The Westboro Bus Crash Inquest Recommendations

These are the recommendations of the jury in the 2019 Westboro station bus crash inquest:

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To the City of Ottawa (“the City”):
Guiding Principles
1. The City shall ensure that all decisions regarding public transit consider safety as the prime
concern by adopting the following measures:
a. All decisions regarding fleets, infrastructure and passengers should be viewed through a
safety lens, with consideration of a safe systems approach at planning, implementation and
maintenance stages.
b. All safety decisions should be actioned in a timely, coordinated manner. To this end,
automated alarms or a “bring forward system” should be implemented for all safety
decisions.
c. A responsible person should be designated for the tracking of any safety initiatives or
responses, and these initiatives and responses should be reported on a regular basis to a
high level of authority, with clear accountability assigned.
d. Key Performance Indicators for safety should be reviewed at the highest level of Ottawa
transit decision making on a regular basis, with a focus on continuous improvement.

Infrastructure

2. The City should reduce the approach speed to transit stations located on transitways to 30 km/hr
until such time as the following conditions are met:

a. Canopies of stations with a lateral offset less than three (3) meters from the face of the curb
are either removed or replaced with a frangible structure; and,

b. Physical countermeasures, such as tapered concrete barriers or other form of guardrail, are
installed to divert an errant bus away from waiting transit customers.

3. The City should make use of traffic speed reduction strategies designed to slow down vehicles as
they approach a transit station along transitways.

4. The City should assess all bus routes on the transitway for double-decker buses for potential
intrusion hazards, both by obstructions on the carriageway and by obstructions that are within a
three (3) metre “clear zone”.

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5. The City should install radar speed signs on all bus transitways in order to encourage speed limit
compliance specifically where the speed limit transitions to a lower speed limit (e.g., approaching
a bus shelter).

6. The City should amend the Transitway and Station Design Guidelines on a regular basis to
incorporate developments in best safety practices, including Ministry of Transportation and
Transit Association of Canada Guidelines, where applicable.

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7. For all transitway construction projects, the contractor and contract administrator should identify
and discuss any safety considerations at the preconstruction meeting and record the information
in the minutes of that meeting, so that they can be appropriately tracked and addressed as the
project progresses. A responsible person should be identified to oversee this task.

8. Where a construction project involves temporary pavement markings, the following steps must
be taken:
a. The Contract Administrator is to remind the contractor of the requirement to physically
remove pavement markings via the issuance of a site-specific instruction.

b. Construction Inspector is to be present on-site when the contractor removes the markings
to ensure the work is performed in accordance with the contract.

9. The City must identify a transit planning representative responsible for attending the site following
the completion of a transitway construction project to ensure the path is clear and safe for a bus
to travel on before resuming normal operations.

10. The City should conduct proactive safety inspections of transitways at a fixed regular interval to
identify safety hazards such as potentially misleading directional lines from previous construction
projects. The interval for inspections should be at a minimum yearly.

11. The City should ensure appropriate management/removal of snow on the approach to transit
stations along the transitways.

12. The City should ensure that their response reports to road safety audits are produced in a timely
manner and provided directly to the road safety auditors who conducted the initial road safety
audit.

13. The City should incorporate the perspective of bus operators in all road safety audits.
Training
14. During New Bus Operator Training (“NBOT”), the City should assess new bus operators for
proficiency on all bus types before they are permitted to operate each bus type with passengers.

15. To allow for feedback, additional guidance and support, the City should expand the bus operator
mentorship program to ensure that:

a. Where operationally feasible, a qualified mentor should be present to observe trainees
driving each type of bus towards the end of New Bus Operator Training (“NBOT”); and,

b. New bus operators, during the first three months of their probationary period, have a
qualified mentor present to observe them driving each type of bus in revenue service for at
least one shift.

16. The City should enhance current New Bus Operator Training (“NBOT”), providing trainees with
practical in-vehicle training and assessment on emergency braking on all bus types.

17. The City should ensure that Personal Electronic Device Operational Requirement #BPTO?S001-01-OREQ is specifically reviewed during New Bus Operator Training (“NBOT”) and on an
annual basis thereafter.

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18. The City should introduce scenario-based training into New Bus Operator Training (“NBOT”) and
Remedial Skills Building Training by addressing the circumstances of previous collisions in a
trauma-informed manner.

19. The City should introduce training to the New Bus Operator Training (“NBOT”) Program designed
to ensure that new drivers are familiar with the City’s transit routes. The level of training required
can be based on drivers’ existing familiarity navigating the city.

20. The City should continue to encourage the hiring of individuals who have experience operating
buses or other commercial vehicles.

21. The City should continue to include comprehensive training focused on the risks associated with
distraction, fatigue and other human factors in the New Bus Operator Training (“NBOT”) Program.

22. For Remedial Skills Building Training following a serious collision, the City should require
continued follow up of operator performance to assess the need for further training, including
through on-road observations, on-road assessments and telematics, as appropriate.

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23. The City should examine the feasibility of upgrades or replacement of the training simulator and
reintroduce simulator training as a component of:

a. New Bus Operator Training (“NBOT”); and

b. Remedial Skills Development Training following a collision, including the recreation of
specific collision conditions and assessment of relevant skills.

24. The City should introduce dedicated buses for training, to ensure there is equal opportunity to
train on all types of buses in service and during all hours where service may be offered, such as
peak service hours. The total amount of driving time should be no less than is currently provided,
and the amount of driving time on each model should be consistent from course to course.

25. The City should establish a separate evaluation procedure for probationary operators following a
serious preventable collision. Prior to the probationary operator returning to service, the operator
shall complete professional skills building training that includes a minimum of 5 days of training
incorporating defensive driving skills and other skills identified through the collision investigation.
The professional skills building training plan shall be approved by the Chief Safety Officer.

Safety Oversight
26. The City should promote a dedicated, 24/7 means of contact for members of the public to report
any transit safety concerns. This means of contact should be advertised on buses, at bus
stations, and, to the extent feasible, on Presto Cards, amongst other options.

27. The City should increase driver license abstract checks for transit operators from twice a month
to daily, for the purpose of safety oversight.

28. The City should post a notice on all transit buses for the operator and members of the public that
communicates in appropriate language and/or infographic, for each intended audience, the duties
laid out in Personal Electronic Device Operational Requirement # BPTO-S001-01-OREQ.

29. The City should conduct an annual safety audit examining the implications of new or modified
recommendations and/or regulations relating to transitway infrastructure and transit vehicles.

Safety Data Collection and Analysis
30. The City should continue to ensure that they utilize a data-driven approach to risk prevention.

31. The City should conduct an analysis of operator incidents, such as collisions, infractions, hard
braking, or other non-safe vehicle handling, to assess whether new bus operators pose an
elevated risk in general, with specific bus types or routes. The results of this analysis should
inform updates to training, where applicable.

32. The City should develop a standard for the volume and frequency of random radar speed tests to
be conducted along all transitways using handheld radar devices. The Chief Safety Officer
should include the analysis of this data as part of the assessments of safety trends.

33. The City should designate a multidisciplinary team that is well versed in traffic safety to conduct
root cause analyses of future serious collisions involving OC Transpo buses, based on a safe
systems approach. Each root cause analysis should consider and document collision causes,
countermeasures, and recommendations for safety improvement, and should be reported to the
Chief Safety Officer.

34. The City should install telematics, similar to Geotab telematics, on at least a sample of buses
such that it provides reliable and valid metrics to be used for safety purposes. This data should
be regularly tracked by an accountable member of the governance team.

35. The City should investigate, with a view to utilizing telematics, operator-facing cameras, or other
technological options that would allow for real-time feedback to transit operators regarding
potential distraction, fatigue and unsafe driving behaviour.

36. The City should install operator-facing cameras on all OC Transpo buses to be used for safety
purposes, while ensuring appropriate protections for employees’ privacy. This data should be
regularly tracked by an accountable member of the governance team. OC Transpo can make use
of the Locomotive Voice and Video Recorder Regulations under the Railway Safety Act as
guidance for the implementation of this initiative.

Driver Assistance Technology

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37. The City should monitor speed assist systems to ensure OC Transpo is aware of new and
emerging technologies that may improve transit safety.

38. In order to incentivize transit bus manufacturers to develop driver assist technologies for future
use by OC Transpo and other municipal bus transit operators, the City should collaborate with
other municipal bus transit operators to develop bus safety standards that endorse the use of
such technologies and ensure that such standards are broadly communicated to transit bus
manufacturers. Such technologies should include, but not be limited to speed assist, lane
support and multi-collision braking systems, as well as telematics that would allow for real-time
feedback to transit operators regarding potential distraction, fatigue and unsafe driving behaviour.

To the City of Ottawa and Ministry of Transportation (“the MTO”):
39. The City should publish, in a transparent and accessible manner, available to the public and
delivered to the Ministry of Transportation (“the MTO”), key performance indicators for reducing
bus collisions.

To Alexander Dennis Limited and the City of Ottawa (“the City”):
40. Alexander Dennis Limited, in consultation with the City, should conduct a study regarding the
effectiveness of barriers at the front upper deck of double-decker buses in preventing passenger
ejections during collisions. If deemed effective, remedial measures should be undertaken to
retrofit existing buses in the City’s fleet.

To the Ministry of Transportation (“the MTO”):
Commercial Vehicle Operator’s Registration (“CVOR”)
41. Where a Commercial Vehicle Operator’s Registration (“CVOR”) certificate applies to an operator
operating both public transit and other fleet vehicles, the MTO should require a breakdown and
identification of Overall Violation Rates (“OVR”) for public transit and other fleet vehicles
separately, with separate triggers for warning letters, inspections and other interventions, in order
to best track safe practices.

42. The MTO should publish, in a transparent and accessible manner, the Overall Violation Rates
(“OVR”) for municipal transit operators in a way that allows meaningful comparison.

43. The MTO should identify municipal transit operators that achieve high safety ratings and
encourage them to mentor municipal transit operators with higher OVRs, with the intent of
sharing best practices and lessons learned in the interest of public safety.

44. In consultation with municipal transit operators, the MTO should develop a standardized root
cause analysis process for transit bus fatalities and other serious collisions, based on a safe
systems approach. This standardized root cause analysis should require that all collision causes,
countermeasures, and recommendations for improvement are considered and documented by a
multidisciplinary team that is well versed in traffic safety.

Driver Certification Program
45. The MTO should establish mandatory minimum drive time requirements on each C class license
vehicle in consultation with municipal transit operators participating in the Driver Certification
Program (“DCP”).

46. The MTO should amend the current Driver Certification Program (“DCP”) policy to require
mandatory minimum drive time requirements on each C class license vehicle that the trainee will
operate following training.

47. The MTO should require that validation audits, compliance audits and “mystery shop audits” of
public transit organizations participating in the Driver Certification Program (“DCP”) are
conducted by MTO staff or third-party auditors with specialized knowledge in operator training,
transit safety, and adult learning.

48. The MTO should require Driver Certification Program (“DCP”) audits to assess the quality as well
as the completeness of the training against objectively measurable assessment criteria including
operator performance, instructor proficiency and adult learning principles.

Roadside Evaluation Manual (2018)
49. The MTO should amend the current version of the Roadside Evaluation Manual to ensure that
crash risk assessment incorporates both the estimation of likelihood of a collision (probability)
and the severity of a collision (impact). Specifically, severity should be proportional to number of
persons in a vehicle.

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Operator-Facing Cameras
50. The MTO should consider adopting mandatory standards for operator-facing cameras on
municipal transit buses, similar to the Locomotive Voice and Video Recorder Regulations under
the Railway Safety Act administered by Transport Canada.

Fit for Duty/ Hours of Service
51. The MTO should establish a standard for municipal transit bus operations that creates a shared
responsibility to avoid unsafe driving related to fatigue. This standard should include robust
controls for duty and rest periods, fatigue management plans and self-assessment and reporting
without fear or reprisal, similar to the Duty and Rest Period Rules for Railway Operating
Employees administered by Transport Canada.

To the Government of Canada and the Transportation Safety Board (“TSB”):

52. The Government of Canada should explore expanding the mandate of the Transportation Safety
Board (“TSB”) to require investigations into serious transit bus collision fatalities.

To Transport Canada:
Research and Testing
53. Transport Canada should continue to collaborate with educational partners, such as the
University of Waterloo, in conducting research and testing related to the human body model and
appropriate computerized crash test dummies, such that bus crash injuries can be better studied
and prevented.

54. Transport Canada should conduct research and testing on any driver assistance technologies
relating to municipal transit buses that are currently on the market or that come onto the market.

55. Transport Canada should endeavour to conduct more research into the safety considerations
related to the use of double-decker buses.

Operator-Facing Cameras
56. Transport Canada should consider adopting mandatory standards for operator-facing cameras
on federally regulated municipal transit agencies, similar to the Locomotive Voice and Video
Recorder Regulations under the Railway Safety Act.

Fit for Duty/ Hours of Service
57. Transport Canada should establish a standard for federally regulated municipal transit bus
operations that creates a shared responsibility to avoid unsafe driving related to fatigue. This
standard should include robust controls for duty and rest periods, fatigue management plans, and
self-assessment and reporting without fear of reprisal, similar to the Duty and Rest Period Rules
for Railway Operating Employees.

To the Canadian Urban Transit Association (“CUTA”) and the Ontario Public
Transit Association (“OPTA”):
58. The Canadian Urban Transit Association (“CUTA”) and the Ontario Public Transit Association
(“OPTA”) should add recent serious transit bus collisions as a standing item at meetings with a
view to sharing lessons learned and developing best practices, using a safe systems approach.

59. In order to incentivize transit bus manufacturers to develop driver assistance technologies for
future use by OC Transpo and other municipal bus transit operators, CUTA and OPTA should
support members in developing bus safety standards that endorse the use of such technologies,
including speed assist, lane support and multi-collision braking systems, similar to the work being
done by Transport for London (UK).

To the City of Ottawa (“the City”), the Province of Ontario (“the Province”) and the
Government of Canada:
60. The City, the Province and the Government of Canada should seek, secure and maintain funding
to support the implementation of the above recommendations.

For You:

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