The jury at a coroner’s inquest into the fatal 2019 OC Transpo bus crash at Westboro Station has made 60 recommendations for improving safety and bus operator training with the aim of preventing future collisions. Judy Booth, Bruce Thomlinson and Anja Van Beek were killed when their double-decker bus slammed into a bus shelter overhang at Westboro Station on Jan. 11, 2019. The jury deemed each of their deaths accidental. The city accepted civil responsibility for the crash in 2020. The bus driver charged with dozens of counts of dangerous driving causing death or bodily harm, Aissatou Diallo, was acquitted of all charges in 2021. Diallo was called to testify at the inquest but did not. The jury made recommendations to the City of Ottawa to improve safety around transit infrastructure and enhance training for new bus drivers. None of the recommendations is binding. Among the recommendations is one to reduce the approach speed for buses approaching transitway stations to 30 km/h, remove canopies from stations or replace them with safer alternatives, and to install physical countermeasures that would prevent an errant bus from crashing into a station platform. The recommendations also call for establishing a dedicated way for the public to contact the city or OC Transpo at any time to report possible safety concerns. The inquest had heard that there had been several collisions at Westboro Station, before it was decommissioned due to LRT construction. Greater oversight of construction projects related to public transit was also recommended, particularly those that require temporary road markings, which was another issue raised at the inquest. The inquest heard that road markings that a judge attributed as one of the factors leading to the deadly crash should have been mechanically removed by a contractor and not painted over. The lines heading to the transitway station had been painted orange in 2018 in order to redirect traffic during a construction project, but had been painted over with black paint, instead of removed, and the paint had worn off by the time of the crash in 2019. The jury recommended that the contract administrator is to remind the contractor of the requirement to physically remove pavement markings via the issuance of a site-specific instruction and that a 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. Twelve of the recommendations concerned driver training, including ensuring that new drivers have proven proficiency on all bus types before being allowed to operate with passengers, ensuring that drivers have more familiarity with transit routes, and improving training about the risks of driver fatigue, distraction and other human factors. In addressing fatigue and distraction, the jury recommended driver-facing cameras be installed in all buses that would allow for “real-time feedback to transit operators regarding potential distraction, fatigue and unsafe driving behaviour.” Recommendations around remedial training, for drivers who are involved in serious, preventable collisions, were also raised. The inquest had heard that Diallo was involved in a collision the month prior to the fatal crash when the articulated bus she was operating collided with a parked bus at St. Laurent station. The cause of that crash was operator error and failing to adjust speed to road conditions. Diallo was placed on a three-week leave and had to complete “skills building training” before resuming work that included reviewing driving procedures, mirror use and steering techniques. The jury recommended that the city 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, and that remedial skills building training address the circumstances of previous collisions in a “trauma-informed manner.” Some recommendations were also made to the Ontario Ministry of Transportation with regard to driver certification, including establishing mandatory minimum drive time requirements on each C class licence vehicle, such as a bus. It also recommended the MTO adopt mandatory standards for driver-facing cameras. A similar request was also made to Transport Canada. The final recommendation called on the City of Ottawa, the Province of Ontario, and the federal government to seek, secure and maintain funding to support the implementation of the jury’s recommendations. List of jury recommendations
