OTTAWA -- The Transportation Safety Board says driving distractions, speed and roadway configuration were among a multitude of factors that led to a deadly 2013 collision in Ottawa between a city bus and a Via Rail train.

In its final report on the crash -- six people on board the double-decker OCTranspo bus were killed, including the driver -- the board concluded that a number of factors conspired together in the moments before impact.

"Given the same circumstances, this accident could have happened to just about any driver," said Rob Johnston, the lead investigator.

The board concluded that the driver's view of the road was obstructed by foliage as the bus approached the crossing just as the train was coming into its path. The driver was also distracted by an on-board video monitor and passenger conversations, the report said.

The board had already concluded that the bus was in good mechanical shape, the brakes were working and there were no drugs or alcohol involved.

"This complex investigation identified 15 inter-related findings that played a part in this tragedy," said board chairwoman Kathy Fox.

"Remove even one, and this may have had a very different outcome. But because of this accident, we are calling for concerted action to reduce the risk of railway crossing accidents."

To address what it calls major safety deficiencies identified during the investigation, the board made five recommendations.

They cover the installation and use of in-vehicle video displays on buses, crashworthiness standards, data recorders for commercial passenger buses, and grade separations at busy railway crossings, both in Ottawa and across Canada.


In the report, which was released on Wednesday, the board recommended:

  • The Department of Transport, in consultation with the provinces, develop comprehensive guidelines for the installation and use of in-vehicle video monitor displays to reduce the risk of driver distraction.
  • The Department of Transport develop and implement crashworthiness standards for commercial passenger buses to reduce the risk of injury.
  • The Department of Transport require commercial passenger buses to be equipped with dedicated, crashworthy, event data recorders.
  • The Department of Transport provide specific guidance as to when grade separation should be considered.
  • The City of Ottawa reconsider the need for grade separations at the Woodroffe Avenue, Transitway, and Fallowfield Road level crossings.