Ottawa bus crash inquest calls on OC Transpo to apply 'safety lens' to decisions
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An inquest jury has called on OC Transpo to filter every decision about buses, infrastructure and training through a “safety lens” to protect passengers from the kind of accident that killed three people in January 2019.
It was one of 60 recommendations the five-person jury issued Thursday at the conclusion of the month-long inquest into the Westboro bus crash.
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The jury also recommended OC Transpo install driver-facing cameras on all buses (to ensure drivers are not distracted by phones or other devices), assess new drivers for proficiency on double-decker and articulated buses, conduct annual safety inspections of the Transitway to identify potential hazards, and dramatically improve retraining for probationary drivers involved in serious, preventable collisions.
The jury further recommended OC Transpo reduce to 30 km/hr the speed at which buses approach Transitway stations until it removes or modifies bus shelter canopies at seven stations, or constructs barriers in front them to deflect wayward buses.
A similar, rigid shelter canopy at Westboro Station cut into the second deck of Bus 8155 on Jan. 11, 2019 with devastating results.
Coroner Dr. Louise McNaughton-Filion thanked jurors for their well-considered recommendations.
The jury deliberated on their recommendations for three days.
The jury was tasked with investigating the circumstances that led to the deaths of three passengers – Bruce Thomlinson, 56, Judy Booth, 57, and Anja Van Beek, 65 – and making recommendations to prevent similar deaths.
Inquest juries are prohibited from assigning blame, and their recommendations are not binding on the organizations involved.
City of Ottawa lawyer Anne Tardif said OC Transpo has embraced a safety culture during the past six years. “Put simply,” she told jurors during the inquest, “OC Transpo is not the same organization today that it was in 2019.”
OC Transpo, she said, has introduced a chief safety officer, a data-based analysis of driver performance, and a new screening process to weed out driver applicants with unsuitable psychological profiles.
The transit service has also increased the amount of time trainees receive behind the wheel of double-decker and articulated buses, she said. Trainees now receive a minimum of eight hours of road training on both double-deckers and articulated buses. In the past, drivers received as little as two hours of such specialized training.
The inquest heard rookie OC Transpo bus driver Aissatou Diallo was behind the wheel of double-decker Bus 8155 on the afternoon of Jan. 11, 2019.
Diallo had returned to work just five days earlier from a three-week leave imposed to investigate her role in a collision at St. Laurent Station.
The inquest heard she went for a one-day retraining session after being found at fault in the Dec. 10, 2018 crash at St. Laurent, where Diallo t-boned a parked bus. Five passengers were injured, and the parked bus was damaged beyond repair.
OC Transpo’s then manager of bus operations, Ken Gordon, told the inquest that, in hindsight, he regrets returning Diallo to the driver’s seat.
Looking back, he said, “I wouldn’t have recommended remedial training: I would have recommended termination.”
Gordon said he felt political and operational pressure to send Diallo back to work because OC Transpo was then suffering a driver shortage which meant some routes could not be staffed.
Diallo was driving westbound on the Transitway into a setting sun when the tragic chain of events leading to the Westboro crash began.
Possibly confused by some temporary lane markings that had not been properly removed after a construction project, Diallo drifted onto the shoulder of the Transitway. Bus 8155 hit a snowbank, a rock wall and another snowbank before slamming into the station’s bus shelter.
The bus was travelling about 10 kilometres per hour above the Transitway’s posted speed limit when it left the dry road and moved onto the snow-covered shoulder.
Evidence showed Diallo did not apply the brakes in the five seconds between drifting onto the shoulder and hitting the station.
The inquest heard Diallo had a cellphone and earbuds in her front pocket, but there was no evidence she was using them at the time of the crash.
Diallo was acquitted in September 2021 of any criminal responsibility for the accident.
Ontario Court Justice Matthew Webber said Diallo’s actions as a driver were not a “marked departure” from the standard of care a reasonably prudent driver would have exercised in the same situation. He found the crash was not due to Diallo’s inattention or unresponsiveness, but to a tragic combination of circumstances: a blinding sunset, some old road markings and snow on the shoulder of the road.
Diallo did not testify at her criminal trial.
Diallo received a legal summons to testify at the inquest but ignored it. McNaughton-Filion must now decide whether to exercise her power under Section 51 of Ontario’s Coroner’s Act, and go to divisional court to have Diallo punished for refusing the inquest summons.
Among the inquest jury’s other recommendations directed at the city:
• Assess all new drivers on their emergency braking in double-decker, articulated and conventional buses
• Create a dedicated, 24-hour reporting system so that OC Transpo passengers can relate any safety concerns
• Standardize the frequency of radar speed tests conducted on the Transitway, and analyse the data
• Designate a multidisciplinary team to conduct “root cause analyses” of future OC Transpo bus collisions
The jury recommended the federal government explore whether the Transportation Safety Board’s mandate should be expanded to include serious bus collisions. It also suggested Transport Canada conduct more research into double-decker bus safety, and assess the value of new driver assistance technologies.
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