Leader Post writer, Terrence McEachern, published a piece today about a coroner’s report on the death of Barbara Supynuk. Here’s a link to his article and link to a page on the L-P site that includes the full coroner report. They’re an important read. And the coroner’s findings are extremely disturbing.

In short, the left rear brake failed on city bus #548 on Feb. 15, causing it to veer to the right and hit a sign which struck and killed Supynuk. This coroner notes that all four brake drums on the bus were “worn beyond the maximum permissible limit which could impact the overall braking ability.”

And the brakes on bus #548 reached this state of disrepair despite transit drivers filling out five Vehicle Defect Reports between Jan 1 and Feb 17, 2013 identifying the brakes on that bus as being a problem.

Also alarming is the fact that, during the accident investigation, the failure of the left rear brake was replicated repeatedly in tests of the bus on Feb. 19. Despite this, according to MacEachern’s piece, deputy city  manager Brent Sjoberg told the media on Sept. 9 that “the brakes ‘didn’t fail’ and were not the cause or a contributing factor in the accident.”

UPDATE 5pm, Dec 10: Pat Book is also covering this story over on the CJME website and he attended a 3pm press conference at city hall. (I couldn’t go… had to get my kid from school.) Deputy city manager, Brent Sjoberg, was on point for city hall, taking questions from the press, and from Book’s coverage, his answers sound kind of maddening. Glad I didn’t go. Here’s a bit from the CJME story

Sjoberg dodged any suggestion that the brakes may have failed, even under direct questioning.

“Do you deny that the brakes failed,” he was asked at one point.

“As I said, the report speaks to evidence that was considered but the conclusion was the incident was accidental,” Sjoberg asserted.

Go read the rest.

After the jump, I’m going to attach some key passages from the report in the hopes that some mindless retyping will help dull my fury.

From the coroner’s report, on the road evidence collected on the day of the incident:

The driver began braking (continuous) midway through the intersection of Hamilton Street and 11th Avenue. The bus failed to slow and skidded to the right. The brakes were locked and steering was ineffective. The road evidence showed significant unusual skid marks specific to the left rear brake. It indicated the rear left brake was not operation which would have caused the bus to veer to the right and leave the roadway.

And on the condition of the left rear brake:

Following the scene examination, the bus was driven up to a flatbed truck and winched onto the flatbed and secured by an RPS member who noted that the brakes failed during this process.

More on the left rear brake:

Brake efficiency testing was conducted by a private vehicle inspector on February 19th which revealed consistent left rear brake failure; it failed to engage.

On a later brake inspection (emphasis mine):

Saskatchewan Government Insurance (SGI) again inspected the brake system between February 27 and March 5 after the bus was fully thawed out in a heated inspection area. It was determined that the rear left brake was working at that time; however, one has to keep in mind this occurred after the braking system had been setup and corrected at the initial inspection. SGI did identify that all 4 brake drums were worn beyond the maximum permissible limit which could impact the overall braking ability.

On the maintenance records for the bus:

A review of the maintenance records for bus #548 indicated that between January 1, 2013 and February 17, there were 11 vehicle defect reports of which 5 were for braking issues. The City indicates that inspection and maintenance was completed in each case, the last being February 7, 2013. However, no details of the repairs completed on the bus were provided byt he City in their reports. The investigation also included a review of records relating to the Regina Transit Preventative Maintenance Program which indicated that SGI has identified on-going maintenance issues as far back as 2010 including mechanical and structural defects.

On the age of the lack of Anti-Lock Braking Systems (ABS) on older buses in the city’s fleet:

This incident involved an older bus that was not equipped with ABS. The driver indicated that he stepped on the brake and he maintained his foot on the brake until the bus came to a stop. He indicated that the steering locked. At that point, the driver would have had no steering input to the road surface. In non ABS equipped vehicles in order to maintain or restore steering, it is important for the driver to corrective action by releasing the brake or pumping the brake. This is an important consideration driving this type of vehicle.

The coroner’s recommendation:

That the regulation of all municipal transit buses carrying more than 10 passengers be incorporated into the The Traffic Safety Act for the purpose of establishing and enforcing provincial standards governing the use, condition, and safety maintenance of transit buses including standards for transit bus drivers and passengers.