Inquest closing remarks reveal rifts in how to make OC Transpo safer

CBC

26-04-2025

The inquest will resume on Monday, April 28, at 9:30 a.m. Stream it live here.
Not everyone at the coroner's inquest into the fatal OC Transpo bus crash of 2019 agrees on all of the ideas pitched for making bus riding in Ottawa safer, as the public deep dive's closing remarks made clear on Friday.
In particular, the issues of driver-facing cameras, reducing the speed limit for buses approaching Transitway stations, the decades-old procedure for scheduling OC Transpo bus drivers, and potentially allowing the city to intervene during the driver booking process if it has safety concerns, exposed the dividing lines in an inquest meant to prevent similar tragedies in the future.
On Jan. 11, 2019, a packed double-decker bus slammed into a shelter canopy at Westboro station. Three passengers — Judy Booth, Bruce Thomlinson and Anja Van Beek — died in the crash, while many other riders were injured.
While the city accepted civil responsibility, the driver, Aissatou Diallo, was charged with 38 counts of dangerous driving causing death or bodily harm. She was acquitted of all charges in a judge-only trial in 2021.
At the inquest over the last three weeks, a jury of five Ottawa-area civilians heard emotionally and technically challenging testimony from 20 witnesses. It will be up to the jurors to issue recommendations to prevent future collisions, after the presiding coroner gives her instructions on Monday morning.
But on Friday, the Thomlinson and Booth families, as well as lawyers representing the city, the union for OC Transpo drivers, and the coroner's office (known as "inquest counsel"), made their own pitches for change to the jury.
Here's where those groups are aligned — and not.
What they agree on
All the groups supported measures meant to tighten the refresher training OC Transpo drivers receive after being in an on-duty collision.
The inquest has heard that only one month before the fatal Westboro crash, in December 2018, Diallo was at the wheel of an articulated 60-foot bus when it careened into a parked bus at St. Laurent station.
Diallo was found to be at fault and was placed on a three-week investigatory leave. She was ultimately dubbed a "low risk" driver, was paired with a very experienced instructor, and received only one day of refresher training before being cleared to go back behind the wheel of a bus.
The manager who approved Diallo to return to work testified that if a situation like it happened today, "it's probably best that we part ways with the employee and not look at remedial training."
One of the recommendations suggested Friday called for more monitoring of drivers who get refresher training. That might include the use of telematics — GPS technology that relays information about a driver's performance in real time.
Another recommendation would require refresher training to last a minimum of five days for probationary drivers involved in serious, preventable collisions.
Everyone also agreed newly trained bus operators need more one-on-one time with more experienced drivers, and that a dedicated fleet of buses for training would help ensure drivers get adequate training on all bus types.
What the city takes issue with
As Diallo approached the Westboro shelter canopy from about 69 metres away, she was travelling between 58 km/hr and 60 km/hr, slightly over the 50 km/hr limit, according to a narrative of the crash filed at the inquest.
On Friday, the jurors were asked to consider a recommendation that would temporarily reduce the speed limit to 30 km/hr for buses approaching four Transitway bus stations: Billings Bridge, Greenboro, South Keys and Lincoln Fields.
Those locations were selected because they have canopies similar to Westboro station (which is currently decommissioned because of LRT construction), and because they have a "lateral offset" of less than three metres between the canopy and the curb face. The offset at Westboro was less than one metre, while three metres is the current guideline in Ontario.
The speed reduction would get lifted depending on the results of an audit looking at the "safety benefit" of removing the canopies altogether, according to the suggested recommendation. The inquest already prompted the city to place safety striping on the canopy at Lincoln Fields, as it did at Westboro following the crash, after having failed to do so years before.
Inquest counsel and the victims' families supported that recommendation while the union took no position. The city opposed it.
Anne Tardif, one of the lawyers representing the city, said there was no evidence those canopies pose a risk, noting that three of the locations have lateral offsets that one engineer told the inquest were "desirable."
Under another recommendation, the speed limit for approaching buses elsewhere on the Transitway would be reduced to anywhere from 30 km/hr to 40 km/hr.
The city didn't oppose this suggestion, but Tardif pointed to a road vehicle safety expert's testimony that even if Diallo have been driving 50 km/hr, she would only have had about one second more of reaction time and would likely have still struck the canopy.
"That's not a lot of time," she said.
What the union opposes
The inquest comes at a key moment for the city and the Amalgamated Transit Union (ATU) Local 279, which represents OC Transpo bus drivers. Their last collective agreement expired at the end of March and negotiations on a new contract will begin after the inquest wraps.
The inquest heard about the seniority system that results in senior drivers getting first dibs on shift selection, which leaves newer drivers with fewer options — or what one official at the city called "crumbs."
In his closing remarks on Friday, the lawyer representing ATU 279, John McLuckie, spoke out against proposals he described as "disruptions" to the seniority system, which he said is the industry standard. He also criticized suggested steps toward restricting what type of buses newer operators could drive.
McLuckie was referring to a thorny multi-part recommendation calling for a review of the driver scheduling process. Among other things, the review would consider whether the city should be allowed to step into the scheduling process following a collision or if it identifies "a safety-related performance issue."
The review would also contemplate allowing the city to intervene specifically in the scheduling of new bus operators who are still within their nine months of probation, as Diallo was.
That latter intervention would depend on the outcome of another proposed recommendation: an analysis of collisions to determine if new bus operators, or specific bus types and routes, pose an "elevated risk."
"Restricting access to the buses doesn't make sense based on the training that the operators have," McLuckie said, noting that trainees these days receive a mandated number of hours on each bus type.
As well, given that OC Transpo's fleet is in what McLuckie called a "maintenance crisis", which can make some bus types harder to allocate, adding driver restrictions into the mix would make the system "unworkable," he said.
There's also no evidence that Diallo — who ultimately did not testify at the inquest — ever expressed any discomfort about driving a double-decker or ever sought any additional training on them, McLuckie said.
McLuckie instead championed another element of that multi-pronged recommendation: reducing the amount of interlining at OC Transpo. That's the practice of making drivers do various routes in one shift, instead of getting familiar with a dedicated route.
He also said it's in the power of the city — which designs the work drivers chose from — to make it easier for drivers to be able to book two consecutive days off.
"It's a question of money, it's a question of cost, and it's a question of efficiency of the service that the city doesn't want to give up," McLuckie said.
Driver-facing cameras and other proposed recommendations
The bus that crashed into the Westboro station canopy was equipped with GPS technology; that's how the inquest was able to dissect Diallo's speeds on a second-to-second basis.
But the bus was not equipped with a driver-facing camera and that remains the case for all OC Transpo buses, though the inquest is seeking to change that.
Under another of the proposed recommendations — supported by everyone except the union — the city would install such cameras on all buses in the fleet. They're to be used for "safety purposes" while also "ensuring appropriate protections for employees' privacy," a nod to the union's concerns about "Big Brother" abuses.
Ken Gordon, a training and development manager at OC Transpo who is currently on leave, was among the city officials who strongly endorsed the move.
"I've been involved in incidents where operators are getting into bad collisions ... and they say, 'The person just came out of nowhere or the bus didn't operate right,' and we review the footage from the bus and ... you can see the driver was texting on his cell phone in his lap rather than looking out the window," Gordon testified.
McLuckie said drivers' concerns about privacy need to be addressed through robust consultation.
Some of the other recommendations pitched on Friday include:
Assessing all Transitway bus routes for potential "intrusion hazards" to double-deckers. (All the parties agreed except for the union, which took no position.)
Making sure remnants of Transitway construction — including the orange lines that some have argued may have been a distraction to Diallo — are properly taken care of. (Supported by all parties.)
New driver training that emphasizes emergency braking and the prohibition on cell phone use while driving. (Supported by all parties.)
Increasing checks on driver licence abstracts from twice a month to daily. (Supported by inquest council, the city and the Thomlinson family. The Booth family and the union took no position.)
Calling on the city and the maker of the double-decker involved in the Westboro crash to study "the effectiveness of barriers at the front upper deck of buses [to prevent] passenger ejections during collisions." (Supported by inquest council and the Thomlinson family. No position taken by the city, the union nor the Booth family.)
Having the federal government consider making the Transportation Safety Board of Canada investigate serious bus transit collisions that involve deaths. (Supported by the Booth and Thomlinson families and inquest counsel. The city and the union took no position.)
Whatever recommendations the jurors adopt — or draw up themselves — they will not be binding. Though, the parties on Friday also asked that all levels of government commit funding to make them a reality.
The jurors also heard a painful call from the wife of Bruce Thomlinson, one of the three people who died in the Westboro crash. She said inquests need to happen sooner to the events they dredge up.
"I have found the inquest process emotionally draining, retraumatizing and upsetting," Elaine Thomlinson told the jury.
"To be re-examining the evidence, after having attempted to move forward in my life in some way, has not been easy."
The inquest resumes Monday morning.