Coroner Says City Bus Brake Failure Killed Barbara Supynuk UPDATED

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.

Author: Paul Dechene

Paul Dechene is 5'10'' tall and he was born in a place. He's not there now. He's sitting in front of his computer writing his bio for this blog. He has a song stuck in his head. It's "Girl From Ipanema", thanks for asking. You can follow Paul on Twitter at @pauldechene and get live updates during city council meetings and other city events at @PDcityhall.

13 thoughts on “Coroner Says City Bus Brake Failure Killed Barbara Supynuk UPDATED”

  1. Brent Sjoberg should be ashamed of himself. It’s bad enough to not know the condition of your buses, but to outright lie and deflect…

    I don’t know what is going on with the City of Regina in the past couple of months, but they all need to remember what the purpose of their jobs are: to serve the citizens. Sjoberg continued to put citizens at risk by denying brake problems and leaving dangerous vehicles on the road. Between that, not clearing roads to ensure the safety of citizens walking and driving in winter, the stupid waste-of-tax-dollars referendum, the consistently awful service when responding to the public (through social media and through Service Regina, as well as bold-faced lying to the media…)

    Shame on you, City of Regina. Shame on you for your terrible mismanagement. You now have this woman’s blood on your hands.

  2. I am both disgusted and pleased that this report came out.

    Disgusted in that an innocent person was taken from this world far too soon, in a tragic circumstance that could have very easily be prevented.

    Disgusted in that the City of Regina played dumb for months, claiming that the investigation was “ongoing” and they knew nothing as to what the possible cause was.

    Disgusted in that Mr. Brent Sjoberg, CMA, our Chief Financial Officer – given sole deciding authority over two MAJOR projects in excess of over a half a billion TAX dollars – would dare to try to cover up something that he inevitably HAD to know would come out in the coroner’s report.

    Disgusted in that this poor family has been battling with the City for months now, just to get treated with respect and dignity.

    Disgusted in that the City of Regina is far more concerned about their public image in ensuring we have “ample” buses on the streets – regardless of condition – than the safety of not only those that rely on this mode of transportation day in and day out, but also innocent pedestrians who would never have, in a million years, thought that the simple act of waiting for a bus, would cost them their lives.

    Pleased, though, that this scathing report SHOULD finally open the door to the mainstream media finally starting to ask the TOUGH questions of those that are paid to represent our great City. Ask the TOUGH questions, and hold them accountable for their deplorable actions that cost people’s livelihoods (affordable housing) and in the worst cases, their lives.

    No matter how much you think we need to have a good “public image” to cover your mayor’s ass, our safety should come before anything – anything – else!!! PUT OUR MONEY WHERE YOUR MOUTH IS City of Regina, and start giving the Transit Department the money they desperately need and have been asking for, for a long, long time. This is not the fault of the driver, not the fault of the inspectors, this falls squarely on those that choose to continue to funnel dirty money through City Hall to their friend’s pocketbooks.

  3. Putting it as mildly as possible: the city and province should follow the coroner’s recommendations, and somebody other than the bus driver, who probably feels terrible already, should be sanctioned and sanctioned firmly.

  4. This city sadly does not listen to its residents or workers and now that has cost a life. The needless fatality occurred in a downtown that daily suffers from plugged one lane traffic that nobody wanted. It involved a bus that nobody would take the time to repair to standards. Even worse the city ducks and continues to shrug off responsibility.

  5. It’s not accidental if gross negligence is involved. The bus drivers and Inspectors did their job by reporting it repeatedly. They did their part. The only way City Hall will take this more seriously if there is a big lawsuit against them.

  6. Are there any other related stories that could have helped predict and prevent this tragic organizational failure?

    For example wasn’t the highly regarded transit manager bizarrely fired for no reason a few years ago?

    And hasn’t management of transit maintenance become so ineffective that routes had to be abandoned last winter due to lack of functioning buses?

  7. The current playbook at City of Regina will be to robocall everyone and blame the union driver and all unions everywhere for this. They’ll also blame the unions for the cost of the robocalls, claiming that unions make delivery of slanted propaganda a necessary city service.

    They’ll tell us this is why transit has to be given away to a private company in a lucrative and secret 30 year deal.

    Like Loraas and Emterra before them, the private bus contractor won’t actually have the necessary equipment, so taxpayers will pay for the buses and facilities. Mayor Fougere will reassure us that at the end of 30 years, we will get our obsolete buses back, and all the private contractor gets to keep is a few decades of monopolized profit.

    Brent Sjoberg will distract the public and media with meaningless risk transfer bafflegab.

    Glen Davies will continue to focus on his ringtone collection and $300,000 salary.

    Mayor Fougere will mumble his way through a pre-recorded simulation of a town hall meeting. His robocall will say “We will always own and operate the transit system”. But when John Klein records this lie, the city will run a full denial and cover up operation and claim the robocall wording was “own and manage the transit system.”

    Voter opinion will be evenly split, which Fougere will falsely call “a clear and decisive victory” for a plan to privatize the transit system.

  8. The city should close down the bus lines if there is any type of issue with the bus service. If there is one problem with one bus who is to say there is nothing visible with the other buses. I mean, it makes sense to understand what is going on within the bus system. I mean, the public can be straight up abusive and that is what I know for a fact. Why not look into the issue with the city buses. Why not spin around and look the issue into the eye. Why not sniff out the issue with the bus lines, I mean they are probably just angry at the public and probably don t have enough security at the bus lines for checking mechanics do their job appropriately and for not allowing them back in after the buses are fixed properly and having security on buses to prevent assholes from jumping back onto the buses. I guess the issue should be that people should pay more for taking the city bus or money should be taken off of other people s paycheque so that the city can address the bus city issues within the city.

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