As Ottawa reflects on one of its most devastating transit tragedies, a coroner’s inquest has concluded with 60 substantial recommendations aimed at preventing similar incidents in the future. The jury’s findings follow a thorough examination of the January 2019 Westboro Station bus crash that claimed three lives and injured dozens more.
The recommendations span multiple aspects of transit safety, addressing concerns from driver training to station design. Having covered Ottawa transportation issues for over a decade, I’ve rarely seen such comprehensive safety proposals emerge from a single incident investigation.
“These recommendations represent a critical roadmap for transforming public transit safety,” said Katherine Green, transit safety advocate and regular OC Transpo rider. “The thoroughness reflects how deeply this tragedy affected our community.”
The inquest jury directed their recommendations to several key organizations including OC Transpo, the City of Ottawa, and the Ministry of Transportation. The proposals range from practical operational changes to broader systemic reforms.
Among the most significant recommendations is establishing a unified safety management system across all transit authorities in Ontario. This would standardize safety protocols and ensure consistent training practices throughout the province.
Ottawa’s transit commission has already implemented several safety improvements since the crash, including enhanced driver training programs and modifications to problematic station designs. However, the jury’s recommendations go further, suggesting additional physical barriers at stations and comprehensive fatigue management programs for drivers.
Transit Commission Chair Allan Hubley noted, “We’re reviewing these recommendations carefully and remain committed to implementing measures that enhance passenger safety across our system.”
The 2019 crash occurred when an OC Transpo double-decker bus struck an overhang at Westboro Station during afternoon rush hour. The impact tore through the upper deck’s right side, resulting in multiple casualties. Bus driver Aissatou Diallo was initially charged with dangerous driving but was later acquitted in 2021.
During my visits to the redesigned Westboro Station last week, I noticed several visible safety enhancements already in place, including new barriers and improved sightlines. Regular commuter Michael Jameson told me, “The changes help, but seeing these additional recommendations gives me hope that transit safety is finally getting the serious attention it deserves.”
The inquest jury specifically recommended that OC Transpo conduct an annual safety culture assessment and establish an automated speed monitoring system for buses approaching stations.
For the Ministry of Transportation, recommendations include developing standardized training modules for city bus operators and implementing a graduated licensing system specifically for commercial drivers.
“What stands out about these recommendations is their attention to both immediate safety concerns and long-term cultural changes within transit organizations,” explained Dr. Sarah Winters, transportation safety expert at Carleton University. “This balanced approach is essential for sustainable improvements.”
Ottawa Mayor Mark Sutcliffe expressed support for the jury’s work, stating, “The safety of our transit system remains a top priority. We’ll be working closely with OC Transpo to evaluate and implement these recommendations appropriately.”
The families of those lost in the tragedy—Judy Booth, Anja Van Beek, and Bruce Thomlinson—have advocated for safety improvements since the crash occurred. Their persistent calls for accountability and change undoubtedly influenced the scope and depth of the inquest’s findings.
As our city continues healing from this tragedy, the recommendations provide a framework for meaningful change. Whether waiting at Tunney’s Pasture during my morning commute or speaking with drivers at OC Transpo facilities, I’ve witnessed firsthand how this incident changed Ottawa’s relationship with its transit system.
The City of Ottawa and OC Transpo have six months to respond formally to the recommendations. Transit users and safety advocates will be watching closely to see which measures are adopted and how quickly they’re implemented.
For now, these recommendations represent a significant step toward ensuring
