killing himself and five passengers, was distracted by a video monitor, the perceived need to tell riders to sit down, and conversations that were taking place around him, a Transportation Safety Board investigation has determined.
The board found that the OC Transpo bus being driven by Dave Woodard was in good mechanical condition, Mr. Woodard was both fit for duty and familiar with the route, and the automated lights and warnings at the railway crossing were functioning as intended.
But a combination of visual impediments, multiple distractions inside the bus, and excessive speed, meant he did not see the Via Rail train on that morning of Sept. 18, 2013 until it was too late.
"This accident goes far beyond the actions of any one individual," Rob Johnston, the investigator in charge, told a news conference on Wednesday morning when the results of the study were released. "In fact, given the same circumstances, the accident could have happened to just about any driver."
The board found that the bus departed from the Fallowfield station about four minutes after its scheduled departure time with 95 passengers on board. By that time, the flashing lights at the railway crossing less than a minute ahead and around a left-hand curve in the city's bus Transitway were already activated. But the driver's view was obstructed by trees, shrubs and foliage.
OC Transpo requires drivers to monitor the video at station stops and while buses are in service and to announce that no standing is permitted on the upper deck. Although Mr. Woodard believed there were empty seats, a passenger who was on the second level did not see any available place to sit and remained standing.
As the bus continued along the Transitway, the driver was distracted by conversations about whether there was seating on the upper deck and by the perceived need to make an announcement that no standing was permitted. As a result, he was watching the video screen as he rounded the curve.
When passengers who were looking ahead noticed the train and began to shout for him to stop, Mr. Woodard began to apply the brakes. But it was too late. The train sliced off the front portion of the bus and then derailed.
Mr. Woodard and five of his passengers – Kyle Nash, Michael Bleakney, Rob More, Karen Krzyzewski and Connor Boyd – were killed, nine people were seriously injured and about 25 people sustained minor injuries.
Kathy Fox, the chair of the Transportation Safety Board, said Ottawa has taken steps to make the crossing where the crash occurred safer but more must be done to lower the risks. Her organization is making five recommendations to help prevent similar tragedies from occurring anywhere else in Canada.
A driver cannot watch a video monitor and the road at the same time, said Ms. Fox. Although Ontario has a distracted driving law, some commercial vehicles are exempt, she said. The TSB is asking Transport Canada to work with the provinces to set guidelines on the placement and use of in-vehicle monitors.
The board is also asking for the development of crash-worthiness standards for passenger buses. The bus involved in the Ottawa crash met existing federal standards but there were no requirements for impact, rollover or crush protection. "A more robust, crash-worthy design may have reduced damage to the bus and prevented loss of life in this accident," said Ms. Fox.
Buses should be equipped with data recorders similar to trains, ships and airplanes, she said, adding that investigators were hampered in their ability to obtain information, which added months of work to their analysis.
There are no federal regulations or guidelines to determine when there is so much traffic at a railway crossing that the trains and motor vehicles should be separated by an underpass or an overpass. Transportation should provide that guidance, said Ms. Fox.
And the City of Ottawa should consider building that separation at the site of the crash, she said.
Mr. Johnston said the TSB investigation revealed no evidence of any drugs, alcohol, fatigue or medical issue to be affecting Mr. Woodard's performance. The train was being driven properly, and the bus's brakes were fully operational, he said.
But the bus was travelling 7.6-kilometres faster than the posted speed limit, possibly because Mr. Woodward intended to make up for the fact that he was late, said Mr. Johnston.
That increased the stopping distance, he said, and Mr. Woodard did not initially apply the full brakes, which was consistent with company training to reduce the risk of passengers from falling.