Jury urges driver-facing cameras at end of OC Transpo bus crash inquest
Exhaustive deep dive explored safety culture and driver assignment system
The jury at the coroner's inquest into the fatal 2019 OC Transpo bus crash has issued dozens of recommendations for preventing similar tragic accidents — everything from driver-facing cameras on all Ottawa buses to requiring more time for retraining drivers involved in on-duty collisions.
The 60 prompts for change also cover Transitway speed limits and maintenance.
The jury's recommendations are not binding, but they do also include a call for government funding to make them a reality.
They were delivered on Thursday afternoon, the 19th day of an exhaustive deep dive into the events and fallout of Jan. 11, 2019.
On that afternoon, a packed OC Transpo double-decker slammed into a Transitway bus shelter at Westboro station. Three people — Judy Booth, Bruce Thomlinson and Anja Van Beek — died in the crash and many others were injured.
While the city accepted civil responsibility, the driver, Aissatou Diallo, was charged with 38 counts of dangerous driving causing death or bodily harm. She was acquitted of all charges in a judge-only trial in 2021.
The fact-finding (as opposed to fault-finding) inquest homed in on a number of areas including tightened driver training and recruitment, the already-numbered days of double-deckers in Ottawa, and the knotty issue of how the city designs routes and OC Transpo drivers book their work.
The inquest heard that booking is a seniority-based system that can result in less-experienced drivers like Diallo driving double-deckers, though there was disagreement about whether those larger buses are in fact harder to handle than single-deckers. Jurors also heard that the Westboro collision was "unique and so unusual" in its circumstances.
The jurors ultimately did not issue recommendations on the booking system, to the relief of the union local representing OC Transpo workers.
"Almost all — if not all — transit properties use this seniority-based system, and to try and suggest that that had anything to do with this, personally, I didn't see it that way," said Noah Vineberg, the president of Amalgamated Transit Union (ATU) Local 279.
"I don't think we need to revolutionize the entire industry because of an incident."
The Thomlinson and Booth families, as well as lawyers representing the city, the union, and the coroner's office, made their own pitches for change to the jury last week.
But while the jury of five Ottawa-area civilians could consider those suggestions, the final list of recommendations was up to the jurors.
Their recommendations, more than half of which were directed to the city, touched on the following areas:
Driver monitoring and safety
- Installing driver-facing cameras on all buses, a move the union opposed for privacy reasons. The jury also called on regulators to adopt standards for the use of such cameras.
- Closer monitoring of drivers who get in an on-duty collision and undergo refresher training.
- A separate evaluation procedure for probationary operators following a serious preventable collision. Before those drivers return to service, they must undergo a minimum of five days of retraining. The inquest heard that Diallo only underwent one day of retraining after crashing a bus one month before the Westboro collision.
- Increasing checks on driver licence abstracts from twice a month to daily.
Transitway and bus design
- Temporarily reducing the speed of buses approaching stations on the Transitway to 30 kilometres an hour.
- Once that's done, removing or replacing canopies with a narrow lateral offset from the curb (as was the case at Westboro station), as well as installing tapered concrete barriers or other forms of guardrail.
- Regularly inspecting the Transitway for safety hazards.
- Making sure remnants of Transitway construction — like the orange lines that some have argued may have been a distraction to Diallo — are properly removed.
- Ensuring the "appropriate" removal of snow on the road leading to Transitway stations. The ditch on the day of the Westboro collision was icy and snow-packed.
- Calling on the city and the manufacturer of the double-decker involved in the Westboro crash to study the effectiveness of barriers at the front upper deck of buses to prevent passenger ejections during collisions.
Training
- More one-on-one time between experienced drivers and recruits undergoing OC Transpo's New Bus Operator Training (NBOT) program.
- A dedicated fleet of buses for training purposes to help ensure recruits get adequate time on all bus types in spite of fleet availability issues.
- Enhanced new driver training on emergency braking and the existing prohibition on cell phone use while driving.
Accident oversight
- Having the federal government consider making the Transportation Safety Board of Canada investigate serious bus transit collisions that involve deaths.
The entire list of recommendations can be viewed here.
The jurors also declared the Westboro crash an accident. Other choices included homicide, natural causes and suicide.
The city said via email that it appreciates the work of the jury and that staff are committed to carefully reviewing each recommendation and will provide a response to city councillors "in due course."
"The City of Ottawa recognizes this is a difficult time for friends and family impacted by the 2019 Westboro bus collision, and the entire community," said the statement attributed to interim city solicitor Stuart Huxley.
The inquest has concluded as the city and ATU Local 279 prepare to negotiate a new contract after their last expired in March.
"I don't think any of the recommendations will factor into these particular negotiations," Vineberg said. "A lot of these items have been on the table for a long time and we work very well alongside management and both sides."
WATCH | Looking back on the Westboro crash and its lingering impacts:
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with files from Julie Delaney