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The Transportation Safety Board went over Dave Woodard’s habits with a magnifying glass.
It was only fitting. After all, he drove OC Transpo’s No. 76 into a train on Sept. 18, 2013, killing six people, including himself, the worst accident in the history of the transit system.
They knew he was diabetic and a little colour blind. Could he have been sleep-deprived, given the shifts operators must work?
The answer is probably not, but the TSB produced a chart — buried in the 241-page report released last week — that showed his sleeping habits in the preceding week. He went to bed each night at 10:30 p.m., sleeping between six and 7.5 hours, except for two nights when he slept for 12: one of those he was sick, the other he was off.
The report also drilled deep enough to tell us he usually drank chai tea before bed, which may have affected his sleep pattern. (No alcohol or drugs were found in his system.)
“Although these two factors could affect quality of sleep, the driver’s sleeping habits and environment were generally good,” the report says, though it does note he had a “sleep debt” estimated at 1.3 hours at the time of the crash, just before 9 a.m.
There are other nuggets. From Sept. 1, 2012 until the crash, Woodard worked 407 shifts at OC, of which 67 were on the double-deckers, the ADL E500 he was driving that day. (Split shifts in a single day, common for drivers, are counted twice.)
Records indicate he was familiar with the Transitway crossing near Fallowfield Station: he drove over it southbound 16 times and northbound 44 times in the previous year. It is unclear how many times he would have encountered a train, but the report suggests “rarely.”
And this leads to a potentially serious problem, creature of habit or not.
“When a driver becomes familiar with a particular level crossing or with a particular type of level crossing, and where the driver has never, or seldom, encountered an approaching train at the level crossing, the driver will tend to have a ‘no trains’ expectation at the crossing.”
Several paragraphs later: “The driver’s actions were consistent with this expectation.”
Woodard would have known he was a little behind schedule that day, but nothing serious (less than four minutes.) And he knew this: “As it was common for drivers to use the section of the Transitway immediately following the crossing to make up time, and because the driver did not expect to encounter a strain, the bus was accelerated beyond the posted speed limit.”
One might have thought such a horrendous accident would have the entire OC fleet obeying the new speed limit of 50 km/h in this section (down from 60), but it was not to be. In June 2014, a TSB speed check found 25 per cent of buses were still exceeding the posted limit of 50.
What is frightening when all the pieces are put together is how plausible it was for the accident to occur. Woodward, by accounts, was a good, experienced driver, with no pressing medical condition, no cell phone distraction, no reckless behaviour. The “distractions” were just the everyday ones.
“Could have happened to just about any driver,” was the verdict from the lead TSB investigator Rob Johnston.
Well, guess what? “Just about any driver” is behind the wheel of buses crossing the Transitway as we speak. In other words, it isn’t over.
To wit: “Between 18 September 2013 and December 2014, there were 5 incidents at the Transitway crossing and 3 incidents at the Fallowfield Road crossing involving an OC Transpo bus.”
And in the next paragraph: “In May 2014, VIA installed video cameras at Woodroffe Avenue/Transitway and Fallowfield Road crossings. As of May 2015, there were 5 reports of gates down on top of vehicles that had stopped beyond the roadway stop line. One of the incidents involved a waste management truck while another involved an OC Transpo ADL E500 bus.”
Hardly reassuring.
As for Woodard’s “congenital, red-green colour vision defect,” OC Transpo knew about the imperfection but it’s not considered hazardous to safe driving. The TSB even looked at the effect of his sunglasses, which are thought to have made red lights appear brighter.
OC Transpo declined comment Tuesday, saying it is still reviewing the report. TSB chair Kathy Fox mentioned the improvements the city has made at the crossing (bush removal, better signs, slower speeds) but left the impression things aren’t ideal.
“Well, I’d say, overall, the risk has been somewhat reduced but there’s still more work to be done.”
To contact Kelly Egan, please call 613-726-5896 or email kegan@ottawacitizen.com
Twitter.com/kellyegancolumn
查看原文...
It was only fitting. After all, he drove OC Transpo’s No. 76 into a train on Sept. 18, 2013, killing six people, including himself, the worst accident in the history of the transit system.
They knew he was diabetic and a little colour blind. Could he have been sleep-deprived, given the shifts operators must work?
The answer is probably not, but the TSB produced a chart — buried in the 241-page report released last week — that showed his sleeping habits in the preceding week. He went to bed each night at 10:30 p.m., sleeping between six and 7.5 hours, except for two nights when he slept for 12: one of those he was sick, the other he was off.
The report also drilled deep enough to tell us he usually drank chai tea before bed, which may have affected his sleep pattern. (No alcohol or drugs were found in his system.)
“Although these two factors could affect quality of sleep, the driver’s sleeping habits and environment were generally good,” the report says, though it does note he had a “sleep debt” estimated at 1.3 hours at the time of the crash, just before 9 a.m.
There are other nuggets. From Sept. 1, 2012 until the crash, Woodard worked 407 shifts at OC, of which 67 were on the double-deckers, the ADL E500 he was driving that day. (Split shifts in a single day, common for drivers, are counted twice.)
Records indicate he was familiar with the Transitway crossing near Fallowfield Station: he drove over it southbound 16 times and northbound 44 times in the previous year. It is unclear how many times he would have encountered a train, but the report suggests “rarely.”
And this leads to a potentially serious problem, creature of habit or not.
“When a driver becomes familiar with a particular level crossing or with a particular type of level crossing, and where the driver has never, or seldom, encountered an approaching train at the level crossing, the driver will tend to have a ‘no trains’ expectation at the crossing.”
Several paragraphs later: “The driver’s actions were consistent with this expectation.”
Woodard would have known he was a little behind schedule that day, but nothing serious (less than four minutes.) And he knew this: “As it was common for drivers to use the section of the Transitway immediately following the crossing to make up time, and because the driver did not expect to encounter a strain, the bus was accelerated beyond the posted speed limit.”
One might have thought such a horrendous accident would have the entire OC fleet obeying the new speed limit of 50 km/h in this section (down from 60), but it was not to be. In June 2014, a TSB speed check found 25 per cent of buses were still exceeding the posted limit of 50.
What is frightening when all the pieces are put together is how plausible it was for the accident to occur. Woodward, by accounts, was a good, experienced driver, with no pressing medical condition, no cell phone distraction, no reckless behaviour. The “distractions” were just the everyday ones.
“Could have happened to just about any driver,” was the verdict from the lead TSB investigator Rob Johnston.
Well, guess what? “Just about any driver” is behind the wheel of buses crossing the Transitway as we speak. In other words, it isn’t over.
To wit: “Between 18 September 2013 and December 2014, there were 5 incidents at the Transitway crossing and 3 incidents at the Fallowfield Road crossing involving an OC Transpo bus.”
And in the next paragraph: “In May 2014, VIA installed video cameras at Woodroffe Avenue/Transitway and Fallowfield Road crossings. As of May 2015, there were 5 reports of gates down on top of vehicles that had stopped beyond the roadway stop line. One of the incidents involved a waste management truck while another involved an OC Transpo ADL E500 bus.”
Hardly reassuring.
As for Woodard’s “congenital, red-green colour vision defect,” OC Transpo knew about the imperfection but it’s not considered hazardous to safe driving. The TSB even looked at the effect of his sunglasses, which are thought to have made red lights appear brighter.
OC Transpo declined comment Tuesday, saying it is still reviewing the report. TSB chair Kathy Fox mentioned the improvements the city has made at the crossing (bush removal, better signs, slower speeds) but left the impression things aren’t ideal.
“Well, I’d say, overall, the risk has been somewhat reduced but there’s still more work to be done.”
To contact Kelly Egan, please call 613-726-5896 or email kegan@ottawacitizen.com
Twitter.com/kellyegancolumn
查看原文...
