Coroner's inquest focused on infrastructure, training, technology, and oversight to improve public transit safety
A coroner’s jury in Ontario has released a comprehensive set of 60 recommendations aimed at improving public transit safety following an inquest into the 2019 OC Transpo bus crash that killed three people and injured dozens more.
The recommendations, issued May 1, are directed at the City of Ottawa, the Province of Ontario, the federal government, and various transit stakeholders, urging a sweeping transformation of operational practices, driver training, infrastructure planning, and oversight.
The inquest focused on the deaths of Judy Booth, Bruce Thomlinson, and Anthonia Van Beek, who were killed on January 11, 2019, when a double-decker bus collided with a shelter at Westboro Transitway Station.
The jury ruled all three deaths accidental, due to multiple blunt force injuries.
Key findings and recommendations
1. Safety-First Governance and Accountability
The jury recommended that safety become the City of Ottawa’s primary consideration in all transit decisions, implemented through:
- A safe systems approach in fleet, infrastructure, and passenger planning;
- Formal assignment of safety responsibilities with performance reporting to senior transit leadership;
- Regular review of Key Performance Indicators (KPIs) for safety;
- Adoption of automated alert systems and formal “bring forward” mechanisms for unresolved safety actions.
2. Infrastructure and Transitway Safety
Major recommendations for infrastructure focus on slowing speeds and modifying hazardous environments:
- Reduce speed limits to 30 km/h near transit stations until physical safety upgrades are completed.
- Install tapered concrete barriers or guardrails and modify or remove station canopies with less than a 3-metre lateral offset from the curb.
- Introduce radar speed signage at critical transition points along the Transitway.
- Conduct annual proactive inspections and ensure safe removal of outdated road markings and snow accumulations.
3. Training and Operator Development
Recommendations for improving driver training include:
- Expanding New Bus Operator Training (NBOT) to require proficiency on all bus types.
- Implementing in-service mentoring for probationary drivers, including at least one observed shift for each bus model.
- Incorporating emergency braking, fatigue management, and scenario-based training into NBOT and remedial programs.
- Introducing dedicated training buses to guarantee consistent exposure across all vehicle types.
Notably, the jury proposed a minimum five-day retraining requirement for probationary drivers following a serious preventable collision, subject to approval by the Chief Safety Officer.
4. Oversight, Data and Driver Monitoring
To enhance safety oversight, the jury called for:
- Daily driver licence abstract checks (up from twice monthly);
- Expanded use of telematics, including real-time feedback and operator-facing cameras for detecting fatigue and distraction;
- Mandatory safety signage outlining personal electronic device use policies for both drivers and the public;
- Formation of a multidisciplinary collision analysis team to investigate serious incidents and identify root causes.
The City was also urged to conduct annual safety audits, promote 24/7 public reporting of safety concerns, and publicly share bus collision KPIs.
5. Technology and Vehicle Safety Standards
The jury encouraged:
- Use of driver assistance systems, such as speed assist, lane support, and multi-collision braking;
- Collaboration with other municipalities to develop industry-wide bus safety standards;
- A feasibility study on upper-deck barriers in double-decker buses, with retrofits recommended if effective.
6. Provincial and Federal Engagement
Several recommendations target provincial and federal authorities, including:
- The Ministry of Transportation (MTO): to amend the Driver Certification Program to set mandatory minimum drive time requirements and improve audit practices;
- The Transportation Safety Board (TSB): to expand its mandate to include investigations into fatal municipal bus collisions;
- Transport Canada: to establish standards for fatigue management, operator-facing cameras, and to expand research on bus safety technologies and crash modelling;
- CUTA and OPTA: to integrate serious bus collisions as a regular discussion item and support development of safety-enhancing technologies.
The full list of recommendations is available here.
The inquest has concluded as the city and ATU Local 279 prepare to negotiate a new contract after their last expired in March, according to a CBC report.
"The City of Ottawa recognizes this is a difficult time for friends and family impacted by the 2019 Westboro bus collision, and the entire community," read a statement attributed to interim city solicitor Stuart Huxley, according to the report.
