Place du Centre
4th Floor
200 Promenade du Portage
Gatineau, Quebec
K1A 1K8
617-10/14
R13T0192
24 September 2014
His Worship Jim Watson
Mayor, City of Ottawa
110 Laurier Avenue West
Ottawa, Ontario
K1P 1J1
Dear Mayor Watson:
SUBJECT:
RAIL SAFETY ADVISORY LETTER –10/14
Video Monitoring System on OC Transpo Double Decker Buses
At 0832 EDT on 18 September 2013, westward VIA passenger train No. 51 (the train) departed
Ottawa VIA Station on time and proceeded en route to Toronto. At 0847, OC Transpo double
decker bus No. 8017 (the bus) departed OC Transpo Fallowfield Station on the OC Transpo Bus
Transitway (Transitway). At 0848, while proceeding at about 47 mph, the train entered the
Transitway crossing located at Mile 3.30 of VIA Rail’s Smiths Falls Subdivision (the crossing)
and was struck by the northbound bus. As a result of the collision, the front of the bus was
sheared off. The train, consisting of 1 locomotive and 4 passenger coaches, derailed but
remained upright. Among the bus occupants, there were 6 fatalities, 8 serious injuries and
approximately 25 minor injuries. No VIA crew members or passengers were injured.
The Smiths Falls Subdivision consists of single main track that extends from near the Ottawa
VIA Station (Mile 0.0) to Smiths Falls, Ontario (Mile 34.40). From Monday to Friday, up to
21 passenger trains and 2 freight trains operate over the crossing each day. The authorized train
speed in the vicinity of the crossing is up to 100 mph. However, trains depart VIA’s Fallowfield
Station at 10 to 15 mph and VIA trains arriving at the station are slowing to stop.
The Transitway is a 2-lane asphalt road that is restricted to transit (bus) traffic. Transitway
traffic comprises about 1000 buses per weekday. From the OC Transpo Fallowfield Station, the
Transitway extends for 812 feet (247.5 m) eastward towards Woodroffe Avenue. From that
point, the Transitway transitions into a left-hand curve (in the direction of travel) that turns
northward where it runs parallel and adjacent to Woodroffe Avenue (see Appendix 1). From
the stop sign at Fallowfield Station, the roadway speed limit at the time of the accident was
60 km/h up to just north of the crossing, where the speed limit changed to 90 km/h.
The crossing traverses the Transitway at a 50-degree angle. It is equipped with Automatic
Warning Device (AWD) protection that includes flashing lights, bells, gates and constant
warning time track circuits. At the time of the accident, the crossing protection was operating as
intended with no malfunctions. The gates were fully horizontal for 26 seconds prior to impact.
.../2
-2All double decker buses at OC Transpo were designed and manufactured by Alexander Dennis
Limited (ADL) in the United Kingdom. A total of 657 ADL double decker buses currently
operate in Canada and the United States. This includes 60 buses in Victoria, British Columbia,
14 buses in Sherwood Park, Alberta, 127 buses in Toronto, Ontario, and 75 buses at OC Transpo.
All ADL double decker buses are equipped with a video monitor that provides the driver with
interior views and exterior views of the bus. In the United Kingdom, where these buses are also
operated, optical or other devices are required to allow the driver to be able to see the interior of
all service doors and within the vicinity/area around the staircase on the upper deck. 1
Although there are no similar requirements in Canada, all ADL double decker buses are
delivered to clients equipped with the video monitor. The client determines which views are
presented on the monitor.
Within the driver workstation of an ADL double decker bus, the video monitor is located on the
left side of a forward panel above the driver seat (see Photo 1). The location of the monitor
creates a significant upwards viewing angle for the driver (i.e., 30 to 40 degrees from the
horizontal). The location and angle of the monitor is not adjustable, images are not recorded,
there is no sound provided and the driver is not able to turn the display off or change the
camera views.
The video monitor measures 6” (15 cm) wide by 3 ¾” (10 cm) high. The monitor is divided into
4 quadrants, each measuring 3” (7.5 cm) wide by 1⅞” (5 cm) high. Each quadrant shows a view
from 1 of 4 on-board video cameras (see Photo 2).
Photo 1. Bus driver workstation on double decker
bus
Photo 2. Driver’s view of video monitor quadrants
At OC Transpo, the 4 quadrant views have been fixed in a standard configuration on all double
decker buses as follows:

the lower left image displays the side doors;

the upper left image displays the stairwell;

the lower right image displays the upper deck; and

the upper right image displays the exterior rear of bus.
…/3
1
European Commission Directive 2001/85/EC and United Nations Economic Commission for
Europe Regulation No. 107.04.
-3When reverse gear on the bus is selected, the video monitor goes blank for 1 or 2 seconds and
then displays the exterior rear camera view in full screen with guiding arrows to assist the
driver with reversing manoeuvres. OC Transpo drivers are required to have an additional
person guide them when reversing a bus.
With respect to the video monitor, OC Transpo provides the following guidance:

Drivers are instructed not to stare at the video monitor while driving.

At station stops, OC Transpo drivers are required to view the monitor before departing
to ensure that upper deck passengers are seated.

If passengers are seen to be standing on the upper deck, drivers are required to make an
announcement informing the passengers that standing is not permitted on the upper
deck or in the stairwell. While signs are posted on the side of the stairwell and on the
lower deck indicating that standing on the stairs while the bus is in motion is not
permitted, there are no signs on the upper deck indicating that standing is not allowed.
When the bus is moving, to observe the video monitor, a driver must alternate his/her gaze
from the roadway view ahead to the video monitor upwards and to the left. The upward
viewing angle of the video monitor combined with the small image displayed on the 4-quadrant
screen will normally result in the driver’s eyes being directed completely away from the
forward roadway while looking at the screen. Research has determined that driver eye glances
away from the forward visual scene, especially glances lasting 2 seconds or longer, are
significantly associated with accidents and near-accidents. 2
To find available seating after boarding a double decker bus, some passengers may be moving
or standing on the upper deck after the bus is in motion. Under these conditions, to monitor the
upper deck, a driver will need to periodically glance at the screen while the bus is in motion.
This situation can lead to a driver being visually distracted from the driving task.
A number of events occurred between the time the bus departed the OC Transpo Fallowfield
Station and came to rest following the accident. 3 To summarize:

At 0846:24, the bus arrived at the OC Transpo Fallowfield Station, south side bus shelter.

At 0846:53, the bus side door closed. People continued to board the bus at the front door.

At 0847:20, as passengers continued to board, the driver asked a group of 3 or 4
passengers standing near him to move behind the yellow line on the floor so that his
vision would not be restricted. The driver then looked at the video monitor and
announced to passengers standing on the lower deck that there were still seats available
on the upper deck.
.../4
2
3
S.G. Klauer et al., The Impact of Driver Inattention on Near-Crash/Crash Risk: An Analysis Using the
100-Car Naturalistic Driving Study Data, U.S. Department of Transportation, National Highway
Traffic Safety Administration, DOT HS 810 594, April 2006.
The events were recorded from various sources including the train, the crossing signals, the bus
and video cameras at the OC Transpo Fallowfield Station. Some event times for activities that
occurred on board the bus have been approximated based on various witness accounts of what
transpired. Event times have been normalized to coincide with the locomotive event recorder
(LER).
-4
At 0847:23, a passenger accessed the upper deck while the bus was stopped but did not
see any available seats. The passenger remained standing on the upper deck and held on
to a pole at the top of the stairs (see Photo 3 for simulated passenger standing). The
passenger remained in this position until the time of the accident.
Photo 3. Monitor display with simulated passenger standing in location on the
upper deck

At 0847:27, with the lower deck seating full and a number of passengers standing on the
lower deck, the bus began to move and departed the OC Transpo Fallowfield Station.

At 0847:57, while the bus was travelling towards the crossing, the driver looked
upwards and to the left towards the video monitor, likely noticing that a passenger was
standing on the upper deck.

At 0847:59, the bus passed the point at which all of the red flashing lights at the
Transitway crossing came into full view, about 397 feet (121.0 m) from the south
crossing stop line.

At 0848:01, the driver continued to monitor the video screen, glancing towards it
intermittently while looking towards the road ahead.

At 0848:02, with the bus travelling at 42 mph (67.6 km/h) and with throttle (gas pedal)
on, passengers began yelling for the driver to stop the bus.

At 0848:03, the driver began to apply the bus brakes.

At 0848:06, with the bus speed reduced to 4.8 mph (7.7 km/h) and with no throttle on
and the brakes applied, the bus collided with the south side of the train.
.../5
-5As part of the joint U.S.-Canada Regulatory Cooperation Council (RCC) agreement, Canada and
the U.S. have pledged to work together on auto safety issues, which include distraction. 4 In
April 2013, driver distraction guidelines 5 were published in the United States. The guidelines
are based on the fundamental principle that a driver’s eyes should be looking at the road ahead
rather than at an in-vehicle device. The guidelines are designed to encourage automakers to
forego in-vehicle systems that require the manual input of data while a vehicle is in motion, or
that require unreasonably long glances away from the forward visual scene. The guidelines
recommend:

Disabling certain in-vehicle system operations unless the vehicle is stopped and in park.

Locking out video displays and making them inaccessible to the driver while driving.

Locating any active displays as close as practicable to the driver’s forward line of sight,
with a maximum viewing angle of 30 degrees downward from horizontal.
The perils of distracted driving have been well documented. Many jurisdictions, including the
Province of Ontario, now have laws 6 in place to limit the opportunity for driver distraction.
However, for the OC Transpo double decker bus, the video monitor was deemed to be
necessary for the operation of the bus and was therefore exempt from the Ontario Highway
Traffic Act restricting the use of display screens.
Given the importance of minimizing driver distraction, the City of Ottawa may wish to review
the procedural/operational aspects of the video monitor on double decker buses to ensure that
safe bus operation is always maintained.
We would appreciate if you would inform us of any safety measures you plan to implement.
We will take these measures into consideration as part of our ongoing investigation.
Yours sincerely,
Original signed by
Kirby Jang
Director
Investigations, Rail/Pipeline
4
5
6
P. Burns, Emerging Technologies, Emerging issues, presented at the International Conference on Distracted
Driving, Toronto, 01 March 2012, available at
http://www.distracteddriving.ca/presentations/EmergingTechnology-SpeakerBurns.pdf.
U.S. Department of Transportation, National Highway Traffic Safety Administration, VisualManual NHTSA Driver Distraction Guidelines for In-Vehicle Electronic Devices, Federal
Register,Volume 78, No. 81, 26 April 2013, available at http://www.gpo.gov/fdsys/pkg/FR2013-04-26/pdf/2013-09883.pdf.
Ontario Highway Traffic Act, R.S.O. 1990, last amendment: 2012. On 26 October 2009, a ban on
hand-held devices became law (Ontario Regulation 366/09).
cc:
Kash Ram
Director General, Road Safety and Motor Vehicle Regulation
Transport Canada
Luc Bourdon
Director General, Rail Safety
Transport Canada
Kent Kirkpatrick
City Manager
City of Ottawa
John Manconi
General Manager, Transit Services
City of Ottawa
Jean Tierney
Senior Director, Safety, Security & Risk Management
VIA Rail Canada Inc
Marc Tessier
Director, Corporate Security & Regulatory Affairs
VIA Rail Canada Inc.
Nicolas Panetta
Manager, Risk Management
VIA Rail Canada Inc.
Colin Robertson
President & Chief Executive Officer
Alexander Dennis Limited - United Kingdom
Stephen Walsh
Vice-President, North America
Alexander Dennis Inc.
617-10/14
BACKGROUND INFORMATION
TSB Occurrence:
R13T0192 (Class 2)
CONTACTS:
Rob Johnston
Investigator-in-Charge (IIC)
Manager, Head Office & Central Region
TSB Ottawa, ON
819-956-8736
Appendix 1 – Site Diagram