TSB Rail Safety Advisory Letter re: OC Transpo buses traversing crossings with activated AWD protection

TSB Rail Safety Advisory Letter re: OC Transpo buses traversing crossings with activated AWD protection
Posted on March 31, 2014 | Unpublished Admin | Written on February 25, 2014
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Publisher

Publisher:
Transportation Safety Board

Author's Note:

Author's Note:

On Feb. 25th, the Transportation Safety Board of Canada issued two letters to the City of Ottawa regarding their investigation into the OC Transpo Via Rail bus crash on September 18, 2013. This is the first letter of the two.

Below the letter you will find the City's response in a memo to the Mayor and City Council from Deputy City Manager Steve Kanellakos.

Click here to read the 2nd letter.

25 February 2014

His Worship Jim Watson
Mayor, City of Ottawa
110 Laurier Avenue West
Ottawa, Ontario
K1P 1J1

Subject:

RAIL SAFETY ADVISORY LETTER – 01/14
OC Transpo buses traversing crossings with activated AWD protection

Dear Mr. Mayor:
 
At 0832 EDT on 18 September 2013, westward VIA passenger train No. 51 (the train) departed Ottawa VIA Station on time and proceeded westward en-route to Toronto. At 0847, OC Transpo Double Decker (DD) Bus No. 8017 (the bus) departed Fallowfield Station on the OC Transpo Bus Transitway (Transitway). At 0848, while proceeding at about 47 mph, the train entered the OC Transpo 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, comprised of 1 locomotive and 4 passenger coaches, derailed but remained upright. Among the bus occupants, there were 6 fatalities, 5 serious injuries and 30 minor injuries reported. No VIA crew members or passengers were injured.
 
The Transitway is a 2-lane asphalt road that is restricted to transit (bus) traffic. It extends from the OC Transpo Fallowfield Station 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 is 50 km/h Footnote 1 up to just north of the crossing, where the speed limit changes to 90 km/h. Traffic on the Transitway comprises about 1000 buses per weekday.
 
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). Train movements are governed by the Centralized Traffic Control System as authorized by the Canadian Rail Operating Rules (CROR) and supervised by a Rail Traffic Controller (RTC) located in Dorval, Quebec. About 14 passenger trains per day operate over the crossing. The authorized train speed in the vicinity of the crossing is up to 100 mph. However, trains departing VIA's Fallowfield Station are restricted to 10 – 15 mph until they are clear of the crossings at Woodroffe Avenue and Fallowfield Road, respectively. Likewise, VIA trains arriving at the station are slowing to stop.
 
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. Based on the data download from the signal bungalow, it was determined that:
  • the crossing lights, bells and gates were activated about 47 seconds prior to the accident;
  • once activated, the crossing lights flash/bells sounded for about 12 seconds before the gates began to descend;
  • it took an additional 12 seconds for the gates to fully deploy; and
  • the gates were fully horizontal for 25 seconds prior to impact.

Since the accident, there have been 4 reports of an OC Transpo bus travelling over a crossing while the lights and bells of the AWD crossing protection were activated. These incidents are not normally reportable to the Transportation Safety Board of Canada (TSB). However, in light of the accident and in response to heightened public concern, the TSB has followed up on these incidents as part of its ongoing investigation (R13T0192). Each of the following cases occurred at the Transitway crossing:

  1. On 01 October 2013, at about 0745, a northbound articulated bus (Route 73), which had departed OC Transpo's Fallowfield Station, approached the crossing when the lights and bells activated. The driver indicated that the bus was about 30 feet from the crossing at the time and observed a westbound train about 1 km to the east. As the crossing gate had not yet descended, the driver believed that it was safe to proceed. In addition, since the bus was full and a number of passengers were standing, the driver believed that the bus could not be stopped without putting passengers at risk and proceeded through the crossing while the AWD was activated.
  2. On 11 October 2013, at about 1848, a southbound DD bus (Route 77) proceeded through the crossing while the lights and bells were activated as an eastbound train was departing VIA's Fallowfield Station. At the time, the bus was travelling southbound on the Transitway enroute to OC Transpo's Fallowfield Station. The bus approached the crossing at just under 60 km/h when the crossing lights and bells activated. The driver indicated that the bus was about 15 feet from the crossing and the gates had not descended. The driver believed that the bus could not be stopped safely without putting passengers at risk.
  3. On 30 October 2013, at about 1940, a southbound bus (Route 95) proceeded through the crossing while the crossing lights and bells were activated as a train approached. A review of OC Transpo GPS data determined that the bus was travelling at 58 km/h (8 km/h over the speed limit). OC Transpo Transportation department stated that it was “not illegal to go through flashing train lights.” Several days later, an OC Transpo Supervisor met with the driver and suggested that the driver “hover” over the brake when approaching a railway crossing and to be prepared to stop when the crossing lights are activated.
  4. On 27 January 2014, at about 0745, it was reported that a southbound OC Transpo bus had proceeded through the crossing while the lights and bells were activated. Follow-up by OC Transpo determined that the bus involved was northbound, travelling at 52 km/h at the time. The bus was running 27 minutes behind schedule due to poor driving conditions during a winter storm. The driver indicated that the bus was about 20 feet from the crossing when the lights and bells activated. However, a bus passenger suggested that the bus was about 100 metres from the crossing at the time. Believing that the bus could not be stopped safely without putting passengers at risk, the driver proceeded through the crossing while the lights and bells were activated.

Based on the 4 OC Transpo reports, the following observations were made:

  • Two cases involved northbound buses and 2 involved southbound buses. Although the City of Ottawa had previously committed to install advance warning lights (prepare to stop) on the northbound approach, the cases involving southbound buses suggest that additional measures on both sides of the crossing may be required.

  • One driver was driving just over the speed limit even though the road conditions were very poor due to a winter storm. Vehicle drivers are expected to drive safely according to posted speed limits and road conditions. When driving conditions are poor, even driving the speed limit may be unsafe when approaching a railway crossing.

  • In 3 of the 4 cases, the drivers indicated that the bus was within 15 – 30 feet from the crossing when the lights activated. They believed that the bus could not be stopped safely without putting passengers at risk. One of the cases was contradicted by a passenger who suggested the crossing lights activated when the bus was about 100 metres from the crossing. At 100 metres, there would likely have been sufficient time to safely stop the bus in advance of the crossing, if driving was appropriate for the road conditions.

  • The bus drivers in these occurrences approached the crossing at or slightly above the posted roadway speed without being prepared to stop. Roadway signage is posted alongside most public roads and guidance for the use of signage is detailed by the Manual of Uniform Traffic Control Devices (MUTCD) for Canada. Vehicle drivers are trained to observe the roadway signage and take appropriate action as required. Among the primary roadway signs are “Regulatory” signs which include the STOP, YIELD and RAILWAY CROSSING signs (See Figures 1 to 3).

Figure 1. Stop sign

Figure 2. Yield sign

Figure 3. Crossing sign

 

The railway crossing sign is X-shaped. With its white background and red outline, it has similar coloring to a Yield sign and means essentially the same thing. As outlined in the Ontario Ministry of Transportation Driver's Handbook, the railway crossing sign warns that railway tracks cross the road and drivers should slow down when approaching a crossing, be prepared to stop and yield the right of way to a train.

  • There is about a 12 second delay between the time the signals activate and the time that the gate begins to descend. The time delay is a safety feature built into the crossing system that allows a vehicle that has entered the crossing zone adequate time to clear before the arrival of a train. While crossing signals are generally reliable, there may be situations where the gate does not come down. If this occurs, a decision to “run” the crossing before the gate drops may place the vehicle at risk.
  • It was suggested that it is not illegal to drive through activated crossing signals. Failing to stop at railway crossing signals when activated is a violation under Section 163 of the Ontario Highway Traffic Act (OHTA). However, the OHTA does not apply to vehicles operating on the Transitway as the Transitway is a private road.

The operation of vehicles on the Transitway is governed by Ottawa City BY-LAW NO. 2007 – 268 Respecting Public Transit (enacted 13 June 2007). The BY-LAW contains no provision that requires vehicles to stop at a railway crossing signal when activated which renders a violation under the OHTA unenforceable on the Transitway.

  • Operation Lifesaver (OL) is a national public awareness program aimed at educating Canadians about the hazards surrounding rail property and trains. OL indicates that opportunities for improving crossing safety include: Education for vehicle drivers on risks associated with railway crossings, Engineering to improve crossing protection, and Enforcement of crossing violations to reinforce safe driving habits. A weakness in one or more of these elements at a crossing may increase the risk of a crossing accident.

While these 4 incidents involved OC Transpo buses proceeding through activated railway crossing signals, similar situations can happen anywhere in Canada. Trains always have the right of way at railway crossings. Even when train emergency brakes are applied, the train will require a great distance to stop. To reduce crossing accidents, 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.

With regards to these specific incidents and in consideration of public concern, the City of Ottawa may wish to put appropriate measures in place to ensure that buses are able to stop safely in advance of an activated railway crossing signal.

We would appreciate if you can 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:

Mr. Luc Bourdon,
Director General,
Rail Safety
Transport Canada

Mr. Kent Kirkpatrick

City Manager
City of Ottawa

Mr. John Manconi

General Manager Transit Services
City of Ottawa

 
Ms. Jean Tierney

Senior Director,
Safety, Security & Risk Management
VIA Rail Canada Inc

 
Mr. Marc Tessier

Director,
Corporate Security & Regulatory Affairs
VIA Rail Canada Inc.

 
Mr. Nicolas Panetta

Manager Risk Management
VIA Rail Canada Inc.

 

Appendices

Appendix 1 – Site Diagram

 

Appendix 1 – Site Diagram

 

Footnotes
Footnote 1

The speed limit for this portion of the Transitway was reduced to 50 km/h shortly after the accident on 18 September 2013.

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Letter Response

In response to the Transportation Safety Board's letters, Deputy City Manager Steve Kanellakos sent the following memo to Mayor Jim Watson and City Councillors on March 12th...
 

The purpose of this memorandum is to provide Members of Council and the Transit Commission with an update on the work the City has undertaken in response to the Transportation Safety Board observations presented to the City at a Technical Briefing which took place with the Transportation Safety Board (TSB) on Friday, October 11, 2013 and the TSB safety advisory letters issued on Monday February 25, 2014.

Council will recall that in the response to the Technical Briefing Observations made by the TSB on October 11, 2013, the City immediately took the following actions:

  • Removal  and trimming  of vegetation in the crossing/Transitway area;
  • Reducing  the  speed in both directions  approaching the crossing to 50 km/hour; and,
  • Enhancements to the signage in the crossing area.

In addition to this work, the City also undertook a review of the feasibility of installing an amber warning signal (a flashing light) before the crossing which may provide enhanced notice and visibility for northbound traffic. Such a warning signal would potentially be coordinated with the crossing light signal. With respect to this item, I can advise that City staff and VIA Rail are continuing their work on the proposed signal and will be recommending options in this regard shortly.

On February 25, 2014, the TSB issued two safety letters to the City. The first letter noted that the City may wish to put measures in place to ensure that buses are able to stop safely in advance of an activated railway crossing signal.  Suggested measures included reviewing the by-law that governs the operations of vehicles on Transitway, reviewing potential speed reductions, and installing an amber early warning signal for southbound traffic.

The second letter noted that OC Transpo, in conjunction with VIA Rail, may wish to develop and implement Standard Operating Procedures to ensure safe operations when unusual activations or malfunctions of crossing automated protection occur.

With respect to these Safety Letters issued on February 25, 2014, I can provide the following updates:

  • Legal Services and OC Transpo staff have reviewed City of Ottawa Transit By-law 2007-268, Schedule A, which currently governs the operations of vehicles on the Transitway and have concluded that an amendment to the By-law is justified in order to create an offence similar to what is currently found in the Highway Traffic Act to prohibit vehicles from crossing at a railway crossing when a warning of an approaching train is given. Staff are finalizing the details and will bring forward the appropriate report(s) and amendments in the near future;
  • City staff will conduct a comprehensive review of speed limits on the Transitway along the corridor from the Nepean Sportsplex to south of the Fallowfield Station, including the approaches to the railway crossing near Fallowfield Station.  The review will consider the physical design, speed of the roadway, the operating characteristics of OC Transpo buses, the sight line to traffic signals and railway crossings signals, the reaction times of operators to signals, and other physical factors such as gradient and curvature of the Transitway.  The review will follow the best safety engineering practices and also the newest draft railway crossing regulations published recently by Transport Canada, and will be conducted by qualified engineers with assistance from City staff.

Following the comprehensive review, staff will make any required adjustments to enhance signage and to improve operating practices along the Transitway, and will work with VIA Rail if any further issues are identified with the design or configuration of the railway crossing.

  • With respect to the suggestion made by the TSB of installing an amber early warning signal for the southbound Transitway traffic, I can confirm that staff are conducting the engineering review regarding a southbound signal.
     
  • I can also confirm that senior Via Rail and City staff have met to improve information sharing and to establish communications protocols between the two organizations. Integrated and comprehensive procedures are being finalized and will be implemented shortly. As an interim measure, all parties involved have confirmed contact numbers and processes for notifications.

As noted in my memorandum of February 26, 2014 to Members of Council the review of OC Transpo’s procedures for rail crossings is ongoing with work being finalized by our external engineering firm MMM Group. An update to the Transit Commission is expected for April 2014.

In addition to the work related to the TSB, I wanted to provide updates on the following work that is also being undertaken:

  • The City received a direction from Employment and Social Development Canada (ESDC) in January 2014 that advised us that in their officer’s opinion, OC Transpo had not sufficiently identified and assessed the workplace health and safety-related hazards at railway crossings where operators are required to work. While all of the railway crossings meet the applicable safety standards for design and maintenance, the ESDC direction requires the City to assess the crossings in a different way – that is, as part of the workplace for transit operators pursuant to the Canada Labour Code. The City has retained safety engineering consultants from MMM Group, and their subcontractors Flood Murray International and Human Factors North, to review this matter.  The consultants will assess the ergonomic considerations for transit operators at railway crossings and the current OC Transpo operating procedures, and define assessment methods that can be used consistently into the future. This work will include a review of Canadian and international best practices, an assessment of human factors such as driver workload, and on-site physical reviews under both summer (full foliage) and winter (bare trees) conditions.

Following this safety engineering assessment, staff will arrange for any necessary changes to operating procedures, bus configuration and road configuration and will also work with the railway companies with respect to any issues identified that are within their responsibility.

Finally, OC Transpo has taken additional measures which include:

  • Written directives to operators reminding them to:
  • Follow the Highway Traffic Act and exercise safe and defensive driving practices;
  • Watch for railway crossing flashing lights (signals).  If the lights are flashing, stop safely and well before the railway tracks;
  • Always follow the posted speed limits and, when approaching the railway crossings, slow down, hover over the brake pedal and watch for train movement in both directions of the railway tracks.  Proceed with caution; and,
  • Always be prepared to stop.
  • Daily internal radio announcements to operators to remind them to exercise caution when approaching a rail crossing, and to adhere to the posted speed limits;
  • Transit Supervisors and Special Constables have undertaken proactive speed monitoring, and conduct routine monitoring of bus operations at this and other locations. This operation is performed throughout the year at various locations on our system, as part of our safety program, In addition OC Transpo special constables will proactively enforce speed compliance on the Transitway;
  • Rail safety is covered in all New Bus Operator Training including a minimum of three visits to rail crossings;
  • All new bus operators visit the Transitway crossing at Fallowfield as part of the rail and Transitway training;
  • Licensing testing for all operators is sanctioned by Ministry of Transportation and includes a field test over a railway crossing to ensure compliance with all regulations and training;
  • The importance of adhering to and being familiar with all aspects of rail crossing procedures is addressed with operators in all employee assessments;
  • Special Constables and Fare Inspectors have been certified to present Operation Lifesaver presentations for the public, which is a rail safety education program with the goal to prevent collisions between trains and motor vehicles;
  • Operation Lifesaver, Rail Safety Operations Program or an equivalent is being assessed for operator training;
  • For any crossing incident, reporting protocols are clearly established so that staff in the OC Transpo control room has direct contact with VIA Rail and their contractor, Rail Term, in order to respond appropriately; and,  

I would like to also acknowledge the cooperative work demonstrated by all staff and unions at OC Transpo.  Their commitment to safety is recognized and appreciated. 

I will continue to report as more information becomes available.

Original signed by:

Steve Kanellakos

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