Westboro bus crash inquest gives families new hope for justice

Article content

Elaine Thomlinson is just now clearing out her husband’s clothes — more than six years after he was killed in the Westboro bus crash. She still yearns for justice.

Thomlinson’s husband, Bruce, a Canada Borders Services employee, was on his way home from work on Jan. 11, 2019 when OC Transpo Bus 8155 slammed into Westboro Station on what was a cold, clear afternoon.

Article content

A father of two boys, a Scout leader and a volunteer with Big Brothers, Thomlinson sat passenger side, front row, on the second floor of the double-decker bus.

His family had to wait an agonizing 27 hours to find out he was among the three people who died in the crash.

Thomlinson’s family then waited two years for the driver of Bus 8155, Aissatou Diallo, to go on trial. A rookie bus driver and a single mother, Diallo was charged with three counts of dangerous driving causing death and 35 counts of dangerous driving causing bodily harm.

She was acquitted on all charges as the judge ruled Diallo’s actions were not a “marked departure” from the standard of care a reasonably prudent driver would have exercised in the same situation. He found the collision was not due to Diallo’s inattention or unresponsiveness, but to a tragic combination of circumstances: a blinding sunset, some confusing road markings and snow on the shoulder of the road.

Article content

It left Elaine Thomlinson with a profound sense of disquiet. She believes the driver was ultimately responsible for keeping passengers safe — and failed in that job.

“In my opinion, we didn’t get any justice at the criminal trial,” Thomlinson says. “Is nobody responsible? I just don’t believe it.”

The question of responsibility hangs in the air more than six years after the crash. It promises to colour the month-long coroner’s inquest scheduled to begin April 2.

The inquest jury will investigate the circumstances that led to the deaths of three passengers — Bruce Thomlinson, 56, Judy Booth, 57, and Anja Van Beek, 65 — and make recommendations to prevent similar deaths. It will hear from 15 witnesses.

The jury is prohibited from assigning blame, and the recommendations they make are not binding.

Article content

Article content

Which means it’s unlikely that Thomlinson or the families of the other victims will walk away from the inquest with a sense that justice has been done.

Jac Van Beek, the older brother of Anja Van Beek, says he sought a public inquiry because he wants someone to accept responsibility for his sister’s death.

“We see the whole thing obviously through a different lens because it’s so personal,” he says. “But you keep looking at what my sister went through, and it makes you mad, it makes you upset. You want it to be somehow put in its right place instead of on the shelf and out of the way. That’s what we want.”

Van Beek is convinced the crash was the result of a bad driver and a poorly designed station — factors ultimately under the control of OC Transpo. He hopes the inquest finds as much.

Article content

“I want someone to accept blame,” he says. “Go through all the articles you want, and you won’t find anybody saying, ‘We made a mistake,’ or, ‘This could have been done way better than it was.’ ”

Says Thomlinson: “I really don’t know what to expect. But I really hope that it changes things for the better.”

Given that the inquest is being held six years after the fact, much has changed.

Westboro Station and its steel awning — the principal instrument of death and injury in the crash — have been demolished to make way for the LRT.  The station was torn down in October 2022, one year after the city made cosmetic changes to improve its safety.

OC Transpo has also made changes to the way it trains bus drivers. An investigation by the city’s auditor general in late 2019 resulted in 20 recommendations that OC Transpo agreed to act upon.

Article content

The auditor general found OC Transpo had an inconsistent approach to training, which meant some drivers received only a few hours of practice on harder to handle articulated and double-decker buses. The auditor’s report revealed that 56 per cent of OC Transpo bus drivers were involved in preventable collisions during their first three years on the job. (Many of them involved minor bumps and scratches.)

The auditor also found no correlation between a driver’s experience and the kind of bus they operate, or the routes to which they are assigned. Such decisions, governed by the collective agreement, are based on seniority.

“In our view,” the auditor’s report concluded, “by not aligning the work that is booked by new operators to the experience level of the bus operator, the risk of preventable collisions by bus operators is increased.”

Article content

The auditors also found problems with OC Transpo’s approach to winter driver training. Many drivers who graduated in the spring, summer and fall did not get winter driver training during their first winter on the road.

OC Transpo rolled out improvements to its training program in early 2020. The new measures included mandatory hours on double-decker and articulated buses, and winter training for all first-year drivers.

OC Transpo created a new management position to supervise driver training, and a system to track and score the progress of trainees.

The transit authority has also announced the phase out of double-decker buses as part of its move towards a zero-emissions fleet. OC Transpo’s 78 double-decker buses are expected to be retired within the next 10 years.

Article content

The six years since the Westboro bus crash have also revealed many of its significant details. Aissatou Diallo’s 2021 criminal trial examined the mechanics of the crash in minute detail.

Court heard that Bus 8155 was travelling westbound at 59 km/h — over the posted limit of 50 km/h — when it left the bare, dry road and drifted north onto the ice and snow-filled shoulder of the Transitway as it approached Westboro Station.

Diallo did not testify at trial, so why she left the roadway was the subject of conjecture. The Crown blamed inattention; the defence pointed to an unhappy constellation of circumstances.

Engineer Richard Lamoureux, a collision reconstruction expert, said he believed the glare of the setting sun, combined with faded road lines painted during an earlier construction phase, disoriented Diallo, and led her to steer the bus off the roadway and onto the shoulder. (Lamoureux was the only collision reconstruction expert to testify at the trial. Unusually, the lead Ottawa police investigator was not called as a witness.)

Article content

A defence witness, Lamoureux told court the weight of the double-decker bus, combined with the snow and ice, put it into a skid that made it unresponsive to Diallo’s attempt to steer it back to safety. Video evidence showed the bus hit a snowbank one second after leaving the road and then smashed into the rock wall that lines the Transitway, shattering the glass of its front door.

“At this point, the bus is out of control,” Lamoureux told court.

The bus then hit a second snowbank before it slammed into Westboro Station at 3:50:17 p.m., five seconds after first leaving the road.

During those five seconds, court heard, Diallo did not apply the brakes.

Lamoureux suggested Diallo faced a cascading series of events that made it impossible for her to react to any one of them. He estimated that Bus 8155 was moving at 39 km/h when it hit the rigid, steel canopy of Westboro Station — a robust structure compared to the lightweight components of the double-decker’s upper floor.

Article content

“The shelter canopy was much stiffer and much stronger than the bus,” Lamoureux said.

In finding Diallo not guilty of all charges, Ontario Court Justice Matthew Webber largely endorsed Lamoureux’s reconstructed version of the collision.

Outside court, defence lawyer Solomon Friedman said Diallo had been thrust into an awful situation by circumstances beyond her control. “She did her very best, and tragically, unfortunately, her very best was not good enough,” he said.

In an interview with the Citizen’s Gary Dimmock, Diallo said she was traumatized by the collision and its aftermath, and suffers from severe PTSD. She said she thinks every day about the people who died on her watch.

“I have to live with this,” she said.

Article content

The inquest will have that history in front of it as it begins Wednesday. Still, some critical questions remain unanswered. Among them:

Why was a rookie driver, on the road for only six months, assigned to a double-decker bus on a busy commuter route one month after she was involved in a collision?

Diallo had been at the wheel of an articulated bus that collided with another bus at St. Laurent Station on Dec. 10, 2018 — one month before the Westboro crash. Paramedics treated several passengers at the scene. Diallo subsequently completed a retraining program with an in-service driving assessment.

In a Jan. 4, 2019 email to an OC Transpo manager, Diallo said she refreshed her defensive driving skills during the session, “which helped me gain more confidence in myself after my accident.”

Article content

The city refused access to information requests from the Citizen to view the accident report of the incident at St. Laurent Station. In the crash’s aftermath, OC Transpo also repeatedly refused to answer questions about Diallo’s training, driving record or assignments, citing her court case.

The inquest could finally force OC Transpo to explain why Diallo, a rookie driver struggling with her confidence after a collision, was assigned to a double-decker bus with more than 80 people on board.

What can be done to ensure other OC Transpo drivers perform better in crisis situations?   

According to Justice Webber’s ruling, Diallo’s driving did not amount to a criminal offence. But there’s no doubt she made some critical errors, which contributed to the deadly chain of events.

Article content

Diallo was in the right-hand lane as she approached Westboro Station even though Route 269 Bridlewood express buses (the route has since been renamed) normally used the left-hand lane to bypass the station. Why Diallo was in the right-hand lane has never been fully explained.

OC Transpo logs, entered at trial, revealed Diallo had travelled through Westboro Station on 25 different shifts in the three months before the crash so she was familiar with its layout.

Diallo exceeded the speed limit on the Transitway despite driving towards a setting sun. Then, after losing control of the bus on the icy shoulder, Diallo did not apply the brakes and did not manage to steer the bus away from the principal hazard in front of her: the bus shelter.

Article content

In fact, according to Lamoureux’s testimony, Diallo activated the left-turn signal on the bus floor with one foot and stamped on the accelerator with the other foot two seconds before the final impact. (The bus did not have time to accelerate, he said, in response to what was likely the driver bracing for impact.)

At all events, Diallo’s response to the crisis did not safeguard her passengers.

Airplane pilots regularly have their crisis response tested on flight simulators. The same kind of simulation-based training is now available for bus drivers.

Why was the danger posed by Westboro Station never recognized by OC Transpo?

For all of her failings on Jan. 11, 2019, Diallo might still be driving an OC Transpo bus today were it not for the design of Westboro Station.

Article content

In his 94-page report on the Westboro crash, Richard Lamoureux said the tragedy was “entirely foreseeable” given the design of the Transitway and the danger posed to double-decker buses by the rigid steel awnings of its shelters.

“In our opinion, a safety audit ought to have identified the potential risks posed by the Transitway shelters to double-decker buses,” Lamoureux concluded in his April 2021 report.

The Transitway was designed and built before OC Transpo introduced a fleet of double-decker buses in 2013.

It appears some OC Transpo stations were modified to accommodate the tall, new buses. Using cached versions of online maps, Lamoureux demonstrated that the metal canopies at Queensway Station were removed sometime between August 2012 and May 2014. The modifications, he said, were likely made as part of an OC Transpo safety audit.

Article content

For some reason, however, the danger posed by Westboro Station was not identified even though OC Transpo already had evidence of the damage that could be wrought by the awnings.

In July 2003, a single-deck Route 86 bus slammed into the steel awning at Lees Station and tore open the roof. Six passengers were taken to hospital with minor cuts and bruises. (Pictures of the incident are eerily similar to those from the Westboro crash.)

Lamoureux’s report recommended that double-decker buses be removed from the Transitway until the stations could be equipped with raised curbs or some other kind of barrier protection.

Again, for some reason, the city did not act on that recommendation, nor on the demand of Clint Crabtree, president of the bus drivers’ union, ATU Local 279, to tear down the awnings.

Article content

What is the safety record of double-decker buses in Ottawa, and what can be done to make them safer?

Are double-deckers involved in more collisions per kilometre than other OC Transpo buses? Does their weight and size make them harder to stop and steer in winter conditions? Are they equipped with the right winter tires?

Transit riders in Ottawa have reason to mistrust the vehicles.

Double-decker buses have been involved in OC Transpo’s two deadliest crashes. In addition to the three people killed in Westboro, six passengers were killed on Sept. 18, 2013, when a double-decker OC Transpo bus collided with a Via Rail train on Woodroffe Avenue.

The federal Transportation Safety Board investigated that OC Transpo-Via Rail crash because it involved a train. In its final report, the TSB recommended that Transport Canada “develop and implement crashworthiness standards for commercial passenger buses.”

Article content

Double-deckers are built with lightweight materials — the upper deck is made from steel tubing and thin metal panels — in order to accommodate passengers and meet road weight requirements.

Transport Canada has done considerable work developing crashworthiness standards, but it says more extensive crash tests must be done before new regulations can be designed. It’s also working on crash avoidance systems for transit buses.

Transport Canada notes that public transit remains one of the safest means of travel, accounting for 0.04 per cent of road fatalities and 0.10 per cent of serious injuries.

Should the Transportation Safety Board investigate serious bus crashes?

The federal standing committee on transport has recommended that TSB’s mandate be expanded to include serious highway collisions and all bus collisions.

Article content

The TSB’s counterpart in the United States, the National Transportation Safety Board, already has the mandate to investigate significant motor vehicle collisions.

The TSB now investigates select accidents involving airplanes, ships, trains and pipelines. An independent agency, the TSB publicly reports on the causes and contributing factors of those accidents even in cases where legal liability is an issue.

Critics say the current crash investigation system for serious motor vehicle collisions wrongly prioritizes the legal process over public safety. It’s why the inquest into the Westboro crash is being held more than six years after the fact.

Anja Van Beek worked at the Treasury Board of Canada Secretariat, where she was fondly described as a “work mother” by colleagues. Family largely defined her life.

Article content

Her parents emigrated from the Netherlands when she was an infant, and she grew up with three brothers in a close-knit family. Married for 33 years to David Throop, Van Beek was devoted to their two children.

Jac Van Beek says his sister’s death has been hard to come to terms with because of its absolute senselessness.

“This one didn’t have to happen — and that always leaves of an open sore, doesn’t it?”

Our website is your destination for up-to-the-minute news, so make sure to bookmark our homepage and sign up for our newsletters so we can keep you informed.

Article content