Place du Centre

Place du Centre

4th Floor

200 Promenade du Portage

Gatineau, Quebec

K1A 1K8617-12/14R13T0192

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 – 12/14

Braking Analysis and Bus Speed Approaching Crossings

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. Since the accident, the roadway speed approaching the crossing has been reduced to 50 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 horizontal for 26 seconds prior to impact. .../2

- 2 -

All double decker buses at OC Transpo were designed and manufactured by Alexander Dennis Limited (ADL) in the United Kingdom. The bus was an Enviro 500 (E500) double decker model, manufactured in August 2012. It was delivered to OC Transpo in September 2012. A series of mandatory certification tests had been conducted to verify compliance with the Canada Motor Vehicle Safety Standards (CMVSS). Upon delivery of the bus, an Ontario Ministry of Transportation (MOT) inspection was performed on 21 September 2012 with no exceptions noted. The vehicle met or exceeded all required criteria for operation in Canada.

The bus did not have a single event recorder to store vehicle performance and operation data (i.e. black box). However, there were a number of electronic units that contained Non-Volatile-Memory (NVM). A total of 8 units [footnoteRef:1] were recovered and all available data were downloaded and examined at the TSB Engineering Laboratory. The review of the recovered modules was completed by May 2014. Only the Engine Control Module (ECM) contained any information relevant to the operation of the bus just prior to the accident (see Appendix 2). While the ECM data were useful, they lacked sufficient detail to conduct a meaningful analysis. Subsequently, an examination of the bus braking system and a braking analysis were required. [1: The units included the anti-lock braking system/anti-slip regulation (ABS/ASR) control module, the central controller, the transmission control module (TCM), the heating-ventilation and air conditioning (HVAC) system memory, the automatic fare recording Presto units, the Intelligent Vehicle Network (IVN) system, Global Positioning System (GPS) data from the City of Ottawa and the Engine Control Module (ECM).]

Examination of the bus braking system was completed in June 2014 and determined that:

The bus design met or exceeded all requirements of the CMVSS 121: Air Brake System.

The bus was being maintained in accordance with the operator’s approved maintenance program.

There were no reported brake defects on the occurrence bus.

There were no mechanical discrepancies identified that would preclude normal operation of the air brake system. When brakes were applied, the bus deceleration was within the design criteria for braking.

The braking analysis was performed to determine event timing, braking distance and amount of brake force applied to a loaded bus during the accident scenario. The analysis incorporated measurements and observations made on site immediately following the accident and detailed engineering calculations based on ECM data, brake system reaction time and brake performance charts from both the bus certification tests and manufacturer tests. This work was completed in August 2014 and the following observations and calculations were made:

The ECM data indicate that the initial application of the bus brakes occurred when the bus was travelling at a speed of 42 mph (67.6 km/h), which exceeded the posted speed limit of 60 km/h (37.3 mph).

The speed of the bus was between 4 and 4.8 mph (6.4 to 7.7 km/h) when it initially collided with the train. The bus moved a further 4.3 feet (1.3 m) in the forward direction after the initial impact.

The bus was 116.8 feet (35.6 m) away from the point of collision when braking was initiated.

ECM data indicate that full braking force was not initially applied.

…/3

- 3 -

If full braking force had been applied from the beginning of the brake application and assuming a constant deceleration of 0.6 g, [footnoteRef:2] the stopping distance for the bus was calculated to be 112.5 feet (34.1 m). [2: 0.6 g is the manufacturer’s minimum value specified for deceleration (1g is equal to an acceleration / deceleration of 32.1 ft/s2 or 9.8 m/s2).]

Because the exact load on the bus at the time of the accident is not available, the actual bus load may have been greater than the load used for the CMVSS braking tests. Any additional load would also increase the stopping distance, in which case, there may not have been sufficient distance to stop the bus from the point at which the brakes were initially applied.

In order to assess the influence that speed may have had, additional calculations were performed based on the posted speed limit of 60 km/h (37.3 mph) with the following results:

The stopping distance for a bus travelling at the posted speed limit (60 km/h), with all other factors remaining the same, would have been 29.5 m (96.8 feet), which would be 6.1 m (20 feet) before the point of collision.

Even a modest increase of 7.6 km/h in excess of the posted speed limit can significantly increase the stopping distance required to bring a vehicle to a stop, particularly in emergency situations.

On 25 February 2014, the TSB issued Rail Safety Advisory Letter (RSA 01/14), entitled OC Transpo Buses Traversing Crossings with Activated AWD Protection, to the City of Ottawa. The letter indicated that it is imperative that all roadway vehicle drivers slow down when approaching any railway crossing, look both ways, be prepared to stop and yield the right-of-way to a train. The letter suggested that the City of Ottawa put appropriate measures in place to ensure that buses are able to stop safely in advance of an activated railway crossing signal.

In response to RSA 01/14, the City of Ottawa implemented the following actions:

· On 28 February 2014, OC Transpo issued Bulletin No. 050/14, entitled Safety at Railway Crossings to all operators (drivers), transit supervisors and dispatchers. The bulletin noted that, when approaching a railway crossing, drivers are to observe posted speed limits, slow down, listen and look both ways before crossing the tracks.

· On 02 May 2014, OC Transpo and the Amalgamated Transit Union (ATU) jointly issued a handout, entitled Railroad Crossings, Important Information for all Operators, to all drivers. Amongst other points, the handout reinforced that, when approaching a railway crossing, drivers are to observe posted speed limits, slow down, listen and look both ways before crossing the tracks.

In June 2014, the TSB conducted a number of speed tests on the Transitway from a location near the crossing. The speed test results are summarized as follows:

Date

(2014)

Total Vehicles

Recorded

< = 50 km/h

51-55 km/h

56-60 km/h

61-65 km/h

66-70 km/h

+ 70 km/h

Total >50 km/h

17 June

73

58

10

2

2

-

1

15

18 June

254

194

37

18

4

1

-

60

19 June

152

105

31

10

3

3

-

47

25 June

191

144

27

12

2

5

1

47

Total # vehicles

670

501

105

42

11

9

2

169

.../4

- 4 -

OC Transpo has taken some steps to raise driver awareness of railway crossing safety and to reinforce the need for its drivers to slow down. However, a number of drivers continue to travel in excess of the posted speed limit in the vicinity of the crossing. Engineering analysis has identified that even a modest increase in excess of the posted speed limit can significantly increase the bus stopping distance. Therefore, the City of Ottawa may wish to implement additional measures to monitor and control bus speed, particularly in the vicinity of railway crossings.

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

Cc:Kash Ram

Director General, Road Safety and Motor Vehicle Regulation

Transport Canada

kash.ram@tc.gc.ca

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.

617-12/14

BACKGROUND INFORMATION

TSB Occurrence:R13T0192 (Class 2)

Contacts:Rob Johnston

Investigator-in-Charge

Manager, Head Office & Central Region

TSB Ottawa, ON

819-956-8736

Appendix 1 – Site Diagram

Appendix 2 – Bus Engine Control Module Recorded Data

PowerSpec - Sudden Deceleration Data Report

Time (Seconds)

Vehicle Speed (mph)

Engine Speed (rpm)

Engine Load (%)

Throttle (%)

Brake Status

Clutch Status

Cruise Status

Lamp Status

-39

0

735

60.2

38.9

-

-

-

-

-38

0

942

48.8

42.1

-

-

-

-

-37

2

1079

65.6

81.8

-

-

-

-

-36

4

1404

71.9

88.9

-

-

-

-

-35

7

1760

85.2

89.0

-

-

-

-

-34

9

1855

84.4

89.0

-

-

-

-

-33

11

1801

85.2

89.1

-

-

-

-

-32

13

1854

84.4

88.9

-

-

-

-

-31

15

1849

84.4

89.1

-

-

-

-

-30

17

1575

88.7

89.1

-

-

-

-

-29

19

1329

93.4

89.1

-

-

-

-

-28

20

1398

93.4

89.1

-

-

-

-

-27

22

1495

91.0

89.1

-

-

-

-

-26

23

1438

91.8

89.1

-

-

-

-

-25

24

1152

99.6

89.1

-

-

-

-

-24

25

1208

98.0

89.1

-

-

-

-

-23

26

1254

95.7

89.1

-

-

-

-

-22

27

1306

93.8

89.1

-

-

-

-

-21

28

1354

93.4

89.1

-

-

-

-

-20

30

1401

93.4

89.0

-

-

-

-

-19

30

1444

92.2

89.1

-

-

-

-

-18

31

1484

91.0

89.1

-

-

-

-

-17

32

1513

89.8

89.1

-

-

-

-

-16

33

1156

98.8

89.1

-

-

-

-

-15

34

1184

99.6

89.1

-

-

-

-

-14

35

1206

98.4

89.1

-

-

-

-

-13

35

1234

96.9

89.1

-

-

-

-

-12

36

1256

95.7

89.1

-

-

-

-

-11

37

1275

94.9

89.1

-

-

-

-

-10

37

1307

93.4

89.0

-

-

-

-

-9

38

1323

85.5

83.2

-

-

-

-

-8

39

1345

65.6

68.8

-

-

-

-

-7

39

1359

66.4

69.4

-

-

-

-

-6

40

1373

92.6

88.4

-

-

-

-

-5

40

1397

92.6

88.6

-

-

-

-

Time (Seconds)

Vehicle Speed (mph)

Engine Speed (rpm)

Engine Load (%)

Throttle (%)

Brake Status

Clutch Status

Cruise Status

Lamp Status

-4

41

1422

92.2

88.7

-

-

-

-

-3

41

1444

91.4

88.8

-

-

-

-

-2

42

1270

94.5

88.6

-

-

-

-

-1

42

1250

0.0

0.0

-

-

-

-

0

35

1004

0.0

0.0

On

-

-

-

1

25

708

0.0

0.0

On

-

-

-

2

5

659

20.3

0.0

On

-

-

-

3

2

285

0.0

0.0

On

-

-

On

4

0

51

0.0

0.0

On

-

-

On

5

0

0

0.0

0.0

On

-

-

On

6

0

0

0.0

0.0

On

-

-

On

7

0

0

0.0

0.0

On

-

-

On

8

0

0

0.0

0.0

On

-

-

On

9

0

0

0.0

0.0

On

-

-

On

10

0

0

0.0

0.0

On

-

-

On

11

0

0

0.0

0.0

On

-

-

On

12

0

0

0.0

0.0

-

-

-

-

13

0

0

0.0

0.0

-

-

-

-

14

0

0

0.0

0.0

-

-

-

-

15

0

0

0.0

0.0

-

-

-

-