Assessment of the response to Rail Safety Recommendation R15-03
Vehicle event data recorders
On 18 September 2013, at about 0832 Eastern Daylight Time, westward VIA Rail Canada Inc. (VIA) passenger train No. 51 departed from the VIA Ottawa Station on time and proceeded en route to Toronto. At 0847:27, OC Transpo double-decker bus No. 8017 departed from the Fallowfield Station on the OC Transpo bus Transitway. At 0848:06, while proceeding at about 43 mph, the train entered the OC Transpo Transitway crossing, located at Mile 3.30 of VIA's Smiths Falls Subdivision. At the time, the crossing lights, bells and gates were activated. The northbound bus was travelling at about 5 mph with the brakes applied when it struck the train. As a result of the collision, the front of the bus was torn off. The train, comprising 1 locomotive and 4 passenger cars, derailed but remained upright. Among the bus occupants, there were 6 fatalities and 9 serious injuries, and about 25 minor injuries were reported. No VIA crew members or VIA passengers were injured.
The Board concluded its investigation and released report R13T0192 on 02 December 2015.
TSB Recommendation R15-03 (December 2015)
The Alexander Dennis Limited (ADL) double-decker buses were equipped with a video monitor that provides the driver with interior views and exterior views of the bus. However, the system monitoring the video cameras installed on the bus did not have recording enabled, and no video information was recovered from the system.
Each of the rail, air and marine modes of transportation require locomotives and many commercial aircraft and vessels to be equipped with event data recorders (EDRs) that record a number of specified elements. In contrast, the Canada Motor Vehicle Safety Standards (CMVSS) contain no requirements for buses (including school, transit and inter-city) to be equipped with an on-board crashworthy EDR. While nothing precludes an operator from installing such technology on its fleet, OC Transpo had no such requirement. As a result, the occurrence bus was not equipped with a crashworthy EDR (i.e. black box) to record and store vehicle operation data that occurred prior to and during the accident sequence. Consequently, 8 electronic units that contained non-volatile memory (NVM) were recovered and analysed.
Of the 8 units recovered, only the engine control module (ECM) retained useful data. The ECM is programmed to automatically record a sudden deceleration event when the bus decelerates at greater than 9.0 mph/s (14.5 km/h/s). Had the bus decelerated at less than 9.0 mph/s (14.5 km/h/s), the ECM would have contained no data at all. While, in this case, the recovered ECM data were useful, when compared to locomotive event recorder (LER) data, the ECM data lacked sufficient detail to conduct a meaningful analysis. Specifically,
Consequently, a detailed braking analysis had to be performed to determine event timing, braking distance and amount of braking force applied by the bus during the accident. The complexity of this work added a number of months to the investigation process. In comparison, comprehensive data from the LER were available for review the next day. The LER data clearly identified the operating parameters of the train and actions of the train crew, which permitted investigators to make informed decisions as to the direction of the investigation and turn their attention to the condition and operation of the bus.
In the United States, the National Transportation Safety Board (NTSB) has recommended EDRs for buses since 1999. While progress has been made, the use of EDRs remains voluntary for roadway vehicles, and the NTSB has classified the related safety recommendations as “Open—Unacceptable Response” because the United States National Highway Traffic Safety Administration (NHTSA) has not required the use of EDRs on buses.
Through years of experience with EDRs in the air, rail and marine modes of transportation, the TSB, the NTSB and the transportation industry have learned a great deal about the effective use of recording technology. Establishing industry standards for recording in these modes has been critical to effective implementation of EDRs by ensuring consistency in the recorded data in standardized formats.
Railway companies routinely use LER data in conjunction with operator (driver) proficiency testing to identify potential areas of improvement within the context of a railway company's safety management system (SMS).
EDRs have been commonly used by over 100 United States jurisdictions to manage school bus fleets. Studies have determined that, when integrated into a company's safety program, the review of EDR data has led to operational safety improvements for vehicle fleets. A sampling and review of EDR data can identify emerging driver trends, and modifications to company training and/or employee mentoring can be made to improve safety accordingly. Such reviews can also be used to identify and reinforce positive and safe driver behaviour. This demonstrates that EDR information can be used in a non-punitive way as a tool for monitoring driver behaviour and performance in conjunction with a transportation company's safety program that can further reduce risk and improve safety before an accident occurs.
Although accidents involving transit buses at level crossings are rare, they are considered to be high-risk events due to the number of passengers transported in each bus and the potential for injury to the travelling public. When these accidents occur, it is imperative that all investigators have access to real-time recorded data that are consistent and meaningful to quickly identify safety deficiencies and prevent recurrence. Understanding driver behaviour and identifying the related human factors are critical to understanding why accidents happen.
All safety, regulatory, law enforcement and company accident investigations benefit from the efficient, timely and accurate collection, assimilation and analysis of available information. In many cases, EDRs provide and validate much of this valuable information. Early recovery of the information can also result in more timely communication of safety deficiencies and accident reports to industry, regulators and the public, which in turn can result in the implementation of measures to prevent a recurrence. Considering that today's vehicles are capable of supporting crashworthy technology that has the capacity to record safety-critical information that enables safety improvements as well as comprehensive and timely accident investigation, the Board recommends that
The Department of Transport require commercial passenger buses to be equipped with dedicated, crashworthy, event data recorders.TSB Recommendation R15-03
Transport Canada's response to Recommendation R15-03 (February 2016)
Transport Canada (TC) acknowledges the recommendation.
There are no United States or United Nations safety regulations requiring event data recorders (EDR) on large commercial vehicles of any type. At the same time, TC will commit to scan current EDR technologies available for commercial passenger buses. This research will look at vehicle-based systems, engine-based systems as well as global positioning systems developed both by original equipment manufacturers and after-market suppliers. TC will review available international commercial vehicle EDR standards and recommended practices. TC will also evaluate the feasibility of developing a commercial passenger bus EDR standard by undertaking a review of technical and scientific reports/papers and validation studies on the accuracy, reliability and limitations of commercial vehicle EDRs. The results of this work would help to determine the need for standards and guide TC on how to proceed. Such work could produce useful guidelines for the installation of such equipment.
TSB assessment of Transport Canada’s response to Recommendation R15-03 (March 2016)
Transport Canada (TC) has acknowledged this recommendation.
TC will initiate research on event data recorder (EDR) technologies, including vehicle-based systems, engine-based systems as well as global positioning systems developed both by original equipment manufacturers and after-market suppliers. After reviewing the results of the research, TC will evaluate the feasibility of developing an EDR standard for commercial passenger buses. This work will help determine the need for standards and could lead to guidelines for the installation of such equipment.
The Board is encouraged that TC will initiate research to help determine the need for standards and/or guidelines for the installation of EDRs for commercial passenger buses. However, this work will take time, and no specific timeline has been provided. In addition, beyond this commitment, there are no explicit plans for the development of EDR standards for commercial passenger buses.
Therefore, the Board assesses the response to Recommendation R15-03 as being Satisfactory in Part.
Transport Canada's response to Recommendation R15-03 (February 2017)
TC will research current EDR technologies available for heavy commercial vehicles, document current EDR standards and recommended practices, undertake a thorough literature review of commercial vehicle EDRs, review any existing national or international standards and evaluate the feasibility of developing a commercial passenger bus EDR standard.
TC has posted the Request for Proposal (RFP) to hire a consultant to do the research. The bid period has closed and a contract has been awarded.
In addition, recognizing that it is important to develop expertise and operational procedures within TC for commercial vehicle EDRs, TC staff (a collision investigator and a defect investigator) have recently taken further training in “Accessing and Interpreting Heavy Vehicle Event Data Recorders”.
TSB reassessment of Transport Canada's response to Recommendation R15-03 (March 2017)
TC recently hired a consultant to conduct research on EDR technologies. This work will include researching current EDR technologies for heavy commercial vehicles; documenting current EDR standards and recommended practices; undertaking a literature review of existing commercial vehicle EDRs; reviewing any existing national or international standards; and evaluating the feasibility of developing a commercial passenger bus EDR standard.
The Board is encouraged that TC has initiated research to help determine the need for standards and/or guidelines for the installation of EDRs for commercial passenger buses. TC has also invested in the development of in-house expertise by providing selected staff with specialized training. However, no explicit plans have yet been established for follow-up work, including the development of EDR standards for commercial passenger buses.
Therefore, the Board reassesses the response to Recommendation R15-03 as being Satisfactory in Part.
Next TSB action
The TSB will follow up with TC for information on the project timeline and next steps.
This deficiency file is Active.
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