Railway Investigation Report R15V0191
The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Grade crossing collision
Canadian National Railway Company
Langley, British Columbia
On 11 September 2015, at approximately 1120 Pacific Daylight Time, Canadian National Railway train Q10251-11, travelling northward on the Canadian Pacific Railway Page Subdivision, collided with an ambulance at the Crush Crescent–Glover Road crossing (Mile 18.81) in Langley, British Columbia. The paramedic in the patient compartment and the patient suffered injuries and were airlifted to hospital. The driver was transported to hospital, treated, and released. The patient later died of injuries sustained in the accident.
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1.0 Factual information
1.1 The accident
On 11 September 2015, the ambulance crew of British Columbia Ambulance Service (BCAS) ambulance No. 62769 began its shift at 1000.Footnote 1 Shortly before the crew came on shift, a non-emergentFootnote 2 call had been received, requiring the transfer of a patient from a Langley, British Columbia, long-term care facility to the Abbotsford Regional Hospital in Abbotsford, British Columbia. When the ambulance arrived at the long-term care facility, the patient was loaded into the patient compartment of the vehicle. One of the paramedics remained in the patient compartment with the patient.
The chosen route to Abbotsford included traversing the grade crossing at the intersection of Crush Crescent and Glover Road (Figure 1). The ambulance driver had limited experience with this route.
At about 1120, the ambulance was travelling eastward on Crush Crescent, intending to turn left (north) at the Glover Road intersection. The left-turn traffic signal was green. The ambulance was proceeding slowly toward the crossing.
During the approach to the crossing, the grade crossing warning system (GCWS) activated. The crossing bell was ringing, the flashing lights were activated, and the gates were descending. The ambulance stopped, but was on the track. Shortly after, with the gates fully descended for the train's arrival, the ambulance was moved forward to a position between the south rail of the main track and the crossing gate for the opposing traffic (westbound vehicles). However, even at this location, the ambulance was foul of the main track (Figure 2).
On 11 September 2015, at about 0928, Canadian National Railway Company (CN) train Q10251-11 departed from Roberts Bank in Delta, British Columbia, on the Port Subdivision and proceeded eastward.Footnote 3 At Pratt, the train continued onto Canadian Pacific Railway's (CP's) Page Subdivision. At about 1120:05, while approaching the crossing at Mile 18.81, the train crew observed an ambulance proceeding onto and occupying the crossing.
At 1120:09, with the train about ¼ mile from the crossing, the locomotive horn was sounded, as required by Canadian Rail Operating Rules (CROR) Rule 14(l), which states (in part):
(l) ___ ___ o ___ [2 long blasts, 1 short blast, 1 long blast]
A whistle post will be located 1/4 mile before each public crossing where required. Whistle signal must be sounded by movements:
Whistle signal must be prolonged or repeated until the crossing is fully occupied.
The ambulance was observed to move slightly forward twice in an attempt to clear the crossing. Recognizing that the ambulance was still foul of the track, the train brakes were placed into emergency (i.e., maximum brake application) approximately 2 seconds before the train made contact with the ambulance. Table 1 provides further details of the events for this occurrence, including crew actions.
|Time||Event / Train crew actions|
|1120:05||Travelling at 34 mph, the train was about 1520 feet from the crossing.
The ambulance first came into view and was observed proceeding slowly onto the crossing.
|1120:09||The lead locomotive passed the whistle post for the crossing located about 1320 feet south of the crossing. The sounding of the whistle signal was initiated with the locomotive horn.
The ambulance was stopped, fully occupying the crossing.
|1120:13||At about 1120 feet from the crossing, the locomotive horn was sounded continuously.|
|1120:22||After having been stopped on the crossing for about 13 seconds (from 1120:09 to 1120:22), the ambulance moved forward slightly, in an attempt to clear the crossing.|
|1120:28||The ambulance was moved forward slightly a second time, until the rear of the ambulance was in line with the south rail of the main track and still foul of the crossing.|
|1120:33||About 100 feet from the crossing, travelling at 34 mph, the train brakes were placed into emergency.|
|1120:35||The train collided with the ambulance while travelling at 34 mph. The train contacted the rear of the ambulance. The resultant force spun the ambulance 180 degrees, with the train further contacting the front end of the ambulance.|
|1121:14||The train came to a stop approximately 1135 feet past the crossing.|
* Times and events specified are correlated to the locomotive event recorder and the forward-facing video from the lead locomotive on the train.
As a result of the collision, the paramedic and the patient in the rear of the ambulance sustained injuries, requiring them to be transported by air ambulance to the hospital. The patient later died of the injuries sustained in the accident. The ambulance driverFootnote 4 was transported to hospital by ground ambulance, treated, and released.
The weather on the day of the occurrence was sunny. Although the sun was high in the sky at the time of the occurrence, there was no indication that the sun was affecting the ability of vehicle drivers at the Crush Crescent crossing approach to see the traffic signals or the crossing signals.
1.2 Recorded information
Forward-facing video from the lead locomotive and a dash-cam video from a vehicle travelling southbound on Glover Road were reviewed.
Based on the recorded information, it was determined that
1.3 The train
The distributed powerFootnote 5 train comprised 3 locomotives and 62 cars consisting of 168 loaded container platforms.Footnote 6 There were 2 locomotives at the head end of the train and 1 locomotive at the tail end. The train was 10 615 feet long and weighed 10 403 tons.
1.4 The train crew
The 3-member train crew consisted of a locomotive engineer (LE), a conductor, and a locomotive engineer trainee (LE trainee). The LE trainee, who was operating the train at the time of the occurrence, was under the supervision of the LE. The LE and the conductor were qualified for their respective positions, met regulatory safety and rest requirements, and were familiar with operating over the Page Subdivision. The LE trainee, who was a qualified conductor, had been in the LE training program since March 2015. Over the previous months, the LE trainee had been working primarily with the LE.
1.5 Page Subdivision
The Page Subdivision starts at Riverside (Mile 0.0) and ends at Pratt (Mile 24.0), where it connects to the British Columbia Railway's Port Subdivision. On the Page Subdivision, between Mile 16.4 (Livingstone) and Mile 24.0, train movements are governed by the centralized traffic control system, as authorized by the CROR, and controlled by a British Columbia Railway rail traffic controller located in Roberts Bank, British Columbia. The authorized train speed in the vicinity of the crossing was 35 mph.
CP is the owner of the Page Subdivision. However, CN and the Southern Railway of British Columbia also operate trains over this subdivision. In 2015, on the Page Subdivision, there were 2806 train movements, increasing from 2715 train movements in 2014.
1.6 The crossing
The occurrence crossing (the crossing) is located in Langley at Mile 18.81 of the Page Subdivision. The crossing, which intersects Crush Crescent and runs parallel to Glover Road, is equipped with a GCWS consisting of flashing lights, bell, and gates. The GCWS was working as intended at the time of the occurrence.
The crossing signal system, which is linked to the traffic signal system at the intersection, uses a grade-crossing predictor to provide a constant warning time and advanced pre‑emption for the roadway traffic signal controller.
A second crossing for the Milner storage track is positioned approximately 13 m to the west of the occurrence crossing. The second crossing is equipped with a railway crossing sign (RCS).
The crossing and the connected roadways are under a number of jurisdictions. Crush Crescent and 216th Street are under the jurisdiction of the Township of Langley. The British Columbia (BC) Ministry of Transportation and Infrastructure (MOTI) has responsibility for Glover Road (Highway 10) and the traffic signals on Glover Road, which also control movements to and from these adjoining roads. MOTI shares responsibility with CP for the interconnection of the traffic signals with the GCWS at the railway crossing that intersects Crush Crescent. The operation and maintenance of the GCWS at the grade crossing is the responsibility of CP. Responsibility for the application and the maintenance of the roadway markings at this crossing is unclear.Footnote 7
At the time of the occurrence, the roadway markings on Crush Crescent were faded and not clearly visible (Figure 4). The 3 lanes (eastbound, left turn, and westbound) at the crossing were not clearly marked with lines and arrows. The stop line for eastbound traffic (located west of the Milner storage track crossing) was visible but severely degraded.
Since 1993, there have been 3 other TSB-reportable occurrences at the Crush Crescent–Glover Road crossing:
In 2015, using the Transport Canada (TC) Pacific Region's risk model, this crossing was identified as one of the crossings of highest concern in British Columbia.
1.7 Grade crossing warning systems at grade crossings
In Canada, GCWS are installed at many railway crossings. The primary function of a GCWS is to provide visual and audible warnings of an approaching train to vehicle drivers and pedestrians. TC's Grade Crossings Standards (GCS)Footnote 8 identify various criteria for determining whether a GCWS is required at a railway crossing. These criteria include the speed of the trains, the frequency of trains, the number of tracks, the volume of road traffic, and the railway sightlines for vehicle drivers.
GCWS are designed and configured to provide adequate warning times, ensuring that approaching vehicles can safely stop prior to the railway tracks and/or safely egress from the crossing. The GCS specify a minimum warning time of 20 seconds. Additional warning time may be required, depending on the geometry of the intersection between the roadway and railway corridor. In some cases, additional warning time is required to ensure that vehicles can move clear of the intersection prior to a train's arrival.
Flashing lights and bells are the primary warning devices employed with a GCWS. Pairs of flashing lights are always employed. The number and position of flashing light pairs is determined by the geometry of the roadway at the railway crossing and any nearby roadways intersecting this road. If 1 bell does not provide adequate audible warning level to pedestrians and cyclists, more than 1 bell can be used.
Gates, which are a component of a GCWS, are used as a stop enforcement mechanism to block vehicles and pedestrians on the approach to a crossing. Gates are flexible and breakable to enable vehicles to clear the tracks if trapped between a gate and a track. The GCS regulate the use of gates at railway crossings.
Short warning times can result in drivers being unable to clear the railway prior to the arrival of a train. In contrast, longer than necessary warning times can also pose dangers. Nuisance operationFootnote 9 of a GCWS can lead drivers to believe that the GCWS has malfunctioned. With the expectation that no train is approaching, some drivers may decide to traverse the crossing, even while the GCWS is activated.
The need for sufficient warning times has led to the development of technology to predict the time it will take for an approaching train to arrive at the railway crossing. Grade crossing predictors use special track circuits to determine the distance and speed of a train within the track circuit (distance from the crossing) at any time. The minimum warning time required is programmed into the predictor during the installation of the crossing. To allow for the potential change in train speed and other factors in arrival time calculation, more warning time is usually added to the required minimum time—typically, 5 seconds. This additional time is referred to as "buffer time."
1.8 Grade Crossings Regulations and Grade Crossings Standards
The new Grade Crossings Regulations (GCR) came into force on 28 November 2014. Before the implementation of the new GCR, TC had issued a guidance document relating to railway crossing design.Footnote 10 As it was only a guidance document, it was not enforceable.Footnote 11
With the new GCR, clarity was provided in a number of areas, including
The Grade Crossings Standards include the following requirements:
All bells must continue to operate for the same duration as the light units.
The descent of the gate arm must take 10 to 15 seconds and its ascent must take 6 to 12 seconds.
16.1 Warning Time
16.1.1 The time during which the warning system must operate, before the arrival of railway equipment at the crossing surface, must be the greatest of:
Interconnection is to be provided at grade crossings where the railway design speed is 15 mph or more and where there is less than 30 m between the nearest rail of a grade crossing and the travelled way of an intersection.
The interconnection of traffic signals with a warning system must:
1.9 Site examination at crossing
During site examination, operation of the GCWS was observed with a train approaching the crossing. With traffic already stationary at the stop line before the crossing (due to a red highway traffic light), the GCWS started to activate and, simultaneously, the traffic light turned green. This design is to enable vehicles queued at the crossing to vacate the area prior to the train's arrival. However, drivers were presented with both a green light inviting them to enter the crossing area, when in fact it was not safe to do so, and the activation of the GCWS giving warning of an approaching train. The green light could continue until after the train had occupied the crossing.
It was observed that some vehicle drivers were confused when they were presented with the conflicting stop and go commands from the GCWS and the road traffic signals.
On 17 March 2016, the TSB issued Railway Safety Advisory 07/16 concerning the operation of the GCWS and the road traffic signals at the occurrence crossing.Footnote 16
1.10 Crossing geometry at Crush Crescent–Glover Road
Subsequent to the accident, TC determined that this crossing did not conform to the new definition of a grade crossing as specified in the 2014 GCR:
a road crossing at grade, or two or more road crossings at grade where the lines of railway are not separated by more than 30 m.
At the accident location, Crush Crescent crosses 2 tracks that are separated by about 13 m (the main track and the Milner storage track). However, the 2 tracks had 2 different crossing warning systems: the main track crossing had a GCWS, and the Milner storage track crossing had an RCS. By definition, both tracks should have been treated as 1 crossing. While the crossing warning systems met requirements at the time they were installed, with the RCS as the only warning for the Milner storage track, the crossing sightlines did not meet the new GCS. Further, under the graduated implementation of the GCR, unless modifications are being made to the crossing, the crossing warning systems do not have to meet the new requirements until the year 2021.Footnote 17
The following was determined during site examination and review of the crossing:
For eastbound traffic approaching the crossing, the GCWS flashing lights were at times partially obscured for vehicle drivers due to the position of the RCS for the Milner storage track and the stop line sign (Figure 6).
1.11 Interconnection between crossing signals and vehicle traffic signals
Where an intersection between 2 roadways exists adjacent to the railway crossing and the intersection is controlled by traffic signals, information must be provided to the traffic control system to help ensure that vehicles do not remain waiting on or near the railway crossing due to a red light while a train is approaching. From the interconnection between crossing signals and vehicle traffic signals, traffic pre-emption can be performed. These are some of the design issues to consider when implementing traffic pre-emption:
1.12 Timing of the grade crossing warning system controller and the traffic control system at the crossing
When a crossing warning system is interconnected with traffic signals, certain parameters (as specified in the GCS) must be met relating to the timing of functions, including traffic pre‑emption, gate drop delay, and traffic queue clear-out.
The Safetran GCP 62660 MS/GCP controller, which operated the warning devices at the time of the occurrence, had no integrated provisions for data recording. However, this controller did include an external data-logging device. The external data-logging device provides a log file containing pertinent information presented against time.
The GCWS controller was configured to provide 30 seconds of warning time and 50 seconds of total approach time.Footnote 20 This 50-second period was broken up as follows:
The traffic signals for vehicle drivers were controlled by an LMD 8000 controller, which had a built-in recorder capable of recording signal events, limited by the recorder's storage capacity and by its 24-hour overwrite cycle.
For the traffic control system,Footnote 21 when the clearance queueFootnote 22 was first established, the new GCR were not in effect. The clearance queue calculations were therefore not based on the current design vehicle calculations. Instead, the methodology was based on reviewing the best- and worst-case scenario for the right-of-way transfer time of the traffic lights and on ensuring that an adequate clearance (green) time is provided prior to the arrival of a train. Using this methodology, the clearance green time provided was sufficient to accommodate the required design vehicle for this crossing.
For the occurrence crossing, during the advanced pre-emption phase, the traffic signals prepare to clear the traffic queue on Crush Crescent. The particular phase that the traffic signals are in when the advanced pre-emption starts determines the length of time required:
1.13 Regulatory requirements for inspection of crossings
Section 17.1, Table 17-2, of the GCS specifies the elements of a crossing warning system that must be inspected and tested and the frequency of the required inspection and testing. When the crossing warning system is interconnected with the traffic control system, the inspection and testing must be conducted once per year. Although this is not stipulated as such in the regulations, these inspections and tests should be performed jointly by the road authority and the railway.
To perform testing and inspection of interconnected systems, TC developed a document entitled Guideline For Inspecting and Testing Preemption of Interconnected Traffic Control Signals and Railway Crossing Warning Systems. This document and the GCR do not require real-time observation or the use of recorded information as part of the recommended inspection and testing processes.
1.13.1 Railway and road authority testing and inspection results for the Crush Crescent–Glover Road Crossing
Table 2 summarizes the inspection and test results since 2010 for the interconnection between the GCWS and the traffic signals at the occurrence crossing.
|Year||Inspection and test results||Comments|
|2010||A sign-off sheet indicating that the interconnection operation between the GCWS and the traffic signal was observed||No observations were recorded at the time of the inspection.|
|2011||A sign-off sheet with a checklist of 4 tasks to perform:
All items were completed except for item 3, which was not applicable to the GCWS interconnection at this crossing.
No real-time observations (such as approach of a train) of the GCWS−traffic signal system interconnection were made.
|2012||A sign-off sheet with a checklist of 7 items for evaluation:
||All items were completed except for item 2 (there was no fixed distance approach timing) and item 7 (no pre-emption design or observed times were recorded).
No real-time observations (such as approach of a train) of the GCWS traffic signal system interconnection were made.
|2013||A sign-off sheet with the 7 items for evaluation identified in 2012||All 7 items were marked as completed.
No real-time observations (such as approach of a train) of the GCWS traffic signal system interconnection were made.
For item 7, 41 seconds was recorded for both values.
|2014||A sign-off sheet with the items for evaluation identified in 2012 and resubmitted in 2013||The checklist had recorded all items with the exception of item 1.
No real-time observations (such as approach of a train) of the GCWS traffic signal system interconnection were made.
For item 7, 0 seconds was recorded for both values.
|2015||A duplicate sign-off sheet as in 2012, 2013, and 2014 with all items having been completed||No real-time observations (such as approach of a train) of the GCWS / traffic signal system interconnection were made.
For item 7, 0 seconds was recorded for the advanced pre-emption time, and 33 seconds was recorded for the pre-emption time (this inspection was completed 3 days after the occurrence).
* Advanced pre-emption time is the period of time that is the difference between the required maximum highway traffic signal pre-emption time and the prescribed warning time.
** The maximum amount of time needed following initiation of the pre-emption sequence for the highway traffic signals to complete the timing of the right-of-way transfer time, queue clearance time, and separation time.
The typical method of testing the interconnection operations was to apply a track shunt within the crossing approach that would simulate the approach or arrival of a train. However, the use of a shunt in this manner did not allow for detailed observation of the full operation and interaction between the GCWS and the traffic controller. This method of testing would simulate a train that a grade crossing predictor can evaluate only as moving quickly, rather than at the varying speeds that could be encountered during normal train operation to the crossing.
1.13.2 Other available data sources for inspection and testing
The traffic signal pre-emption recorders used by MOTI use a date and time stamp to log 2 types of events during rail pre-emption: when pre-emption is initiated and when the pre‑emption call is terminated. Other events unrelated to rail pre-emption are also recorded.
In 2015, at the occurrence crossing, there were 2806 train movements that generated about 6000 lines of data solely for rail pre-emption events.
1.14 U.S. National Transportation Safety Board investigations and recommendations relating to crossing safety
On 25 October 1995, at 0710, commuter train 624 of the Northeast Illinois Regional Commuter Railroad Corporation (Metropolitan Rail) struck the rear left side of a stationary school bus at a grade crossing in Fox River Grove, Illinois. While in the process of traversing the crossing, the school bus stopped for a red traffic signal, with its rear extended about 3 feet into the path of the train. As a result of the accident, there were 7 fatal injuries, 24 serious injuries, and 5 minor injuries.
As part of this investigation, the U.S. National Transportation Safety Board (NTSB) issued the following recommendations on 14 November 1996:
Require the use and maintenance of railroad and highway/traffic signal recording devices on all new & improved installations at railroad/highway grade crossings that have active warning train detection systems and are interconnected/pre-empted to highway signal systems. These devices record sufficient parameters to allow railroad and highway personnel to readily determine that the highway signals and railroad-activated warning devices are coordinated and operating properly. Require that the information from these devices be used during comprehensive and periodic joint inspections.
NTSB Recommendation I-96-10
Require that existing recording devices for railroad & highway signals systems at interconnected/preempted grade crossings be retained or upgraded as necessary. Require that these recording devices be maintained & that the information from these devices be used during the comprehensive & periodic joint inspections.
NTSB Recommendation I-96-11
In response to these recommendations, the U.S. Federal Railroad Administration issued Safety Advisory 2010-02 (Appendix B) and recommended the following actions:
States and local highway authorities and railroads are encouraged to take action consistent with the preceding recommendations to help ensure the safety of highway-rail grade crossings.
The NTSB considers recommendations I-96-10 and I-96-11 closed with an acceptable alternate action.
1.15 Train operations in the vicinity of a crossing
Train crews are expected to use good judgment and forward planning to deal with emergent situations. Railway guidance on the use of emergency braking is typically non-specific, in recognition that a wide range of circumstances can be encountered and that LE judgment is important.
In this occurrence, the train was being operated by an LE trainee under the supervision of an in-charge LE. Approaching the crossing, the train was travelling at 34 mph, below the maximum authorized speed of 35 mph. There were no speed restrictions for the train in the vicinity of the crossing. From the locomotive cab, there was clear visibility and an unobstructed view toward the crossing. The recorded information indicates that the train was operated in accordance with railway and regulatory requirements.
The train crew members observed the ambulance approach the crossing from the west and then stop on the crossing. The crew members also noted that the GCWS was activated. As required by the CROR, upon reaching the whistle post (about ¼ mile from the crossing), the crew members started to sound the locomotive horn. They observed the ambulance move forward twice. As the ambulance was still on the crossing, the locomotive horn was then sounded continuously. As there did not appear to be any obstruction preventing the ambulance from clearing the crossing, the LE opted to continue toward the crossing, sounding the horn.
Train crews are generally accustomed to encountering vehicles that are momentarily stopped at crossings and encountering unauthorized persons on the railway right-of-way. It is not uncommon for pedestrians and/or vehicles to remain on the track, including at crossings, until the last possible moment. As trains have the right-of-way and cannot stop quickly, crew members generally expect that the audible warning from the train and the activated GCWS will be complied with.
1.16 British Columbia Emergency Health Services
British Columbia Emergency Health Services (BCEHS), which operates under the Provincial Health Services Authority, oversees the British Columbia Ambulance Service (BCAS) and the British Columbia Patient Transfer Network (BCPTN). BCEHS has several offices located strategically across the province, along with 184 ambulance stations and over 4000 employees, including paramedics, dispatchers, and physicians.
BCAS provides pre-hospital care to patients when arriving first at the scene of a medical emergency. With about 500 ground ambulances and a fleet of fixed wing and rotary wing aircraft located throughout British Columbia, BCAS provides both ground and air response.
Collaborating with physicians and health-care professionals, the BCPTN program provides transfer services for patients.
1.17 The ambulance
The occurrence ambulance, a 2009 Chevrolet Crestline series, measured 21.5 feet long (bumper to bumper) and 8.8 feet wide (outside mirror to outside mirror) (Figure 7). Based on the repair and inspection records, the ambulance was in serviceable condition. A post-occurrence teardown and inspection determined that there were no pre-existing defects that would have contributed to this occurrence.
The occurrence ambulance was equipped with an event data recorder (EDR), a tachograph, and an automatic vehicle locator (AVL):
1.18 The ambulance crew
The ambulance crew comprised 2 paramedics. Both crew members were qualified for their respective positions and met company work/rest requirements.Footnote 23 The ambulance crew had been working shifts of 4 days on duty (1000 to 2100), followed by 4 days off duty. The 2 crew members had worked together regularly and were alternating driving duties on a day-to-day basis during their 4-day shifts.
At BCAS, there are 4 levels of paramedics:
Both the ambulance driver and the paramedic in the patient compartment were Level 2 paramedics with an Intravenous endorsement.
All 4 levels of paramedics were required to be licensed by the Emergency Medical Assistants Licensing Board. To drive an ambulance, a paramedic is required to have a minimum Class 4 unrestricted driver's licence. In this occurrence, the driver held a Class 4 driver's licence.
In British Columbia, ambulance drivers are also governed by the BCAS driving policy and procedure, as well as the Motor Vehicle Act and the Emergency Vehicle Driving Regulation.
1.18.1 Training for ambulance drivers at the British Columbia Ambulance Service
The driver training program at BCAS had the following elements:
Driver training at BCAS did not specifically include training relating to operating the ambulance safely over railway crossings. However, as part of acquiring a Class 4 driver's licence, the Insurance Corporation of British Columbia provides drivers with some training on railway crossing safety.
Training records indicated that the occurrence ambulance driver had completed the Emergency Vehicle Driving Regulation course on 27 March 2011. There were no records to indicate that the driver had completed the FOEVO training or had participated in the driving practicum.
During the driver's long-standing employmentFootnote 25 relationship with BCAS, the following additional training opportunities were available:
1.18.2 Operation Lifesaver crossing awareness training for emergency responders
Operation Lifesaver produced a driver's training course aimed specifically at emergency responders who, as part of their duties, interact with railway crossings. The course is titled "Live to Help Another Day." This 60-minute instructor-led course focuses on the dangers at highway-railway crossings. The course teaches emergency responders the steps to ensure safety at highway-railway crossings, including the safety of the people in their care. The course includes
The course includes a 16-question safety quiz for the participants. This training was not part of the BCAS driver-training curriculum.
1.18.3 Supervision and performance monitoring of ambulance drivers
Most transportation industries routinely monitor their drivers' performance to ensure compliance with company policies and procedures and with regulatory requirements. Driver monitoring—such as downloading and reviewing onboard recording devices, real-time monitoring (ride-along) of the driver's performance, evaluation, and review with employees—is also used to assess the effectiveness of driver training programs.
At BCAS, front-line supervisors are responsible for ensuring that policies, procedures, and regulations are followed. Supervisors are expected to work with employees to address any driver concerns. If a skill or ability gap is identified, additional driver education and teaching is to be provided. However, no specific performance monitoring system had been implemented to evaluate drivers for compliance with provincial and company standards and to assess the effectiveness of company driver training.
1.19 Use of cellphones while operating a motor vehicle
Part 3.1, section 214.2 (1) of the BC Motor Vehicle Act states:
A person must not use an electronic device while driving or operating a motor vehicle on a highway.
Section 214.1 (Definitions) states:
"Electronic device" means;
"Use", in relation to an electronic device, means one or more of the following actions:
Part 3.1, section 214.2 (2) states:
Without limiting subsection (1), a person must not communicate by means of an electronic device with another person or another device by electronic mail or other text-based message.
Section 214.3 (Exceptions to prohibition – emergency personnel) states:
Section 214.2 does not apply to the following persons who use an electronic device while carrying out their powers, duties or functions:
Section 214.4 (Exceptions to prohibition – certain permitted activities) states:
Section 214.2 does not apply to a person who uses an electronic device:
1.20 Policy of the British Columbia Ambulance Service on cellphone use
In June 2009, BCAS implemented a policy on the use of cellphones while on company service. The policy, entitled Restrictions on Cellular Telephone Use, states (in part):
- Prohibitions or restrictions on the use of cellular telephones while operating motor vehicles will enhance the safety of patients, the public, and employees. Also, the professional image of the BCAS will be preserved by restricting personal cellular telephone calls to times when employees are not in the presence of the public.
In this policy:
- cellular telephone
- "Cellular telephone" means any electronic telecommunications device used for wireless communications and includes, but is not limited to, devices used as personal organizers, and for text messaging, web browsing, personal scheduling or for similar services, but does not include a data terminal, two-way radio, or a portable radio supplied by the employer.
- hands-free accessory
- "Hands-free accessory" means an attachment, add‑on, built-in feature, or addition to a cellular telephone that, when used, allows the driver to maintain both hands on the steering wheel.
Employees must use cellular telephones provided by the employer as professional business tools required to do their work and to provide efficient service delivery. This use is subject to the same restrictions and management review process as any other Emergency and Health Services Commission resource provided to the BCAS. Research has revealed that the risk of a motor vehicle accident increases when using a cellular telephone because driver concentration and attention can be compromised. This risk can be reduced by restricted and appropriate use. Uniformed employees engaging in private cellular telephone conversations while serving the public create an unprofessional image and this behaviour must be avoided.
Appropriate and Safe Communications
Employees must not use a cellular telephone while driving a vehicle during the course of their employment.
Employees must not use a personal cellular telephone for private communications during an ambulance call, in the presence of the public, or in the presence of other agencies attending at a scene.
Despite subsection A.(1), above, employees driving an ambulance may use the following devices when provided by the employer:
When practicable, the attending paramedic should relieve the driver from the need to communicate by radio or from the need to use a data terminal.
Paramedic attendants or paramedic drivers must not use a cellular telephone supplied by the employer for personal calls.
During an ambulance call all personal cellular telephones must be turned off, or have the ring tone muted, or have the cellular telephone forwarded to another number.
Employees must arrange their private cellular telephone calls in a manner that does not interfere with service delivery, and in a manner that does not detract from the professional image of the BCAS.
All cellular telephones or other wireless transmitting devices must be turned off in or near an intensive patient care area of a hospital or in any area that has signs or employees advising others that such devices must be turned off.
Employees must conduct themselves professionally and refrain from using cellular telephones, two-way radios, portable radios, or any communications device in any manner that would be considered inappropriate or offensive to co-workers, to employees of other agencies or to members of the public.
1.21 Use of cellphones while operating the ambulance
While operating the vehicle, the ambulance driver made 2 phone calls on the approach to the crossing (Figure 8).
Both calls were made using a personal cellphone with which the driver was not familiar. It could not be definitively determined whether a hands-free device was used. The subject of both calls was considered to be complex. Tables 3 and 4 summarize the 2 phone calls and related communications earlier in the morning.
|Call time||Call duration
(caller 1 and caller 2)
|0857:02||2:29||Outgoing call to caller 1|
|0909:52||0:02||Outgoing call to caller 2|
|0940:54||0:19||Outgoing call to caller 2|
|0941:31||0:14||Outgoing call to caller 2|
|0941:57||0:28||Outgoing call to caller 2|
|0942:40||3:00||Outgoing call to caller 2|
|0945:42||2:05||Incoming call from caller 1. Call redirected.|
|0946:19||3:55||Outgoing call to caller 1|
|Call time||Call duration
(caller 1 and caller 2)
|1105:29||0:27||Incoming call from caller 1 during patient pickup. Call redirected.|
|1116:59||1:25||Outgoing call to caller 1 while ambulance was in transit.|
|1119:09||5:29||Outgoing call to caller 2. The call remained connected from prior to until after the crossing collision.|
|1125:00||0:02||Incoming call from caller 2. Call redirected.|
1.22 Driver distraction
Driver distraction is the diversion of attention away from activities critical for safe driving toward a competing activity.Footnote 27 Although distraction can be transient, there is ample evidence that driver distraction impairs driving performance and is a significant cause of motor vehicle crashes worldwide.Footnote 28 Texting and dialling, or other activities that require the driver to handle and look at the device, result in the driver looking away from the road, leading to reduced vehicle control and increased missed events.Footnote 29 This physical and visual distraction is why it is illegal to use hand-held devices while driving.
Research into driver distraction indicates that
Following its investigation into a 2010 multi-vehicle highway accident in Gray Summit, Missouri, the NTSB in 2011 called for the nationwide ban on driver use of portable electronic devices while operating a motor vehicle. The NTSB stated (in part):
In the last decade, the NTSB has identified the use of a portable electronic device as a factor in the probable cause of eight accidents and incidents across all transportation modes. "Forty-six people died and 181 were injured in these events," said Vice Chairman Hart. "In light of this and the growing penetration of portable electronic devices in the United States, the NTSB is concerned and believes that now is the time to act to preserve safety for everyone on our roadways."Footnote 40
In addition, the NTSB concluded that talking or texting while driving, even on a hands-free device, distracts the driver from the driving task, increasing the risk of an accident. In 2015, the NTSB added the use of personal electronic equipment while driving to its "Most Wanted List."Footnote 41
1.23 Situational awareness
Situational awareness can be divided into three levels: the perception of elements in the environment, the comprehension of their meaning, and the projection of their status.Footnote 42 If the first stage of perceiving the critical elements of the environment is not achieved, a vehicle driver may not be able to fully understand the context and the associated hazards.
In this occurrence, to have good situational awareness at the crossing, a vehicle driver would have to
1.24 Driver information processing on approach to crossing
Driver workload associated with an approach to a level crossing depends on the crossing type and characteristics. A passive crossingFootnote 43 equipped with only RCS involves significant workload demands, as no indication is provided to the driver regarding the presence (or absence) of an approaching train. A crossing that is equipped with a GCWS reduces driver workload, as the device removes most of the decision-making demandsFootnote 44 especially if there are gates and the gates have already descended.
Approaching the crossing eastbound on Crush Crescent, a driver is initially presented with an RCS and stop line sign (Figure 9) for the Milner storage track. Prior to passing this line, the driver would need to ascertain the status of the GCWS for the main track. The GCWS features must therefore be both visible and sufficiently conspicuous to be seen and to capture the driver's attention:
1.24.1 Sensory conspicuity
Characteristics of warnings, objects, or conditions that are likely to attract a driver's attention include
With respect to GCWS at crossings, red flashing lights and an audible bell are typical characteristics of warnings that are designed to attract attention. However, the primary purpose of crossing bells is to warn pedestrians and other non-vehicle road users of an approaching train. To attract attention, GCWS features should not be masked by other structures or weakened by the presence of other more notable cues.
Approaching the crossing, a driver was presented with many different visual and auditory cues, which were dispersed across the driver's field of view. The GCWS flashing red lights and bell positioned initially to the right of the driver, and then subsequently to the left, had to compete for the driver's attention in the presence of other prominent cues, such as the traffic signals and movement of traffic in the intersection. In addition, as there was no stop sign at the initial RCS, drivers would normally have been moving when they were assessing the various cues and making a decision.
In 1998, as part of a safety study involving passive grade crossings, the NTSB determined that drivers who are fully stopped at a crossing are in a better position to and are more likely to look for an approaching train compared to drivers who are still moving. The NTSB recommended that stop signs be installed at all passive crossings.
1.24.2 Cognitive conspicuity
Drivers generally seek the most meaningful information needed for that particular road location and point in time,Footnote 48 fixating on the visual cues important to a scenario—often at the sacrifice of other available cues. This phenomenon is known as "perceptual bias."Footnote 49 It could include visually searching for traffic signals relevant for the driver's planned route or turn. To ensure that the driver sees the most important visual cues for that scenario, the driver would need to easily discriminate between the most relevant cues.
At the occurrence location, even with the interconnected traffic signals working as intended, drivers approaching the crossing eastbound can be presented with conflicting information. During site examination, it was noted that the traffic signals at the intersection remained green after the GCWS had initiated. In some situations, the traffic signals remained green throughout the GCWS sequence, and even upon arrival of a train at the crossing. There were also situations when the GCWS initiated at the same time as the traffic signals turned green, presenting stop and go indications simultaneously. Further, not only did red GCWS lights flash when there was an approaching train, but so did the green left-turn signals, indicating that both signal types were important.
1.25 Activation of schemas
Expectations and knowledge about a given situation are referred to as "schemas." Perceiving and thinking based on schemas allows humans to filter, organize, and act on large amounts of information quickly and without error, such as proceeding ahead at the sight of a left-turn green light. The activation of such a schema can reduce the probability of detecting subsequent signals, as the driver may be less likely to expect them. However, activation of schemas can also lead to discordance when a schema and situation do not match.Footnote 50 When drivers receive information contrary to their expectations, their performance tends to be slow or inappropriate.Footnote 51
At this crossing, vehicle drivers sometimes received information that was contrary to their expectations, including a green traffic light with an activated GCWS. This may also occur at other similarly configured crossings.
1.26 Driver workload for left-hand turns
Driving is a complex task characterized by high demands on visual- and information-processing capacity. Certain driving manoeuvres are widely recognized by road safety researchers as being associated with increased driver workload. One such manoeuvre is a left turn across oncoming traffic, such as at an intersection, where a driver is required to (or expects to) wait for a gap in traffic before completing the turn. In-vehicle experimental research, using eye-tracking and other physiological (e.g., heart rate) and subjective measures of driver workload, has found that workload is greatest when drivers are making turns to the left across potential oncoming traffic.,Footnote 46,Footnote 52
If drivers are negotiating a complex manoeuvre, such as a left-hand turn at a busy and unfamiliar intersection, drivers may focus only on cues relevant for that manoeuvre. Such "inattention blindness"Footnote 53 can result in a driver mistakenly filtering out other important information that is available to the senses, something that also occurs with cellphone-related cognitive distraction.Footnote 31,Footnote 34,Footnote 35,Footnote 41,Footnote 43,Footnote 44,Footnote 45,Footnote 54 The TSB has previously identified inattention blindness as a contributory factor in other accidents at level crossings equipped with GCWS.Footnote 55
In this occurrence, the ambulance driver had intended to turn left when approaching the crossing eastbound on Crush Crescent. The driver slowed to acquire traffic sightlines to ensure it was safe to proceed. At that time, the crossing was free of traffic, as all other traffic had been stopped by red traffic signals. On the approach and while in the left-hand lane, the driver's main cue was a green left-turn arrow, positioned ahead of the left-turn lane and in the direction of the turn.
In this occurrence, neither the ambulance nor the train had any pre-existing mechanical defects that would have contributed to the collision. The analysis will focus on the crossing complexity and its operation, on driver distraction, driver training, and supervision, as well as on the operation of the train to the crossing.
2.1 The accident
The collision occurred when the northbound train struck the eastbound ambulance that was foul of the main track at the crossing. The ambulance had proceeded onto the crossing and was stopped on the track in front of the approaching train. In an attempt to fit the ambulance between the main track and the descended gate for westbound traffic, the ambulance was moved forward, but was still not clear of the approaching train. While the driver perceived that the descended gate was impeding the forward progress of the ambulance, the crossing gate was to the north of the front of the ambulance and was not blocking the ambulance's forward progress. Moreover, crossing gates are designed to be easily broken to allow vehicles to force their way through to clear the crossing area if required.
2.2 Driver preparedness for the crossing and intersection
A number of cellphone connections between the ambulance driver and caller 1 and caller 2 had occurred that morning. These cellphone calls were important and/or complex for the ambulance driver, as indicated by the frequency of the calls, the promptness of the returned calls, and the ambulance driver's decision to use the cellphone while driving.
When operating a motor vehicle, a complex conversation can result in cognitive distraction both during the call and after the call. Due to the proximity of the calls to the occurrence crossing, the ambulance driver had likely become cognitively distracted while approaching and traversing the crossing. This distraction would have reduced the driver's capacity for visual scanning and visual processing. Other performance effects on driving included potential inattention blindness with "looked but failed to see" errors and slowed reaction times. In addition, the driver's lack of familiarity with the particular model of cellphone would have contributed to the level of distraction. The distraction of cellphone use likely decreased the driver's ability to detect warning stimuli in the environment while traversing the crossing.
2.3 Recognizing the activation of the grade crossing warning system
An active crossing with a grade crossing warning system (GCWS) is associated with less driver workload compared to a passive crossing, as the GCWS features reduce the demands on decision making. On approaching the crossing eastbound, the driver would have to make a stop/go decision, but this would have required only an assessment of the GCWS status. The ambulance driver perceived the GCWS to be inactive (that it was safe to proceed). As a result, the ambulance proceeded over the Milner storage track. However, the GCWS had begun to activate by this time.
The ambulance driver initially missed the activated GCWS signals as a result of a combination of factors, notably
Once the stop/go decision was made prior to the initial RCS, the driver would not likely have been scanning for or expecting GCWS-related signals, increasing the probability that they would not be detected.
2.4 Activation of schemas
2.4.1 Activation of "green light" schema
A green traffic signal is likely to activate an "it is safe to proceed" schema. However, the interconnection between the traffic signals and the GCWS can result in a scenario where green lights are continually presented even though the GCWS is active.
Having observed the green traffic light at the Crush Crescent–Glover Road intersection, the ambulance driver's initial assessment that the GCWS was inactive would have been reinforced. The reduced available cognitive resources as a result of cellphone-related distraction would have reduced the probability that the driver noticed a discrepancy in the cues presented.
2.4.2 Activation of "gate descent" schema
Upon reaching the second set of tracks (mainline track), the ambulance driver's focus continued to be on the left-hand-turn green arrow. However, with the crossing gate for westbound/opposing traffic now descending directly in the driver's line of sight, the ambulance was brought to a stop. This crossing gate was not intended for the eastbound left‑turn lane. However, the positioning of the ambulance, in part due to the faded road lane markings, had resulted in the ambulance being in close proximity to this crossing gate. The ambulance driver perceived that the crossing gate protruded directly in front of the ambulance when it did not.
Typically, a descended crossing gate will activate an "it is not safe to proceed" schema. Consistent with this schema, the driver stopped at the gate, even though it was feasible to go around the gate or to drive the ambulance past the gate. Even upon seeing and hearing the train, the driver attempted limited vehicle inputs, choosing to remain at a position that the driver thought was securely behind the gate. The driver had likely perceived the descended crossing gate as an indicator that it was not safe to proceed.
2.5 The complexity of the crossing
For eastbound vehicles on Crush Crescent approaching the crossing, drivers were presented with many different visual cues, which were dispersed across their field of view. In addition, as there was no stop sign at the RCS, the vehicles would typically be moving when the drivers were required to assess the cues and to make decisions relating to the operation of the vehicle.
Drivers will generally seek the most meaningful information needed for a particular road location (such as a road crossing) and specific point in time, often fixating on the visual cues important to a scenario to the detriment of other available cues. In this occurrence, the complexity of the two crossings and the adjacent intersection likely reduced the conspicuity of the crossing signals, decreasing the driver's ability to detect warning stimuli in the environment.
2.6 Situational awareness
It is likely that any cellphone-related distraction, coupled with the workload/focus from the more complex task of turning left at an unfamiliar intersection, limited the driver's ability to effectively achieve the first stage of situational awareness: perception of all the relevant elements in the environment. It is also likely that factors related to GCWS conspicuity and obstruction reduced the probability of the driver achieving this first stage.
In the absence of perceiving the relevant elements in the environment, such as the crossing geometry, GCWS signals, left-turn lane positioning, and purpose of the westbound gate, it is likely the driver was unable to have effectively achieved the next stage of situational awareness: assimilation and understanding of the context and associated hazards.
Once the driver positioned the ambulance on the tracks, the driver would not likely have had effective situational awareness of the geometry or features of the crossing and would not be aware of the hazard of the ambulance's position.
2.7 Crossing geometry and design
The crossing installation comprised two road crossings that were within 13 m of each other. The main track was equipped with a GCWS, and the Milner storage track had an RCS. This design did not conform to the definition of a grade crossing, nor did the sightlines for the Milner storage track meet the requirements specified in Transport Canada (TC)'s 2014 Grade Crossings Regulations. This configuration did meet the previous regulatory requirements. The requirements of the Grade Crossings Regulations must be met by 2021.
The engineering drawings prepared by the BC Ministry of Transportation and Infrastructure identified 3 lanes of traffic at the crossing:
With two eastbound lanes and a single westbound lane, the line separating the two directions of travel is not coincident with the true centreline of the road. However, when the railway's site plan drawing for this crossing and its related GCWS was prepared, the centreline depicted on the BC Ministry of Transportation and Infrastructure drawing may have been interpreted by the railway as the line separating the lanes of opposite direction of travel. As a result, the crossing gate for the 2 eastbound lanes was designed shorter than necessary, and the crossing gate for the opposing westbound lane was designed longer than necessary. However, these gate arms met the regulatory requirements as specified in Section 12.1(5) of the Grade Crossings Standards. In addition, the distance from the warning system (flashing lights) to the centreline of the road (measured perpendicular to the road) exceeded 7.7 m, requiring a cantilevered light unit.
TC's Grade Crossings Regulations and, by reference, the Grade Crossings Standards came into effect in November 2014. Railways and road authorities have 7 years from the coming into force of these regulations to upgrade their crossings to comply with the new regulations. While the full impact of the improvements required by the new Grade Crossings Regulations will not be immediate, the risk of crossing accidents will incrementally reduce as the required crossing upgrades are implemented.
2.8 Roadway lane markings at the crossing
Roadway lane markings are designed to keep vehicles on the correct portion of the roadway. The roadway markings at the crossing at the time of the occurrence were worn and degraded, making it difficult for vehicle drivers to appropriately position their vehicle for the intended route. It is likely that the ambulance was out of position in part due to the lack of a clearly marked left-turn lane, leading to the ambulance coming in close proximity to the westbound gate arm. If roadway lane markings at railway crossings are not clearly visible, vehicles may be out of position when traversing the crossing, compromising the effectiveness of the GCWS and the traffic signals, and increasing the risk of a crossing accident.
2.9 Testing the interconnection between the grade crossing warning system and traffic signals
The U.S. Federal Railroad Administration, in its safety advisory of 2010, highlighted 4 items regarding the inspection and testing of the interconnection of traffic signals with a GCWS at highway grade crossings, including the following:
For the occurrence crossing, the 5 previous years of inspections conducted for the interconnection between the GCWS and the traffic controller system were reviewed. During this period, the completeness of these inspections varied, both in quality and in the data that was documented. There was no indication that the review of any recorded information from the GCWS or the traffic controller system was part of the annual inspection, nor was it required by regulation. When this information is synchronized and compared, certain functions of the interconnection can be verified.
The interconnection testing was, at times, conducted by applying a track shunt within the crossing approach to simulate the approach of a train. However, the use of a shunt in this manner did not allow for detailed observation of the full operation and interaction between the GCWS and the traffic controller. Using this method of testing, a grade-crossing predictor can evaluate the simulated train only as a quick-moving train that will arrive at the crossing in a short period of time. Only real-time observation at the crossing will allow a full verification of the interconnection function between the GCWS and the traffic controller system. When yearly joint inspections are completed without the use of available recorded data and real-time observation, there is an increased risk that failures or inconsistencies in the interaction of GCWS with traffic signals may not be identified and corrected.
2.10 Train operation and crew actions in the vicinity of the crossing
The train was being operated at 34 mph, below the maximum authorized speed of 35 mph, as it approached the crossing. The train was not subject to any speed restrictions in the vicinity of the crossing. During the approach to the crossing, there was clear visibility and an unobstructed view from the locomotive cab.
The train crew observed the ambulance approach the crossing from the west and stop on the crossing. From their position, they could also visually verify that the GCWS was activated. They began sounding the locomotive horn as the train neared the whistle post (about ¼ mile from the crossing) as required by the CROR, and they observed the ambulance move forward twice. The train crew then sounded the horn continuously.
The train was being operated by the locomotive engineer trainee under the supervision of the in-charge locomotive engineer. The locomotive engineer opted to continue toward the crossing sounding the horn, as there did not appear to be any obstruction preventing the ambulance from clearing the crossing. Train crews are generally accustomed to encountering unauthorized persons on the railway right-of-way and vehicles that are momentarily stopped at crossings. It is not uncommon for pedestrians and/or vehicles to remain on the track until the last possible moment. As trains cannot stop quickly and they have the right-of-way on the track, train crew members generally expect that drivers and pedestrians will comply with audible warnings of an approaching train and activated GCWS at crossings. Given the absence of any apparent impediment to the ambulance clearing the crossing, along with observing the 2 short consecutive eastward movements of the ambulance and their past experience with vehicles occupying crossings, the train crew expected the ambulance to safely clear the crossing.
2.11 Driver training
The training program for new drivers at the British Columbia Ambulance Service (BCAS) provides instructions on many aspects of the operation of an emergency vehicle, including both practical (hands on) and theory (regulations and policies). However, there was no specific information or instructions concerning grade crossing safety. Operation Lifesaver's driver's training course is specifically aimed at emergency responders, who, through the course of their duties, interact with railway crossings. This information was not a part of BCAS driver training. The Operation Lifesaver course provides important information specific to safely traversing railway grade crossings and conducting emergency response activities in proximity to an active railway crossing. BCAS driver training did not include information specific to the safe operation of emergency vehicles over railway crossings or the safe conduct of emergency response activities at crossings.
For any training program to be effective, it must cover the necessary information and be available to all employees who require the training. This is particularly important for employees working in safety-sensitive positions, including ambulance drivers / paramedics. Even when performing patient transfers that are not emergency situations, paramedics are responsible for the well-being of colleagues and vulnerable individuals.
Effective and practical training in all aspects of vehicle operations is important for professional drivers to acquire the knowledge and skills they need to safely and effectively perform their work. In this occurrence, the ambulance driver had completed only 1 part of the driver training requirements (the Emergency Vehicle Driving Regulation course), which allowed the driver to operate in code 3 situations (emergent).
2.12 Driver supervision and performance monitoring
In addition to driver training, regular evaluation of driving skills through performance monitoring is necessary to ensure that the training has been effective, the drivers are putting into practice what they have learned, and the drivers maintain the knowledge and driving skills they have developed. Performance monitoring also provides a tool to ensure that drivers are adhering to policies, procedures, and applicable regulatory requirements.
At BCAS, the expectation was that supervisors would ensure that policies, procedures, and regulations were being followed and that supervisors were working with the employees to address any concerns. However, BCAS did not have a performance monitoring system in place to evaluate drivers for compliance with provincial and company standards and to assess the effectiveness of company driver training.
3.1 Findings as to causes and contributing factors
3.2 Findings as to risk
3.3 Other findings
4.0 Safety action
4.1 Safety action taken
4.1.1 Transport Canada
On 10 February 2016, Transport Canada (TC) performed a detailed inspection at the crossing and determined that
On 11 February 2016, TC issued a Notice to Canadian Pacific Railway (CP), the BC Ministry of Transportation and Infrastructure (MOTI), and the Township of Langley regarding the occurrence crossing. The Notice highlighted concerns with the railway controller, traffic controller, and pre-emption interconnection. In addition, the Notice identified concerns with timing configuration for traffic light pre-emption and warning system gate arm clearance time due to the selection of an incorrect design vehicle. The Notice also expressed concern that the roadway pavement markings were either absent or faded, such that drivers were not provided with adequate information.
In compliance with the Notice, the following changes were made:
|Seconds to train||Grade crossing warning system (GCWS) activity||Traffic signal response worst case: Green, Glover Road||Traffic signal response best case:
All red, Glover Road and
|54||Equip resp.||Equip resp.||Equip resp.|
|53||Equip resp.||Equip resp.||Equip resp.|
|52||Equip resp.||Equip resp.||Equip resp.|
|51||Equip resp.||Equip resp.||Equip resp.|
|50||Equip resp.||Equip resp.||Equip resp.|
|49||Adv. preempt||Min entry green||RR all red|
|48||Adv. preempt||Min entry green||RR all red|
|47||Adv. preempt||Advance warning||Crush clearance queue begins moving|
|46||Adv. preempt||Advance warning||Crush clearance|
|45||Adv. preempt||Advance warning||Crush clearance|
|44||Adv. preempt||Advance warning||Crush clearance|
|43||Adv. preempt||Advance warning||Crush clearance|
|42||Adv. preempt||Yellow||Crush clearance – design vehicle begins moving|
|41||Adv. preempt||Yellow||Crush clearance|
|40||Adv. preempt||Yellow||Crush clearance|
|39||Adv. preempt||Yellow||Crush clearance|
|38||Adv. preempt||Yellow||Crush clearance|
|37||Adv. preempt||Red||Crush clearance|
|36||Adv. preempt||All red||Crush clearance|
|35||Adv. preempt||All red||Crush clearance|
|34||Flashers||Crush Crescent – queue begins moving||Crush clearance|
|33||Flashers||Crush clearance||Crush clearance|
|32||Flashers||Crush clearance||Crush clearance|
|31||Flashers||Crush clearance||Crush clearance|
|30||Flashers||Crush clearance||Crush clearance|
|29||Flashers||Crush clearance – design vehicle begins moving||Crush clearance|
|28||Flashers||Crush clearance||Crush clearance – design vehicle clears crossing|
|27||Flashers||Crush clearance||Crush clearance|
|26||Flashers||Crush clearance||Crush clearance|
|25||Flashers||Crush clearance||Crush clearance|
|24||Flashers||Crush clearance||Crush clearance|
|23||Flashers||Crush clearance||Crush clearance|
|22||Gates dropping||Crush clearance||Crush clearance|
|21||Gates dropping||Crush clearance||Crush clearance|
|20||Gates dropping||Crush clearance||Crush clearance|
|19||Gates dropping||Crush clearance||Crush clearance|
|18||Gates dropping||Crush clearance||Crush clearance|
|17||Gates dropping||Crush clearance||Crush clearance|
|16||Gates dropping||Crush clearance||Crush clearance|
|15||Gates dropping||Crush clearance – design vehicle clears crossing||Crush clearance|
|14||Gates dropping||Crush clearance||Crush clearance|
|13||Gates dropping||Crush clearance||Crush clearance|
|12||Gates dropping||Crush clearance||Crush clearance|
|11||Gates dropping||Crush clearance||Crush clearance|
|10||Gates down||Crush clearance||Crush clearance|
|9||Gates down||Crush clearance||Yellow|
|8||Gates down||Crush clearance||Yellow|
|7||Gates down||Crush clearance||Yellow|
|6||Gates down||Crush clearance||Yellow|
|5||Gates down||Crush clearance||Yellow|
|4||Gates down||Crush clearance||Red|
|3||Gates down||Crush clearance||Hwy 10|
|2||Gates down||Crush clearance||Hwy 10|
|1||Gates down||Crush clearance||Hwy 10|
|0||Train||Crush clearance||Hwy 10|
|Train||Crush clearance||Hwy 10|
|Train||Crush clearance||Hwy 10|
|Train||Crush clearance||Hwy 10|
|Train||Crush clearance||Hwy 10|
|Train||Hwy 10||Hwy 10|
Source: Transport Canada
In addition, TC is updating its guidance material (Guideline For Inspecting and Testing Preemption of Interconnected Traffic Control Signals and Railway Crossing Warning Systems [TP13755]) for industry stakeholders relating to the maintenance/testing of interconnected traffic signals with GCWS.
4.1.2 Ministry of Transportation and Infrastructure
In June 2016, MOTI upgraded the traffic signal controller from an LMD 8000 to an Econolite Cobalt with a 10-wire interconnection with the railway signal bungalow. This upgrade provided additional safety features such as the following:
In addition, MOTI installed a blank out LED sign in advance of the cantilevered signal on Crush Crescent that would activate immediately upon receiving a rail pre-emption call. This would provide notification to oncoming Crush Crescent eastbound drivers of an approaching train 15 seconds prior to the activation of the railway automated warning devices. A "No Right Turn" blank out LED sign was added on Glover Road approaching Crush Crescent.
To improve the visual conspicuity of the intersection trafﬁc signal displays for Crush Crescent drivers, 2 other displays were added, providing 6 displays in total. Three of the displays are on the near side of the intersection, and 3 are on the far side of the intersection (east side of Glover Road).
At the time of the occurrence, the additional green time for the far-side signals was 4 seconds. This additional clearance green time was increased to 7.1 seconds to accommodate the relocated stop line, the increased gate drop delay, and a clearance travel speed of 15 km/h over the tracks.
4.1.3 Transportation Safety Board Railway Safety Advisory
On 17 March 2016, the TSB issued a Railway Safety Advisory (RSA) concerning the operation of the automatic warning device (AWD)Footnote 56 and the road traffic signals at the occurrence crossing.Footnote 57
The RSA noted that the AWD and the road traffic signals may present conflicting information to queued motorists eastbound on Crush Crescent:
This location presents a complex signaling challenge in which the interconnection of the AWD with the traffic signal system must safely protect vehicular traffic from passing trains. At the same time, the road traffic signals must regulate the safe flow of vehicles through this intersection. With eastbound vehicles being presented with "Stop" and "Go" commands simultaneously from the AWD and the road traffic signals, motorists may become confused. Therefore, Transport Canada, the BC Ministry of Transportation and the Canadian Pacific Railway may wish to conduct a review of the design and function of the Crush Crescent/Glover Road crossing, including a review of the interconnection between the crossing AWD and the road traffic signal system, to ensure that the risks to motorists at this crossing are minimized.
As a result of the RSA, the crossing design was reviewed again by TC. Through this review, TC determined that with the GCWS signal and gate at the mainline crossing, and the Milner storage track protected by the standard railway crossing sign, there were effectively 2 separate crossings. Since the mainline track and the Milner storage track were separated by about 13 m, these 2 tracks should have been treated as 1 crossing, as per the definition of a single-grade crossing in the Grade Crossings Regulations, which states: "… two or more road crossings at grade where the lines of the railway are not separated by more than 30 m."
On 10 May 2017, the TSB issued a second RSA concerning the jurisdictional responsibility for roadway markings at the Crush Crescent – Glover Road crossing. The RSA noted that:
Roadway lane markings are designed to keep vehicles on the correct portion of the roadway. While some of the roadway markings were recently re-painted by CP, these markings will inevitably fade, which may place motorists at risk. With no clear jurisdictional responsibility for roadway markings at this crossing, it is unknown if the roadway markings will be effectively maintained in the future. In addition, it is unknown if there are other grade crossings with adjoining road authorities in the province of BC that have resulted in unclear jurisdictional responsibility for roadway markings.
Given the importance of maintaining roadway markings, particularly in the vicinity of grade crossings, the jurisdictional responsibility for this activity should be resolved in a timely manner for the Crush Crescent - Glover Road crossing, and for other crossings in the province of BC where this responsibility is unclear.
On 26 June 2017, MOTI responded indicating (in part) that:
It is important to identify any locations where jurisdictional responsibility is unclear. While we are unaware of any other locations subject to jurisdictional dispute, ministry staff are currently undertaking a detailed review of all crossings within municipalities that adjoin provincial roads and highways.
4.1.4 Canadian Pacific Railway
On 18 February 2016, Canadian Pacific Railway upgraded the crossing control equipment from a Safetran GCP 62660 predictor to a GETS HXP-3R Unit AH that is capable of operating longer approach lengths to accommodate the additional times requested. On 09 June 2016, the crossing control equipment was further upgraded to a GETS XP4 Unit.
In June 2016, the GCWS located on the west side of the main track was relocated to the west side of the Milner storage track. The flashing lights were incorporated into a cantilever at the same location. These changes resulted in aligning the crossing with the definition of a grade crossing found in the Grade Crossings Standards, as well as addressing some sightline issues that would have had to be addressed by 2021.
In March 2016, while it was not the responsibility of the railway, Canadian Pacific Railway updated (repainted) some of the pavement markings at the crossing.
4.1.5 British Columbia Emergency Health Services
Following the occurrence, British Columbia Emergency Health Services (BCEHS) made the following changes to driver education:
To highlight the roadway lane marking deficiencies at the crossing, BCEHS sent a letter to the Township of Langley on 11 December 2015, and to the Ministry of Transportation and Infrastructure on 03 August 2016.
This report concludes the Transportation Safety Board's investigation into this occurrence. The Board authorized the release of this report on 17 May 2017. It was officially released on 13 July 2017.
Appendix A – Schematics of the crossing and intersection, prepared by BC Ministry of Transportation and Infrastructure and Canadian Pacific Railway
Appendix B – Safety Advisory 2010-02
US Federal Register / Vol. 75, No. 190 / Friday, October 1, 2010 / Notices
DEPARTMENT OF TRANSPORTATION
Federal Railroad Administration
Safety Advisory 2010–02
AGENCY: Federal Railroad Administration (FRA), Department of Transportation (DOT).
ACTION: Notice of Safety Advisory; Signal Recording Devices for Highway-Rail Grade Crossing Active Warning Systems that are Interconnected with Highway Traffic Signal Systems.
FRA is issuing Safety Advisory 2010–02 to address Safety Recommendations I–96–10 and I‑96–11, issued by the National Transportation Safety Board (NTSB) that relate to railroad and highway signal recording devices at highway-rail grade crossings equipped with active warning systems that are interconnected with highway traffic signal systems. This safety advisory recommends that States, local highway authorities, and railroads install, maintain, and upgrade railroad and highway traffic signal recording devices at these types of grade crossings. This safety advisory also recommends that States, local highway authorities, and railroads conduct comprehensive periodic joint inspections of highway traffic signal pre‑emption interconnections and use information obtained from any railroad and highway traffic signal recording devices during those inspections.
In Safety Recommendation I–96–10, the NTSB recommended that DOT require the use and maintenance of railroad and highway traffic signal recording devices at all new and improved highway-rail grade crossings equipped with active warning systems that are interconnected with highway traffic signal systems. These devices should be capable of recording sufficient parameters to allow railroad and highway personnel to readily determine that the highway traffic signals and railroad active warning systems are operating properly and in a coordinated manner. The NTSB further recommended that DOT require the use of information obtained from these railroad and highway traffic signal recording devices during comprehensive and periodic joint inspections.
In Safety Recommendation I–96–11, the NTSB recommended that DOT require the retention or upgrading of existing recording devices installed at highway-rail grade crossings equipped with active railroad warning systems that are interconnected with highway traffic signal systems. In addition, the NTSB recommended that DOT require maintenance of these recording devices and the use of information obtained from the devices during comprehensive and periodic joint inspections.
Highway traffic signal pre-emption interconnections, when present, play a critical role in the proper functioning of a highway-rail grade crossing active warning system. By changing the sequence of the traffic signal to allow highway traffic to exit the crossing prior to the arrival of a train, they can prevent vehicle entrapment on the highway-rail grade crossing. Also, the changed traffic signal sequence prevents conflicting visual traffic control messages for motorists approaching highway-rail grade crossings located in close proximity to highway traffic control signals (i.e., a proceed highway traffic signal display into a nearby highway- rail grade crossing active warning system which is activated to indicate the approach or occupancy of a train).
In order to facilitate the proper functioning of the highway traffic signal pre-emption interconnection, 49 CFR 234.261 requires that railroads test each highway traffic signal pre‑emption interconnection at least once each month. Therefore, States, local highway authorities, and railroads should identify which highway-rail grade crossings are equipped, or intended to be equipped, with a highway traffic signal pre-emption interconnection. If so equipped, railroads should ensure that the circuit plan shows the actual interconnection and the designed pre-emption time. Railroads should also ensure that the interconnection is in place and the train detection device (or equivalent) is programmed or equipped to provide the appropriate designed pre-emption function.
While FRA regulations require the testing of highway traffic signal pre-emption interconnections at least once a month, this requirement has historically only been applicable to the proper functioning of the railroad's control circuit to the highway traffic controller. While inspecting the highway traffic signal pre-emption interconnection, the actual operation of the highway traffic signal should be observed. Railroads should not rely solely on the operation of a relay or the opening of a control circuit to the traffic signal control housing. In fact, the preferred method of testing highway traffic signal pre-emption is by observation of a train movement and of the actual pre-emption function. Therefore, FRA recommends that railroads conduct comprehensive joint inspections of the highway traffic signal pre-emption interconnection with State and local highway authorities. These comprehensive joint inspections should be conducted when the highway-rail grade crossing active warning system is placed in service, whenever any portion of the system which may affect the proper function of the interconnection is modified or disarranged, and at least once every 12 months, during which observation of the actual pre-emption function and its effect on the highway traffic signal system can be made. These comprehensive periodic joint inspections should also include an inspection of the timing and operation of highway traffic signal systems that are interconnected with highway-rail grade crossing active warning devices, in order to ensure that the highway traffic signal system responds appropriately to the railroad control circuit and as designed. By conducting comprehensive periodic joint inspections, the railroad and State and local highway authorities can work together to observe and verify proper functioning of all necessary components of the highway traffic signal pre-emption upon activation of the highway-rail grade crossing active warning system.
Neither the Federal Highway Administration (FHWA) nor FRA require the retention or installation of railroad or highway signal recording devices at highway-rail grade crossings. However, in recognition of the critical role served by highway traffic signal pre-emption interconnections with respect to the proper functioning of a highway-rail grade crossing active warning system, States, local highway authorities, and railroads are encouraged to install railroad and highway traffic signal recording devices at all new and improved highway-rail grade crossings that have (or will have) active warning systems which are (or will be) interconnected with highway traffic signal systems. Railroad and highway traffic signal recording devices can provide a record of any anomalies associated with the operation of the highway-rail grade crossing active warning system and/or the highway traffic signal system, which may prompt further investigation. Thus, as noted by the NTSB, these recording devices should be capable of recording sufficient parameters to allow railroad and highway personnel to readily determine that the highway traffic signals and railroad-activated warning systems are coordinated and operating properly.
States, local highway authorities, and railroads are also encouraged to maintain and upgrade existing railroad and highway traffic signal recording devices at highway-rail grade crossings that have active warning systems which are interconnected with highway signal systems. With respect to signal recording devices for highway-rail grade crossing active warning systems, older devices can record basic information such as approach time and estimated train speed. However, current signal recording devices for highway-rail grade crossing active warning systems can monitor a variety of system functions and provide reports on the ''health'' of the warning system, such as the status of the flashing light units, gate position, power supply, the presence of any grounded circuits, etc. Many modern traffic signal systems feature software that includes various event logs that get recorded in the traffic signal controller itself. These event logs are periodically retrieved by the central system software. Among the data retrieved would be any observed conflicts or preempts, as well as logs and diagnostics on the vehicle detector in-pavement ''loops''. Recognizing that data provided by signal recording devices can assist States, local highway authorities, and railroads with the maintenance of interconnected highway-rail grade crossing active warning systems and highway traffic signal systems, FRA recommends that States, local highway authorities, and railroads use the data provided by these recording devices during their comprehensive periodic joint inspections to determine whether further investigation of any recorded operational anomalies may be warranted. It should be noted that railroad and highway traffic signal recording devices may be eligible for funding through FHWA's Railway-Highway Crossings Program (23 USC 130).
Based on the foregoing discussion and to promote the safety of highway-rail grade crossings on the Nation's railroads, FRA recommends the following:
States and local highway authorities and railroads are encouraged to take action consistent with the preceding recommendations to help ensure the safety of highway-rail grade crossings. FRA may modify this Safety Advisory 2010–02, or take other appropriate action necessary, to ensure the highest level of safety on the Nation's railroads.
Issued in Washington, DC, on September 27, 2010.
Associated Administrator for Railroad Safety/Chief Safety Officer.
- Footnote 1
All times are Pacific Daylight Time (Coordinated Universal Time minus 7 hours).
- Footnote 2
A non-emergent call refers to a non-emergency situation that does not require emergency care.
- Footnote 3
All directions are true geographical directions and may not be consistent with railway timetable directions.
- Footnote 4
The ambulance driver was also a paramedic.
- Footnote 5
Distributed power allows for the physical distribution of locomotives at points through the train. These distributed power locomotives are remotely controlled from the leading locomotive.
- Footnote 6
Intermodal container cars can be made up of 1, 3, or 5 platforms.
- Footnote 7
The Township of Langley, referencing the BC Ministry of Transportation and Infrastructure Jurisdictional Atlas, does not believe it has responsibility for applying and maintaining the roadway markings at this crossing. However, MOTI indicates that a clause in a CTC Order (No. 1993-R-330, for the relocation of the crossing from Mile 18.81 to Mile 18.83 of the CP Page Subdivision) establishes the Township of Langley as the entity responsible for the crossing and the highway approaches to the crossing. As of the writing of this report, the crossing is still located at Mile 18.81 of the CP Page Subdivision.
- Footnote 8
The Grade Crossings Standards are mandatory engineering standards and are incorporated by reference in the Grade Crossings Regulations.
- Footnote 9
Nuisance operations occur when the GCWS is activated, but with no train approaching or in the immediate vicinity.
- Footnote 10
TC's draft technical standards, entitled Road/Railway Grade Crossings: Technical Standards and Inspection, Testing and Maintenance Requirements (RTD 10), were issued in 2002. They set out the minimum safety criteria for the construction or alteration, and maintenance (including inspection and testing) of grade crossings and their road approaches. The RTD 10 draft standards were not enforceable, but they were being used as guidelines by TC and the rail industry / road authorities when reviewing safety at grade crossings.
- Footnote 11
Transport Canada Railway Safety Inspectors are empowered by the Railway Safety Act to take regulatory action in the event of a threat or an immediate threat to safe railway operations.
- Footnote 12
A design vehicle is the longest vehicle permitted by statute of the road authority on that roadway.
- Footnote 13
The gate arm clearance time is the time from the initial activation of the GCWS to the time the gate arm begins to descend.
- Footnote 14
The stopping sight distance means the sum of the distance travelled during the perception and reaction time of a vehicle driver to a signal, plus the vehicle braking distance.
- Footnote 15
The clearance distance is the distance between the departure point, in advance of a grade crossing, and the clearance point beyond the farthest rail (e.g., 7.9 metres beyond the farthest rail).
- Footnote 16
Transportation Safety Board of Canada, Rail Safety Advisory Letter 07/16: Crossing Safety at Crush Crescent–Glover Road in Langley, BC (17 March 2016), available at http://www.bst-tsb.gc.ca/eng/medias-media/sur-safe/letter/rail/2016/r15v0191/r15v0191-617-07-16.asp (last accessed on 21 May 2017).
- Footnote 17
Grade Crossings Standards, section 7, Sightlines 7.1.1, 7.2 (a) (b) (c), Figure 7.1 (a) (b).
- Footnote 18
Section 12.1(5) of the Grade Crossings Standards states (in part), "… for grade crossings used by vehicles, gate arms must extend to within 1 m (3 ft.) of the farthest edge of that portion of the road approach." The gate configuration is considered acceptable if the gate arms are within 1 m of the centreline of the road approach.
- Footnote 19
Grade Crossings Standards, section 13.3, Cantilevered Light Units 13.3.1 (a).
- Footnote 20
This information was taken directly from CP's circuit plan for the configuration of the GCWS controller.
- Footnote 21
MOTI considers that the traffic control system met the following requirements:
- Footnote 22
The clearance queue is the calculated duration required for the design vehicle to clear the crossing.
- Footnote 23
The company's work/rest policy requires that crew members have 8 hours off duty between duty periods.
- Footnote 24
Code 3 is the ambulance response code relating to an emergency response with lights and siren.
- Footnote 25
The driver started as a casual employee with the ambulance service in May 1989 and moved into a full-time role in October 1999.
- Footnote 26
Ambulance services means the use of an ambulance to (a) provide emergency health services, or (b) transport an individual (i) under the care of, or (ii) who requires, or may require, a service provided by a medical practitioner, an emergency medical assistant, or another health-care provider.
- Footnote 27
J.D. Lee, K.L. Young and M.A. Regan, "Defining driver distraction," in: M.A. Regan, J.D. Lee and K.L. Young (eds.), Driver Distraction: Theory, Effects and Mitigation (Boca Raton, FL: CRC Press, 2009), pp. 31–40.
- Footnote 28
World Health Organization, Mobile Phone Use: A Growing Problem of Driver Distraction (WHO, 2011), at http://www.who.int/violence_injury_prevention/publications/road_traffic/distracted_driving_en.pdf (last accessed on 22 May 2017).
- Footnote 29
K. Kircher, C. Patten and C. Ahlström, Mobile Telephones and Other Communication Devices and Their Impact on Traffic Safety: A Review of the Literature (Stockholm: VTI, 2011).
- Footnote 30
D.L. Strayer, J.M. Cooper, J. Turrill, J. Coleman, N. Madeiros-Ward and F. Biondi, Measuring Cognitive Distraction in the Automobile (AAA Foundation for Traffic Safety, 2013), at https://www.aaafoundation.org/sites/default/files/MeasuringCognitiveDistractions.pdf (last accessed on 22 May 2017).
- Footnote 31
D.L. Strayer and F.A. Drews, "Cell-phone-induced driver distraction," Current Directions in Psychological Science, Vol. 16, No. 3 (2007), pp. 128–131..
- Footnote 32
D.L. Strayer and W.A. Johnston, "Cell phone induced failures of visual attention during simulated driving," Journal of Experimental Psychology: Applied, Vol. 9, No. 1 (2003), pp. 23–32.
- Footnote 33
T.A. Schweizer, K. Kan, Y. Hung, F. Tam, G. Naglie and S.J. Graham, "Brain activity during driving with distraction: an immersive fMRI study," Frontiers in Human Neuroscience, Vol. 7 (2013), Article 53.
- Footnote 34
W.C. Maples, W. DeRosier, R. Hoenes, R. Bendure and S. Moore, "The effects of cell phone use on peripheral vision," Optometry, Vol. 79, No. 1 (2008), pp. 36–42. Referenced in reference 33.
- Footnote 35
V. Beanland and K. Pammer, "Looking without seeing or seeing without looking? Eye movements in sustained inattentional blindness," Vision Research, Vol. 50, No. 10 (2010), pp. 977–988.
- Footnote 36
G.F. Briggs, G.J. Hole and M.F. Land, "Emotionally involving telephone conversations lead to driver error and visual tunnelling," Transportation Research Part F: Traffic Psychology and Behaviour, Vol. 14, No. 4 (2011), pp. 313–323. Referenced in reference 29.
- Footnote 37
C.S. Dula, B.A. Martin, R.T. Fox and R.L. Leonard, "Differing types of cellular phone conversations and dangerous driving," Accident Analysis & Prevention, Vol. 43, No. 1 (2011), pp. 187–193.
- Footnote 38
C.J.D. Patten, A. Kircher, J. Östlund, L. Nilsson and O. Svenson, "Driver experience and cognitive workload in different traffic environments," Accident Analysis & Prevention, Vol. 38, No. 5 (2006), pp. 887–894.
- Footnote 39
D.A. Redelmeier and R.J. Tibshirani, "Association between cellular-telephone calls and motor vehicle collisions," New England Journal of Medicine, Vol. 336, No. 7 (1997), pp. 453–458.
- Footnote 40
National Transportation Safety Board, "NTSB Vice Chairman testifies on nationwide ban on driver cell-phone use," at http://www.ntsb.gov/news/press-releases/Pages/NTSB_Vice_Chairman_testifies_on_nationwide_ban_on_driver_cell-phone_use.aspx (last accessed on 2 June 2017)
- Footnote 41
National Transportation Safety Board, "Disconnect from deadly distractions," NTSB "Most Wanted List of Transportation Safety Improvements 2015," at http://www.ntsb.gov/safety/mwl/Pages/mwl1_2015.aspx (last accessed on 03 May 2017).
- Footnote 42
M.R. Endsley, "Toward a theory of situation awareness in dynamic systems," Human Factors, Vol. 37, No. 1 (1995b), pp. 32–64.
- Footnote 43
A passive crossing is a crossing without a GCWS (flashing lights or gates).
- Footnote 44
National Cooperative Highway Research Program, Report 600: Human Factors Guidelines for Road Systems, 2nd Edition (Transportation Research Board, 2012), available at http://onlinepubs.trb.org/onlinepubs/nchrp/nchrp_rpt_600second.pdf (last accessed on 22 May 2017).
- Footnote 45
P.L. Olson, R. Dewar and E. Farber, "Vision, audition, vibration and processing of information," in: Forensic Aspects of Driver Perception and Response, 3rd Edition (Tucson, AZ: Lawyers & Judges Publishing Company, 2010).
- Footnote 46
P.A. Hancock, G. Wulf, D. Thom and P. Fassnacht, "Driver workload during differing driving maneuvers," Accident Analysis & Prevention, Vol. 22, No. 3 (1990), pp. 281–290.
- Footnote 47
P.L. Olson, R. Dewar and E. Farber, "Vision, audition, vibration and processing of information," in: Forensic Aspects of Driver Perception and Response, 3rd Edition (Tucson, AZ: Lawyers & Judges Publishing Company, 2010).
- Footnote 48
- Footnote 49
F.H. Allport, Theories of Perception and the Concept of Structure (Wiley, 1955).
- Footnote 50
K. Smith and P.A. Hancock, "Situation awareness in adaptive, externally directed consciousness," Human Factors, Vol. 37, No. 1 (1995), pp. 137–148.
- Footnote 51
G.J. Alexander and H. Lunenfeld, "Driver expectancy in highway design and traffic operations," U.S. Department of Transportation report no. FHWA-TO-86-1 (April 1986).
- Footnote 52
L. Harms, "Variation in drivers' cognitive load: effects of driving through village areas and rural junctions," Ergonomics, Vol. 34, No. 2 (1991), pp. 151–160.
- Footnote 53
A. Mack and I. Rock, Inattentional Blindness (MIT Press, 1998).
- Footnote 54
P.M. Salmon, G.J. Read, N.A. Stanton and M.G. Lenné, "The crash at Kerang: investigating systemic and psychological factors leading to unintentional non-compliance at rail level crossings," Accident Analysis & Prevention, Vol. 50 (2013), pp. 1278–1288.
- Footnote 55
TSB Railway Investigation Report R13T0192.
- Footnote 56
AWD is called "grade crossing warning system (GCWS)" in this report.
- Footnote 57
Transportation Safety Board, Rail Safety Advisory Letter 07/16: Crossing Safety at Crush Crescent–Glover Road in Langley, BC (17 March 2016).
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