OC Transpo Transitway Traffic Incident February 7th, 2012 After Action Review and Analysis Report

September 18th, 2012

Prepared by:

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

EXECUTIVE SUMMARY
OC Transpo initiated an After Action Review (AAR) project in March 2012 to identify lessons learned and key recommendations stemming from the OC Transpo Transitway Traffic Incident of 7 February 2012. As a result of this incident which involved a collision between two OC Transpo buses during the evening rush hour, numerous passengers were treated for injuries and transported to local hospitals, and the Transitway around the Tunney’s Pasture Station was closed for close to two and half hours disrupting transit operations. The objective of this initiative is to review and assess OC Transpo’s emergency response processes/practices, measure the responses against industry best practices and provide recommendations for improvement. The After Action Review is designed to provide input for OC Transpo’s Incident Response Plan and related protocols and procedures. The After Action Review which included extensive stakeholder consultations, plan and procedure review and analysis of the February 7th incident response has focused on the following: Scene management o Roles and Responsibilities o Response – Transit response; Emergency Services response o Decision-making processes Incident escalation/notification Media and Political Liaison relations Public notification Training and exercises With the benefit of a review of available plans and SOPs and consultations with key staff, the following key activities would be anticipated within the scope of the OC Transpo response to the February 7th incident: Immediate response by Transit Law resources Immediate response by Transit Operations resources The designation of an OC Transpo Incident Commander at the scene Effective initial scene management in cooperation with other responders to include scene cordon, first aid and passenger safety, and road closures/detours. Detailed on-site assessments and initial reporting to the Integrated Traffic Control Centre (to include the Transit Law Communications Centre),the Transit Services Duty Officer, media and communications staff and senior management The declaration of a Level 2 incident in accordance with the Integrated Communications Centre Triage Protocol (ICCTP) and the associated response activities to include those required to inform the public, senior management and i

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

City officials and the media in accordance with the OC Transpo Transit Services Emergency Management Plan. The initiation of a formal Traffic Management Road Network Incident Response in accordance with the City of Ottawa Operational Procedures. The declaration of Enhanced Operations in accordance with the City of Ottawa EM Plan. The conduct of Post incident After Action Review (AAR)/Debrief activities following incident close out. Overall the incident response on February 7th, 2012 resulted in a timely response by both OC Transpo and City of Ottawa first responders and reflects elements of all of the key activities cited above. This multi-agency response proved generally effective and resulted in the restoration of normal transit operations on the Transitway without undue delays. Notwithstanding the general effectiveness of the response, this review has identified a number of potential lessons to be learned specifically in the areas of scene management and communications (internal communications, public notification and media relations). Moreover there is evidence that the lack of proactive communications to stakeholders created a less than favourable impression in relation to the management of the incident response and subsequent communications. A total of thirty (30) recommendations are captured in this report and are consolidated at Annex B for ease of management review and approval. The following recommendations are considered the most significant: 1. Review and update current plans, protocols and procedures based on the results of this report and the approval and implementation of the recommendations presented in this report. Priorities should be placed on; a. Validating and integrating OC Transpo Incident levels and City of Ottawa Escalation Notification Levels in the Transit Services Emergency Management Plan and associated plans and procedures; and b. Clarifying the roles of Program Managers/Chiefs in support of Incident Response when the OC Transpo Service Command Centre (SCC) is not activated. 2. Validate and adopt the Incident Response Protocol based on OC Transpo Incident Levels provided in this report (Annex A1) to assist in mitigating some of the challenges encountered in the response to the February 7th incident; most notably in relation to on scene management, incident command and control and communications; 3. Develop and implement a robust communications plan that supports the timely, appropriate and accurate flow of transit and operational information from the scene up to the operational levels of management and City Government, ridership, the public and media. Efforts to be in a position to provide a detailed
1

Roles and responsibilities and key activities associated with this protocol will also be developed and validated during a Table Top Exercise planned for May 2012

ii

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

first statement within 30 minutes of an incident to all key stakeholders (internal and external) should be considered with due regard for the proliferation of technology with email, text, social media and video capability; and 4. Conduct initial and ongoing refresher training sessions based on the updates to the Transit Services EM Plan and approved Incident Levels and Integrated Response Protocol for key OC Transpo staff (Transit Law; Transit Operations, Communications and Senior Management). It is acknowledged that OC Transpo has implemented several new practices or initiated efforts to address gaps identified though Branch level After Action Review activities; most notably the “No Surprises” approach to communications and reporting and the commitment from Transit Law to develop a checklist and targeted training for the first Transit Law officer on scene (this should consider and clarify the role of Transit Law for both Transitway and off Transitway incidents in collaboration with the applicable law enforcement partners with jurisdiction). Approval and implementation of the recommendations outlined in this report at the discretion of OC Transpo. In the interim, a Table Top Exercise based on the Incident Response Protocol presented at Annex A is planned for Fall 2012 to help further validate the findings of this report and the response protocols. Questions regarding this report can be directed to the undersigned.

Chris Davis Team Leader Lansdowne Technologies Inc 613-236-3333 ext 309 c.davis@lansdowne.com

iii

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

TABLE OF CONTENTS
EXECUTIVE SUMMARY ......................................................................................................................................... I 1 INTRODUCTION ..............................................................................................................................................1 1.1 2 OBJECTIVES OF THE AFTER ACTION REVIEW ...................................................................................................1

PROJECT APPROACH AND METHODOLOGY ........................................................................................1 2.1 2.2 METHODOLOGY ...............................................................................................................................................1 STAKEHOLDER CONSULTATIONS......................................................................................................................1

3 4

SCOPE ................................................................................................................................................................ 2 EVENT OVERVIEW ........................................................................................................................................2 4.1 4.2 4.3 BACKGROUND ..................................................................................................................................................2 OVERVIEW OF OC TRANSPO PLANS, PROCEDURES AND PROTOCOLS ............................................................... 3 OBSERVATIONS AND DISCUSSION ....................................................................................................................3

5

OBSERVATIONS AND FINDINGS ................................................................................................................7 5.1 5.2 5.3 5.4 5.5 5.6 5.7 EMERGENT THEMES .........................................................................................................................................7 FIRST IMPRESSIONS ..........................................................................................................................................8 SCENE MANAGEMENT - ROLES & RESPONSIBILITIES /TRANSIT & EMERGENCY SERVICES RESPONSE ........... 12 INCIDENT ESCALATION/NOTIFICATION AND DECISION MAKING .................................................................... 15 MEDIA AND POLITICAL LIAISON RELATIONS ................................................................................................. 17 PUBLIC NOTIFICATION ................................................................................................................................... 19 TRAINING AND EXERCISES ............................................................................................................................. 21

6

GAPS TO OC TRANSPO PLANS AND PROCEDURES ........................................................................... 22 6.1 6.2 6.3 OVERVIEW ..................................................................................................................................................... 22 OBSERVATIONS AND DISCUSSION .................................................................................................................. 23 RECOMMENDATIONS ...................................................................................................................................... 27

7 8 9

OC TRANSPO INCIDENT RESPONSE PROTOCOL ............................................................................... 29 SUMMARY OF KEY FINDINGS AND RECOMMENDATIONS ............................................................. 30 CONCLUSION................................................................................................................................................. 31

ANNEXES: ANNEX A – OC TRANSPO INCIDENT RESPONSE PROTOCOL ................................................................... 32 ANNEX B – OC TRANSPO TRANSIT WAY AFTER ACTION REVIEW RECOMMENDATIONS MANAGEMENT TABLE......................................................................................................................................... 36 ANNEX C – INTERVIEW/SESSION PARTICIPANTS ....................................................................................... 47 ANNEX D – INTERVIEW GUIDE ......................................................................................................................... 49

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

1 Introduction
Lansdowne Technologies Inc. (Lansdowne) conducted an After Action Review and analysis of the OC Transpo Transitway Traffic Incident of 7 February 2012. This review was conducted during March 2012. This report presents a set of lessons learned and recommendations identified through a series of interviews and group discussions with OC Transpo and City of Ottawa and are designed to assist OC Transpo management to: a. Review, interpret and assess the nature of the lesson learned and any related recommendations; b. Track which of the recommendations have been accepted and approved; and c. Manage the follow-on implementation of selected recommendations to enhance current plans, procedures and protocols and future incident response.

1.1 Objectives of the After Action Review
The objective of the After Action Review was to review and assess OC Transpo’s emergency response processes/practices, measure the responses against industry best practices and provide recommendations for improvement. The After Action Review recommendation will form the framework for updates to the OC Transpo Transit Services Emergency Management Plan and related Incident Response Protocols.

2 Project Approach and Methodology
2.1 Methodology
The review and assessment was based largely on the conduct of interviews with OC Transpo staff and select external stakeholders from the City of Ottawa. In addition, existing plans, protocols and procedures and available best practices were examined as part of this review and assessment.

2.2 Stakeholder Consultations
Stakeholder input to this review was captured through interviews and group sessions held with staff from: a. OC Transpo Safety Coordinator b. Transit Law c. Strategic Initiatives and Business Services 1

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

d. e. f. g. h. i. j. k. l.

Transit Operations Transit Operators that were on the scene Transit Maintenance Customer Service, Marketing and Strategic Development Transit Law Communications Traffic Management (external to OC Transpo) Traffic Operations (external to OC Transpo) Media Relations (external to OC Transpo) Office of Emergency Management

A list of interview/session participants and the interview guide used as the basis for interviews and sessions are provided at Annex C and Annex D respectively.

3 Scope
Within the scope of this review, stakeholder input was solicited on the response, control and recovery of operations and the transition to normal operations. Overwhelmingly, the majority of issues and the applicable recommendations are associated with scene management and control, escalation and communications. This report reflects analysis in the following areas: a. b. c. d. e. f. g. h. Scene management - Roles and Responsibilities Incident escalation/notification Response – Transit response; Emergency Services response Decision-making processes Training and Exercises Media relations Public notification Training and Exercises

In addition, this study explores opportunities and recommendations associated with current plans, procedures and protocols. Further a high level Incident Response Protocol has been developed to supplement current documentation.

4 Event Overview
4.1 Background
On Tuesday, February 7, 2012, a bus-on-bus collision occurred on the Transitway at the Tunney’s Pasture Transitway station at 1617 hrs, resulting in several injuries and significant damage to two OC Transpo buses. OC Transpo responded to the incident as per established response procedures and practices. As a result of the accident, several 2

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

passengers and an OC Transpo operator were injured and portions of the Transitway east and west of Tunney’s Pasture were closed for close to two and a half hours.

4.2 Overview of OC Transpo Plans, Procedures and Protocols
OC Transpo has developed and continues to enhance a comprehensive set of plans, procedures and protocols to support Emergency Management and Incident Response. The following plans, procedures and protocols were reviewed during the course of this After Action Review: Transit Services Emergency Management Plan 31 Jan 2012 Integrated Communications Centre Triage Protocol City of Ottawa Emergency Response Plan Appendix 1 of City of Ottawa Emergency Response Plan (Response Escalation) Decision Centres Concept of Operation Draft. (City of Ottawa) OC Transpo Traffic Management Guidelines (Draft March 2012) Transit Controller Incident Report and Notifications Procedures Accident and Incident Investigation and Reporting Station Detour Plan Traffic Management Road Network Incident Response (Regular Working Hours and After Working Hours)

4.3 Observations and Discussion
A number of the key the plans, procedures and protocols reviewed during this process were considered Draft and had not been fully shared and/or implemented within OC Transpo. Overall all available plans, procedures and protocols provide the necessary framework for effective incident response and include detailed escalation and response guidelines (Transit Services EM Plan, pages 60-62). Although the EM priorities within the Transit Services EM Plan align with those in the City plan, there is not a clear statement of commitment to the passengers as the first priority in any incident. Although the plans allude to the public as one of the priorities it is not definitive. From the perspective of good Public Relations and optics and from the perspective of potential litigation this is viewed as a serious oversight. In reviewing available plans and SOPs the following key activities would be anticipated within the scope of the OC Transpo response to this incident: Immediate response by Transit Law resources Immediate response by Transit Operations resources The designation of an OC Transpo Incident Commander at the scene

3

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Effective initial scene management in cooperation with other responders to include scene cordon, first aid and passenger safety, and road closures/detours. Detailed on-site assessments and initial reporting to the Control Centre, the Transit Law Communications Centre, Communications staff and senior management The declaration of a Level 2 incident and the associated response activities to include those required to inform the public, senior management and City officials and the media. The initiation of a formal Traffic Management Road Network Incident Response in accordance with the City of Ottawa Operational Procedures. The declaration of Enhanced Operations in accordance with the City of Ottawa EM Plan. The conduct of Post incident After Action Review (AAR)/Debrief activities following incident close out. The table below provides a high-level timeline of key activities associated with the OC Transpo Transitway Traffic Incident on February 7th, 2012. Table 1 – Incident Timeline Time
1617 1620 1623 1624 1624 1625 1626

Event
Collision of two buses on the Transitway near the Tunney’s Pasture Station Operations Centre receives initial call about incident from 901-277 Transit Law notified Buses still moving through accident scene Conventional Transit Operations (CTO) resources on scene Transit Law on scene and focus on first aid and treating of injured Police arrives on scene

Comments
Approximate time Level 2 call slip generated ICCTP Call Slip CCTV view of scene

1626 1627 1629 1630

Transit Operations 302 on site requests Transit Law to assist with traffic control Ambulance arrives on scene Media relations were contacted by CTO Initial consultations with OC Transpo GM and media advisory issued.

CCTV and Special Constable statement OPS assumed investigative lead supported by Transit Law. OPS advised that Transitway is private property and not subject to Highway Traffic Act. Initial assessment led to attempt to keep one lane open CCTV view-buses still moving through accident site Exact timings are not available however Corporate and OC Transpo Comms were engaged from approximately 1630 hrs onward in support of communications and media operations

4

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Time
1631 1633 1635

Event
Transitway being closed blocked by a fire truck and an OC Transpo bus. Westbound Tunney’s closed Two more ambulances arrive OC Transpo Duty Office contacts OEM/SEM Duty Officer and advises that OC Transpo “Enhanced Operations” have been initiated

Comments
CTO informed – services now using Scott St. CCTV view - stage to side of scene Full scope of disruption and injuries unknown at this time. SEM Duty Officer notes that Corporate Communications has been advised Buses detoured to upper level although a number stuck on Transitway East bound Traffic Management had not been previously contacted by OC Transpo

1635

Closure Westboro station. All East Bound diverted to Scott St. OEM/SEM Duty Office advises Traffic Management of accident Superintendent Norton on her way to site Initial information posted to the OC Transport web in relation to the accident and associated detour Additional OC Transpo responders arrives on scene Injured passengers being moved to ambulance Request from scene for Traffic Ops to extend lights.

1639

1639 1640 1642 1644 1644

1646

Chief EMS sends email to DCM Ops and Chief OFS

1648 1651

Media film crew viewed on site. Emails from control room to several OC Tpo managers Mayor’s office inquires about an incident on the Transitway near Tunney’s Pasture based on Twitter activity Corp Communications advises Mayor’s office of the incident via email. Some stranded busses being moved out of scene First ambulance leaves scene View of passengers being removed from busses and cross loading to another bus Transit Operations forwards an incident report to Corporate Comms Closure notices posted on OC Transpo website Corp Communications advises Diane Deans of incident via email with available details.

CCTV view CCTV view Transit Ops called Traffic Operations to extend lights at Scott St Advises of collision between two OC Transpo buses with injuries CCTV view A PTE-TS-TOSuperintendents report on the Incident was provided to all subscribers to the service.

1651

1653 1654 1657 1658 1700 1700 1702

CCTV view CCTV view CCTV view

Generic service message Message acknowledged with request for subsequent updates to be sent to her Blackberry.

5

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Time
1705

Event
Email from Transit Operations Program Manager to GM and other associated staff outlining the process for further updates. Reports of passengers at lower level Westboro waiting for service Transit Operations Superintendent arrives on scene Another ambulance leaves with casualties Fire truck (P23) departs scene A police car leaves scene OC Transpo Operations requests Tow trucks

Comments
CTO Program Manager continued to provide updates throughout the evening to GM and other key staff OC Transpo Radio CCTV view CCTV-ambulance #4195 CCTV view CCTV view Towing operations could not commence until Ottawa Police cleared the accident scene for investigative purposes. Number not visible in CCTV view Information to public if they had web access or smart phone CTO log and CCTV view CTO log

1709 1709 1710 1711 1712 1717

1723 1730

Another ambulance leaves scene Detailed detour information on website

1738 1738

1744 1749 1741

Tow trucks on site Email from Traffic Management reports that the Transit Way was closed - Scott St impact assessed as Moderate Another police car leaves scene Media film crew leaves site unaccompanied Chris Swail requests information regarding incident from Corporate Comms and Caroline Barriere.

CCTV view CCTV view Requesting why DCM had not been informed and requesting if the Chairs office had been informed.

1744

1751 1753 1758 1758 1759 1801 1805 1818 1839 1848 1905

Chris Swail sent another email to Corporate Comms correcting that he had been informed but did not indicate original source of information. Update issued noting 12 people transported to hospital GM confirms that Chair and Vice Chair had been informed of incident Bus blocking scene is backed up Chief EMS sends email to DCM Ops and Chief OFS Second tow truck arrives on scene view Overall 20 Buses are cleared through the site Blockage cleared but Transitway still closed O Train told to advise passengers of delays Transitway re-opened Traffic Management issues email to confirm that the Transitway re-opened. Devon Dupuis informs Chris Swail, Jocelyne Turner of Transitway reopening

CCTV view Notification that EMS is clearing from the scene CCTV view CCTV view Ops log Ops log 2hr 22 min after incident

6

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Time
1930

Event
Mobile website updating noting “Average delays of 10 to 15 minutes on many routes due to a major accident at Tunney's Pasture.”

Comments

This timeline is not considered exhaustive but is deemed to provide a comprehensive overview of the incident response and associated incident reporting that occurred on February 7th, 2012.

5 Observations and Findings
5.1 Emergent Themes
Overall the timelines and activities detailed in the Incident Timeline table above reflects a timely multi-agency response and efforts to effectively communicate the scope and impact of the incident to key stakeholders. Notwithstanding the general effective of the response, the following challenges/themes emerged during the course of the AAR: a. The requirement for more clarity of the assignment of the roles and responsibilities for Level 1 and 2 incidents to ensure there is a single identified OC Transpo Incident Commander on scene who can monitor, manage and coordinate the broader OC Transpo response and incident reporting, and collaboration with other responders. Clarification is also required on the role of Program Managers/Chiefs during Level 1 and 2 incidents; b. The requirement for additional upgrades to the OC Transpo incident response plan that details the management of the scene, notification and escalation based on Level 1, 2 and 3 incidents. As well the need to provide more direction on priorities for mitigating the effects of the incident and restoration to normal operations is warranted; c. The requirement for refresher/updated training based on OC Transpo incident levels and response; d. Challenges were encountered that inhibited the timely and accurate flow of information at the scene, within OC Transpo and to external stakeholders (riders, the public and the media); e. The requirement to ensure a better harmonization between the Transit Services EM Plan, response plans and protocols and the associated incident levels and the broader escalation notification protocols within the City of Ottawa EM Plan; and f. The requirement for a communications plan that provides clear tactical information from the scene through to the operational levels of management and 7

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

City Government. Providing ridership, the public and City leadership with timely and accurate information including the public and media is essential. Efforts to be in a position to provide a detailed first statement within 30 minutes of an incident to all key stakeholders (internal and external) should be considered with due regard for the proliferation of technology with email, text, social media and video capability.

5.2 First Impressions
Overall the incident response on February 7th, 2012 resulted in a timely response by both OC Transpo and City of Ottawa emergency services. This multi-agency response proved generally effective and resulted in the restoration of normal transit operations on the Transitway without undue delay. This was a serious incident and the timing of the event exacerbated the commuter situation and traffic as well as the notification and escalation process. Those on the scene did the best they could at an inopportune time (rush hour) and location (Transitway station); however, it has been acknowledged that there are opportunities to improve response management and to create a more robust and responsive incident management and communications reporting structure within OC Transpo. The current Transit Services EM Plan does not define Incident levels (3, 2, 1) outlined in the Integrated Control Center Triage Protocol (ICCTP) but only refers to City of Ottawa Escalation Notification levels (Normal, Enhanced Operations, Activated). The two concepts should be harmonised such that an internal ICCTP level relates to an escalation state in the Transit Services EM Plan or associates response plans, procedures and protocols and the commensurate command structure. It was also suggested that the OC Transpo EM Plan does not provide sufficient detail on key tasks and activities below the Service Command Centre (SCC)/Integrated Traffic Command Centres (ITCC) level. This was further compounded by the fact that many of the individuals interviewed during this AAR process were not familiar or well versed with all of the various plans, procedures, protocols or the incident triage protocol. Post incident AAR activities undertaken by OC Transpo immediately following this incident within respective programs as per the EM Plan and the subsequent formal multi-stakeholder review are to be commended and reflect a commitment to be a learning organization and to effective transit operations. In particular, the Conventional Transit Operations operational review conducted on February 8th, 2012 outlines a number of valid and concrete recommendations and actions that should be expedited where possible.

8

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

In addition to the observations above, the tables below summarize the key first impressions and findings from stakeholder consultations in relation to what worked well and what did not work as well as anticipated during the February 7th incident. Table 2 – What Worked Well What Worked Well? OC Transpo
1. On scene cooperation with good team work and no cross jurisdictional issues apparent. 2. Injured were evacuated from scene and there were no fatalities. Focus on the injured passengers was good. 3. Operations were restored in a reasonable time as the time line shows.

Remarks
1. Speaks well of those on the scene and the individual initiative displayed in the response. 2. Individual initiative gave rise to the idea of evacuating passenger by cross loading over to operational buses. 3. It is unlikely the scene could have been cleared sooner. OC Transpo could not remove the buses involved in the accident until the accident scene had been released by the Ottawa Police Service (OPS). 4. The removal of the glass partition between Transit Law and Operations facilitated a joint response. 5. OPS lead investigation with support from Transit Law. Chain of custody and handling of evidence was effective.

4. Good cooperation between Transit Law and Transit Operations in the Control Centre. 5. Traffic Accident Investigation –Ottawa Police and Transit Law cooperation. Vehicles on the scene were not contaminated with regard to post accident mechanical investigation

9

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Table 3 – What Did No Work As Well As Anticipated What Did Not Work As Well As Anticipated? OC Transpo
1. Scene management coordination was lacking. It was not clear to all OC Transpo responders on the scene who was in charge. 1.

Remarks
It is unclear who the overall OC Transpo Incident Commander on site was.

2. Transitway closure and formal detours should have been implemented and communicated sooner.

2.

Recognition that in an incident of this magnitude the decision to close the Transitway and implement detours should be implemented and communicated without delay.

3. Communications from the scene came from multiple sources i.e. Transit Law, Transit Operations, and EMS.

3.

Without a single OC Transpo Incident Commander timely and accurate information flow from the scene proved problematic. Safety of the passengers and staff is of paramount importance. Moreover, removing the non-injured from the site is also a key priority. Accounting for the passengers that were on the involved buses must be a priority for after incident information and due to the potential for liability and litigation. A cordon and passenger management plan are required for incidents of this nature Traffic Management has resources that can be used to effect detours and facilitate traffic flow around the disruptions. This is a key resource that needs to be in the notification chain. They could subscribe to OC Transpo Twitter feed as one possible source of notification.

4. Passenger/witness management. Time taken to get stranded passengers off trapped busses could have been shorter. Passenger names involved in the accident were not taken in a comprehensive manner.

4.

5. Traffic Management was not contacted directly by OC Transpo to assist with the station closures and detours. They currently don’t get the incident reports from OC Transpo. This delayed an Emergency Road Closure (ERC) message being sent out to key stakeholders.

5.

6. Although the trigger for Enhanced Operations as defined in the City’s EMP had been reached it was not formally declared or fully enacted by the City of Ottawa

6.

Duty Service Officers were not advised and the supporting communications infrastructure was slow to evolve compounding information flow challenges.

10

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

What Did Not Work As Well As Anticipated? OC Transpo
7. Communications to key stakeholders was not adequate and was overcome by external sources. 7.

Remarks
The communication and media plan needs to keep the public and media informed proactively. An official statement should be ideally within 30 minutes of an incident (if not sooner).

8. Plans and procedures are not sufficiently detailed to direct and guide departments or individuals in key roles.

8.

EM plan, procedures and protocols need to have sufficient detail to assign priorities and task to internal organizations and key individual assignments. Basic response and emergency management training for Level 2 and 3 incidents are a good foundation for responders based on current plans and procedures. Training based on the results of this review and the Incident Response Protocol presented at Annex A is planned for May 2012.

9. Many OC Transpo responders suggested they required more training to be better prepared for incidents of this magnitude.

9.

The balance of this section provides a more detailed analysis of specific elements of the OC Transpo response; specifically: Scene management o Roles and Responsibilities o Response – Transit response; Emergency Services response o Decision-making processes Incident escalation/notification Media and Political Liaison relations Public notification

11

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

5.3 Scene Management - Roles & Responsibilities /Transit & Emergency Services Response
5.3.1 Overview The OC Transpo Emergency Plan outlines the core concepts for incident scene management and provides high level guidance in terms of roles and responsibilities. The core plan is supplemented by a number of supporting procedures and protocols. Most notably the Chapter 4 to the Transit Services EM Plan and Addendum 2 – Incident Escalation Protocol to the plan. Incident response roles and responsibilities for OC Transpo staff to ensure effective scene management are generally well defined within existing plans and SOPs. Key entities and appointments associated with OC Transpo incidents include the Integrated Transit Communications Centre, the assigned Incident Commander and associated resources, the Transit Services Duty Officer and the General Manager. During the February 7th incident, OC Transpo staff (Transit Law, Transit Operations and Communications) responded quickly and effectively. Transit Law staff were primarily focused on first aid and passenger safety and supporting OPS in the conduct of the traffic accident investigation. Transit Operations staff were focused on implementing the Transitway closure, establishing detours and continuity of transit operations. Concurrently Communications staff was focused of efforts to advise the media, senior staff and to update various OC Transpo information sources i.e. website. 5.3.2 Observations and Discussion Although this incident occurred during the normal evening rush hour period, current working hours and scheduling practices resulting in a number of key personnel not being in a position to provide optimal support and information in the moments immediately following the incident. Notwithstanding this limitation, the Integrated Transit Command Centre (ITCC) was engaged from the outset and all key staff mobilized as quickly as possible to support the integrated response both at the scene and within the ITCC.2 Overall, on scene cooperation and management was good between all responders with an immediate focus on the care and treatment of injured passengers. There was also very good cooperation between Transit Law and Transit Operations in the ITCC (this was facilitated in part by the opening of the window partition between CTO and Transit Law communications). Similarly there was good cooperation between the Ottawa Police Service and Transit Law in the conduct of the traffic accident investigation. At the macro level all agencies (Fire, Police, Paramedic and OC Transpo) worked very well together
2

During the incident on February 7th, the OC Transpo ITCC was considered the equivalent to the OC Transpo Service Command Centre.

12

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

to resolve the situation. Noting that the Transitway is OC Transpo property jurisdictional issues were addressed effectively and without delay. At the scene, Operators participated fully in caring for injured passengers until first responders arrived on the scene. All worked well together and the injured were cared for in a timely manner. There did not appear to be any congestion of responders on the scene and the evacuation of the casualties was orderly and timely. Following the reopening of the Transitway, demobilization and consequence management was addressed well from operational perspective although elements of follow up reporting was lacking with key City officials. Although general cooperation at the scene was good, from an OC Transpo perspective, it was not clear to all OC Transpo responders on the scene who was in charge. By extension and in the absence of a clear OC Transpo Incident Commander, communications and updates from the scene was fragmented, came from multiple sources i.e. Transit Law, Transit Operations, OPS, and EMS and was provided to multiple and different recipients. In the conduct of interviews and groups sessions, no one could formally identify who the OC Transpo Incident Commander for this incident. Similarly it is not clear who the overall Incident Commander was and although organizations worked collaboratively there was scope for more effective use of resources, better communications resulting in more timely and accurate situational assessments and requests for resources. As a result each agency assigned their own priorities to the site not necessarily in concert with the others. In this incident this was not a serious issue however in a future incident this may take on much more significance. With the benefit of hindsight and this review, Transit Operations would have been the appropriate OC Transpo Incident Commander with support from all other on scene OC Transpo leads i.e. Transit Law. Arguably CTO staff assumed this lead role (Russ Hiil at scene and Cynthia Bush at control) however the formal designation of an OC Transpo lead within a broader command and control structure is not apparent. At the scene, challenges were experienced in establishing and coordinating effective passenger and witness management. Focused almost exclusively on first aid on arrival, initial responders did not establish formal triage and passenger assembly area for the injured and passengers directly involved in the incident. As a result many passengers not injured remained on the buses for a period of time and subsequently were not directed to formal triage or assembly areas and names of the injured and passengers were not collected. Controlling the flow of personnel in and around the scene also proved problematic and a formal cordon was not established. This effort was compounded by the lack of equipment and materials required to effectively isolate the scene and to communicate with the significant number of people in and around the incident scene. Both Transit Law and Transit Operations staff would have benefited from have on-site access to an Incident Command Post and emergency equipment such as scene tape, hard copies of plans maps, radios, and loud speakers.

13

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Although the challenges noted above did not compromise safety and security at the scene, the lack of a clearly designated OC Transpo Incident Command arguably compounded the challenges noted by most OC Transpo stakeholders associated with Scene Management and Communications difficulties. 5.3.3 Recommendations The following recommendations associated with enhancing scene management for OC Transpo emergencies and incidents stem from both stakeholder consultations and this external review: Table 4 – Recommendations – Scene Management Recommendations 1. The Transit Services EM Plan or associated procedures/protocols should clearly establish the process to determine the OC Transpo scene/incident commander. Remarks 1. In situations where another agency has the lead on a scene and OC Transpo is involved there should still be an OC Transpo lead to work with the overall Incident Commander. 2. A common incident command channel would allow the scene commander to manage the resources at their disposal without the distraction of other activities outside the incident scene. The existing radio system has this capability. 3. This should consider and clarify the role of Transit Law for both Transitway and off Transitway incidents in collaboration with the applicable policing partners with jurisdiction (OPP, RCMP). 4. Resources may be required for ICP vehicles.

2. Establish a protocol to have a common OC Transpo incident command channel at the scene of major incidents.

3. Transit Law to develop a checklist and targeting training for the first Transit Law officer on scene

4. Prepare a vehicle to be used as an Incident Command Post (ICP) with spare radios, plans and materials to allow the vehicle to be the basis of the ICP.

14

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendations

Remarks

5. Re-examine and clarify the roles and 5. The plans and procedures should responsibilities of Branches and key include response responsibilities, appointments with the Transit Services priorities and tasks clearly defined for EM Plan or applicable procedures. each incident level and for each Branch or appointment as required. This will be based on the pending Incident Response Protocol.

5.4 Incident Escalation/Notification and Decision Making
5.4.1 Overview Incident Escalation and Notification guidelines for OC Transpo incidents are detailed in the Transit Services EM Plan; specifically at Addendum 2. Currently OC Transpo categorizing emergencies at Level 3 – Minor, Level 2 – Serious or Level 1 – Major. The City of Ottawa details three escalation notification levels in the City EM Plan. These three levels are Normal, Enhanced Operations and Activated. 5.4.2 Observations and Discussion The initial notification from the scene was very good. In response to the February 7th incident, OC Transpo immediately declared a Level 2 incident (within 38 seconds of getting the call). As a result the Transit Services Duty Officer was contacted through the ITCC (Transit Operations Centre and Transit Law Communications Centre). The City of Ottawa SEM Duty Officer was advised of the incident by the Transit Services Duty Officer shortly after its occurrence however the scope of the incident was not fully appreciated at this point. The Transit Services Duty Officer considered the incident as meeting the criteria for OC Transpo Enhanced Operations. At the scene, the Transit Operations Supervision quickly determined the need to close the Transitway and communicated this decision to the ITCC. As a result, two of the four OC Transpo defined thresholds for Enhanced Operations (Transitway closed for more than 60 minutes and Transit Services EM Plan activated) were generally met; however, Normal operational protocols persisted and Service Duty Officers were not advised of the incident. The City remained at “Normal” throughout the incident. The Transit Service Duty Officer encountered challenges in obtaining a comprehensive assessment and situation report from the ITCC and by extension it was difficult to provide comprehensive incident updates to the SEM Duty Officer throughout the evening. As noted above this was compounded by the lack of an OC Transpo Incident Commander and consolidated reporting to the ITCC. Similarly the involvement of Program Managers/Chiefs during this incident added to the challenges faced by the 15

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Transit Services Duty Officer in achieving full situational awareness and keeping the General Manager and other stakeholders fully briefed. As a result there were multiple reporting lines established during the incident and rather that contributing to enhanced situation awareness, compounded the challenge. Current plans reflect that providing situational awareness for applicable Level 2 incidents prompting “Enhanced Operations” rests primarily with the Transit Services Duty Officer whereas this may transition to the lead Program Manager/Chief (through the activated Service Command Centre) for select Level 1 incidents prompting City wide “Activated” notification escalation. Traffic Operations were notified and supported the established detours and adjusted traffic lights in the area to ease congestion on Scott St. Traffic Management was not initially advised nor was the Traffic Incident Management Group (TIMG) activated based on the assessment of the Traffic Management Inspectors that were at site of the incident. Failure to notify the TIMG also limited the scope of incident notification. Although not a critical issue, the time of the incident proved to be after normal working hours for many key staff and complicated notification and escalation. Due to the time of the incident many people could not be contacted directly and a significant amount of operational information was passed by email or voice message. Reliance on voice messages and emails proved an ineffective means of sharing detailed and timely information. 5.4.3 Recommendations The following recommendations associated with Incident Escalation/Notification and Decision Making stem from both stakeholder consultations and this external review: Table 5 – Recommendations – Incident Escalation and Decision Making Recommendations 1. Review current triggers for OC Transpo incident levels and associated triggers for City of Ottawa Escalation Notification Remarks 1. Align both levels where applicable and integrate into applicable plans, procedures and protocols.

2. OC Transpo incident levels should 2. Key appointments include the Incident trigger an associated command and Commander, Transit Services Duty control structure to further clarify the Officer and the Service Command role of the Duty Officer and Centre. See Integrated Response Program Managers/Chiefs during Protocol proposed at Annex A. incident response.

16

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendations 3. Update and maintain duty rosters/fan outs lists for incidents to ensure key staff can be contacted during an incident regardless of their location.

Remarks 3. Consider use of pre- defined duty contact information vice individual contact information.

4. Create and maintain Transit Services Duty Officer package to include key plans, protocols and procedures, contact information, and report templates (based on EMIS). 5. Traffic Management and Traffic Operations should be notified by OC Transpo of any accident or incident that has the potential to disrupt traffic to serve as a warning order.

4. Ideally, this package should be held by all duty officers and key staff.

5. Early notification of potential problems would allow a more proactive approach allowing the Traffic Management to send an Inspector and assess the situation. It would also allow for more timely assistance in executing detours and closures. 6. Consider Duty Officers and SCC leads. A succession plan detailing authority to release information, allocate resources and commitment of funds is an essential element of any response plan.

6. Ensure that applicable plans and procedures include a succession plan outlining delegated authorities.

5.5 Media and Political Liaison Relations
5.5.1 Overview Media and political liaison relations are a shared Departmental and Corporate Communications responsibility. At the time of the incident, OC Transpo was responsible for messaging and content and Corporate Communications was responsible to distribute approved messages to the media and to inform key City officials.

17

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

5.5.2 Observations and Discussion Detailed incident information should have been provided from the scene to Corporate Communications through the ITCC and Transit Services Duty Officer. Although senior OC Transpo and City management and Corporate Communications were informed of the incident shortly after its occurrence (1629 hrs), one of the main criticisms stemming from this incident is that information to the media and key City officials was not provided in as timely and as proactive manner as anticipated. There was a sense that a significant amount of incident related information was being propagated by the public through social media and through traditional media that had attended the scene with little or no input from OC Transpo or the City. At the time of the incident, standard practices for informing the media and City officials relied heavily on email or voice message notification with subsequent follow up calls from the media and City officials to the Media Duty Officer and the General Manager. As previously noted obtaining a clear picture from the scene and preparing a comprehensive media message proved difficult. Based on policies in place on February 7th, OC Transpo did not have anyone on the scene to manage the media and to ensure a clear message was being presented on behalf of OC Transpo. Moreover authority to release a media message rested with senior management and compounded the ability to issue approved media messages in a timely manner. As highlighted previously the lack of a single OC Transpo Incident Commander at the scene to pull a consolidated message together for the ITCC and the failure of the City to adopt an Enhanced Operations posture limited the scope of media support and delayed formal reporting to key City officials. Note: Since the incident, OC Transpo management has introduced a “No Surprises” approach designed to support more effective internal communications and a more proactive approach to media and political liaison relations. 5.5.3 Recommendations The following recommendations associated with Media and Political Liaison relations stem from both stakeholder consultations and this external review: Table 6 – Recommendations – Media and Political Liaison Recommendations 1. Validate the emerging No Surprises approach against the Integrated Response Protocol. Remarks 1. Exercise to validate the Integrated Response Protocol planned for May 2012.

18

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendations 2. OC Transpo should consider having a dedicated or delegated media representative on the scene of serious and major incidents.

Remarks 2. Consider in relation to the No Surprises and media relations approach preferred by OC Transpo senior management.

3. Review the delegation of authorities to release incident related information so that it can be released in a timely manner following a serious or major incident. 4. Develop an incident reporting format to facilitate standardized information sharing and notification.

3. This has may have been addressed in part through the No Surprises approach.

4. Consider available IMS templates to include Situation Awareness report. See City of Ottawa EMIS.

5.6 Public Notification
5.6.1 Overview OC Transpo maintains a significant web presence and twitter accounts to communicate transit related information to its ridership, the public and its twitter followers. The timeliness of public notification was considered questionable as notifications in relation the closure of the Transitway and the impacts to service was widely considered inadequate. This issue is closely linked to the challenges to Media and Political liaison relations. Initial information in relation to the accident and associated detour posted to the OC Transport website at 1640 hrs; less than 15 minutes after the incident. Concurrently OC Transpo and Corporate Communications began providing information relating to the incident to local media and the public began receiving media updates shortly following the incident. No official statements were issued from the City or OC Transpo during the event. 5.6.2 Observations and Discussion The website is one of many means of communication with the public which also includes social media, and mobile applications. The OC Transpo Twitter capability was not optimized during this incident in part due to the lack of timely authorization for updates. 19

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Twitter subscribers for OC Transpo number approximately 400 Anglophones service and 40 on the Francophone service; followers include a number of elected officials. Although this is a very effective means of disseminating information to interested parties it does require the user to subscribe to the service. As well the call center handled many calls the day of the incident to inform those who requested information. Increasing the prominence of services announcement on the current web page and link to the city site would assist those seeking information. However this still requires the initiative of those with access to the media to seek the information. The Twitter service does not have a dedicated person 24/7 capable of delivering bilingual content. Moreover, the notification and approval process is not clear for releasing media. The process needs to have a speedy and robust approval process in order to provide useful and timely information. Public notification i.e. rider notification at the scene was problematic. On scene staff lacked equipment to facilitate the passage of information and as a result most information was passed by word of mouth which proved largely ineffective. 5.6.3 Recommendations The following recommendations associated with Public Notifications stem from both stakeholder consultations and this external review: Table 7 – Recommendations – Public Notification Recommendations 1. Actively promote the OC Transpo Twitter account to increase the number of followers 2. Establish protocols to make maximum and timely use of social media, web based tools, 311 services and the media to inform the public and key stakeholders. Remarks 1. Establish follower targets to enhance capability 2. Consider scope to promote transit status through local media (TTC currently uses local media to communicate status during peak hours).

20

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

5.7 Training and Exercises
5.7.1 Overview EM related training requirements for OC Transpo staff is detailed in the Transit Services EM Plan, Addendum 3. A number of EM training activities and drills had been completed prior to the accident based on the plans in existence at the time of the incident. Current training material was not formally reviewed within the scope of this project. 5.7.2 Observations and Discussion The training recommended in the Transit Services Emergency Management Plan Addendums section, if completed provides a sound foundation for staff involved in emergency response and general incident management. Many of the February 7th incident responders from OC Transpo had received Incident Management System (IMS) 100 for responders and/or IMS 200 for managers. Based on the activities and actions undertaken by responders, individual training for responders appears to be largely adequate. The more pressing concern is that a significant number of personnel involved in this incident were not fully acquainted with the draft Transit Services EM Plan and the associated Branch level incident levels, procedures and protocols. As noted, notwithstanding this limitation, the overall response proved effective; however, key plans, procedures and protocols should be subject to tabletop exercises and actual deployments to confirm checklists, resources allocations and clarity of priorities and roles and responsibilities. As a minimum key personnel likely to be involved in incident response and their backups need to be trained to the same level to contribute to plan success. Additional training associated with first officer on the scene for Transit Law has been identified as a need. It should be noted that Transit Law is currently updating training and developing a checklist for first officer on scene. There may be value in developing a similar checklist for Transit Supervisors. Maintenance noted the need for more post accident investigation training for staff. The requirement for a Wreck master certification for the tow truck operators was also flagged.

21

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

5.7.3 Recommendations The following recommendations associated with Training and Exercises stem from both stakeholder consultations and this external review: Table 8 – Recommendations – Training and Exercises Recommendations 1. Continue with IMS 100 individual training and IMS 200 training for supervisors. 1. Remarks On-site lead Supervisor expressed concern with number of issues to be handled concurrently during this type of incident. A training exercise based on the Transit Services EM Plan and the February 7th incident is planned for Fall 2012.

2. Conduct refresher/updated training based on the approved Transit Services EM Plan. This training should be confirmed by period drills and annual exercises.

2.

3. Conduct refresher post accident 3. investigation training for maintenance staff

Consider joint training with Transit Law and other investigative partners.

6 Gaps to OC Transpo Plans and Procedures
6.1 Overview
Overall appropriate plans, procedures and protocols are in place to support Transit Service emergencies3. As previously noted these include but are not limited to: Transit Services Emergency Management Plan 31 Jan 2012. Integrated Communications Centre Triage Protocol (ICCTP) City of Ottawa Emergency Response Plan Appendix 1 of City of Ottawa Emergency Response Plan (Response Escalation) Decision Centres Concept of Operation Draft. (City of Ottawa) OC Transpo Traffic Management Guidelines (March 2012) Transit Controller Incident Repot and Notifications - Procedures Accident and Incident Investigation and Reporting Station Detour Plan Traffic Management Road Network Incident Response (Regular Working Hours and After Working Hours)
3

Transit Law specific plans and procedures were not examined within the scope of this review.

22

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

6.2 Observations and Discussion
Although current OC Transpo plans, procedures and protocols provide a sound and comprehensive framework for emergency response, the February 7th incident has highlighted that some of these plans had not be approved and/or fully integrated within OC Transpo operations at the time of the incident. Internally through the Integrated Control Centre Triage Protocol (ICCTP), OC Transpo categorizes incidents using a tiered system as follows: Table 9 – OC Transpo Incident Levels OC Transpo Incident Levels
Normal: All events where the expected outcome is to address customer service/service delivery. Events where one or more of the following condition is true, escalation to ICCTP Level 1, 2, or 3: Safety/security risk Threat to employee(s) or customer(s) Law(s) have been broken Reportable property damage Liability risk Reputation risk Motor vehicle collision on Transit-related property Level 3 – Minor: Events that may require Transit Special Constable attendance and the potential for danger or injury may be a factor. Suspect may or may not be on scene. Examples: Fare disputes Mischief – graffiti Transit By-Law 2007-268 offence Wake Sleeper Ill/injured customer Criminal incidents not on Transit-related property (reported) Motor vehicle collisions Level 2 – Serious: Events that require Police and Special Constable attendance and where potential for danger or injury is a factor. Suspect may or may not be on scene. All service vehicles will be stopped as soon as practicable to ensure safety, secure statements and retain evidence. Examples: Mischief Assault Sexual Assault Emotionally disturbed person Theft Motor vehicle collisions Level 1 – Major: Events that require immediate Police attendance and where the potential for danger and/or injury is present or imminent. All Service vehicles will be stopped as soon as practicable to ensure safety, secure statements and retain evidence. Examples: Firearms discharged Homicide Weapons observed Armed Robbery (Theft with violence where a weapon is involved) Suicide Terrorist incident Motor vehicle collisions

23

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Within the City of Ottawa EM Plan and the current Transit Services EM plan, escalation notification is based on a three level approach as outlined below. Table 10 – City of Ottawa Escalation Notification Levels Escalation Notification Levels Normal: Consists of normal daily operations that services must carry out according to standard operating procedures, guidelines, policy and procedures, and legislation. When a response to an event is required it is coordinated by Incident Commanders and Service Command Centres. Enhanced Operations: Indicates a potential event which is outside of normal operating procedures. This event is imminent or occurring and could threaten public safety, public health, the environment, property, critical infrastructure and economic stability. This event may also be politically sensitive. During this phase the Office of Emergency Management and Service Duty Officers are alerted and engaged for full situational awareness and potential coordinated response. Concurrent Activities (City Wide) Normal Surveillance Situational Awareness Enhanced Operations All Service Duty Officers are contacted The services affected by the event are engaged in providing situational awareness to the OEM/SEM Duty Officer Activated Activation of both the Operation Room and Control Group Activated: Indicates an event that requires activation of the Emergency Operation Centre (EOC). Activated is the highest level of response. The OEM Duty Officer in consultation with Service Duty Officers will determine the on-call response team expected to make up the EOC.

24

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

OC Transpo has provided the following transit based triggers to the OEM as the basis for escalation notification. Table 11 – OC Transpo Escalation Notification Levels Escalation N Transit Specific Escalation Criteria ENHANCED OPERATIONS Loss of part of the Transitway for more than 60 minutes Loss of Light Rail services due to significant security or safety incident Activation of the Transit Services Emergency Management Plan Wild Cat Strike/Labour Disruption ACTIVATED None identified

The examples associated with internal OC Transpo ICCTP escalation appear to be Transit Law heavy and do not align with triggers for “Enhanced Operations” and “Activated”. These levels are not currently reflected in the Transit Service EM Plan4 but are associated with a number of procedural documents to include the ICCTP. Although plans and procedures are not definitive on the declaration of an incident level and escalation notification levels, based on the events of February 7th, the triggers for a Level 2 Incident and Enhanced Operations were met based on the following criteria: Level 2 incident due to injuries to customers and motor vehicle collision; and Enhanced Operations trigger based on loss of part of the Transitway for more than 60 minutes. Based on stakeholder feedback and a further review of the Transit Services EM Plan, additional gaps, issues and/or recommendations have been identified. These include but are not limited to: a. The Accident and Incident Investigation and Reporting SOP is a Maintenance Department SOP and is more applicable to a workplace accident rather than the type of incident that occurred on 7 Feb 2012. There is not a dedicated plan/procedure for recovery and post incident investigation. Such a plan/procedure could ensure:   that the scene is not compromised from a mechanical investigation perspective that there is a controlled access quarantine site for vehicles involved

4

The current Transit Services EM Plan aligns with the City Plan and is not specific on response related activities. Many EM plans are inclusive of Prevention/Mitigation, Preparedness, Response and Recovery activities.

25

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

      

a quality engineer attends the site to see firsthand to determine possible mechanical causes of the accident that they Quality Engineering are on the distribution list of incident photos taken by Transit Law the vehicles and equipment evidence are not compromised that debris is collected for investigation any fluid spills are noted, photographed and a sample taken have an annex to guide tow operators in making their report to assist the mechanical investigation detail the distribution of the report

b. The Station Detour Plan currently only provides a written explanation of the road configuration for the closure or detour and of the alternate route around the station. The plan would benefit by having an accompanying graphics for simplicity and ease of use. The temporary stop that was set up on Scott St was too close to the intersections and not more than one bus could enter the stop without blocking the intersection. Moreover a complete station closure plan would detail the necessary steps to divert passengers and control their flow as well as traffic around the station. Crowd control tools such as loudhailers, deployable barriers, warning tape and keys to shut down elevators may also contribute to a more effective response; c. The Transit Services EM Plan and related procedures/protocols do not reflect OC Transpo support to other law enforcement partners who may have primary jurisdiction for select incidents i.e. RCMP, OPP. Mutual knowledge and understanding of applicable EM plans and procedures is a key contributor to effective emergency response.

26

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

6.3 Recommendations
The following recommendations associated with current Plans and Procedures stem from both stakeholder consultations and this external review: Table 9 – Recommendations – Plans and Procedures Recommendations 1. OC Transpo should review escalation triggers and provide a scaled set of criteria for both Enhanced Operations and Activated. OC Transpo should consider any closure of the Transitway as a trigger for Enhanced Operations with closures in excess of 60 minutes with major impacts to traffic and services as a potential trigger for Activated. 2. The Transit Services EM Plan should be updated to reflect OC Transpo support to other law enforcement partners who may have primary jurisdiction for select incidents 3. Review and update current plans, protocols and procedures. Priorities should be placed on; i. Validating and integrating OC Transpo Incident levels and City of Ottawa Escalation Notification Levels in the Transit Services Emergency Management Plan and associated plans and procedures; and ii. Clarifying the roles of Program Managers/Chiefs in support of Incident Response when the OC Transpo Service Command Centre (SCC) is not activated. Remarks 1. All Branches should contribute to this review. The outcome of this review should be reflected in the Transit Services EM Plan and associated procedures and protocols.

2. Consult with the RCMP (Ottawa River Parkway) and OPP (Queensway, Hwy 174 etc) as appropriate.

3. Considered one of the key recommendations stemming from this review. Each Branch should have a list of priorities and actions that need to be taken at each response level.

27

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendations 4. Augment the Station Closure Plan with graphics and a supporting crowd control plan detailing the necessary resources. 5. Augment the existing Accident and Incident Investigation and Reporting SOP to ensure the chain of custody of vehicles or equipment involved in an accident.

Remarks 4. Consult with all Branches.

5. Consider activities that would ensure:          that the scene is not compromised from a mechanical investigation perspective that there is a controlled access quarantine site for vehicles involved a quality engineer attends the site to see firsthand to determine possible mechanical causes of the accident that they are on the distribution list of photos taken by Transit Law the vehicles or evidence are not compromised that debris is collected for investigation any fluid spills are noted, photographed and a sample taken have an annex to guide tow operators in making their report to assist the mechanical investigation detail the distribution of the report

6. Augment the station detour plan to provide the necessary detail to close a station to prevent passengers from using the stations and effectively reroute traffic and buses around the closed station. 7. Insert a clear statement in the Transit Service Emergency Management Plan emphasizing that the first priority is the safety and security of passengers and employees.

6. Consider the use of graphics to enhance the current plan.

7. Reflects the key stakeholder and a service focus. Internally as a good practice ensure EAP support is offered to all personnel involved in incident response (directly and indirectly).

28

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

7 OC Transpo Incident Response Protocol
As noted earlier in this report the following key activities would be anticipated within the scope of the OC Transpo response to this incident: Immediate response by Transit Law (TL) resources Immediate response by Conventional Transit Operations (CTO) resources The designation of an OC Transpo Incident Commander at the scene Effective initial scene management in cooperation with other responders to include scene cordon, first aid and passenger safety, and road closures/detours. Detailed on-site assessments and initial reporting to the Integrated Communications Control Centre, the Transit Services Duty Officer, Communications staff and senior management The declaration of a Level 2 incident and the associated response activities to include those activities required to inform the public, senior management and City officials and the media in accordance with the OC Transpo Transit Services EM Plan. The initiation of a formal Traffic Management Road Network Incident Response in accordance with the City of Ottawa Operational Procedures. As noted in this report, challenges with scene management and communications were experienced. Annex A contains an Incident Response Protocol as a supplement to current plans and procedures. This protocol is intended to prompt key activities and decisions in relation to: The designation of Incident Level; The appointment of an Incident Commander and establishment of an Incident Command and Control structure; and The establishment of effective incident reporting for responders, decision centers, key OC Transpo and City Officials, the public, and the media. Annex A includes tailored protocols for Level 3, 2 and 1 incidents.

29

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

8 Summary of Key Findings and Recommendations
A total of thirty (30) recommendations are captured in this report and are consolidated at Annex B for ease of management review and approval. The following recommendations are considered the most significant: 1. Review and update current plans, protocols and procedures based on the results of this report and the approval and implementation of the recommendations presented in this report. Priorities should be placed on; a. Validating and integrating OC Transpo Incident levels and City of Ottawa Escalation Notification Levels in the Transit Services Emergency Management Plan and associated plans and procedures; and b. Clarifying the roles of Program Managers/Chiefs in support of Incident Response when the OC Transpo Service Command Centre (SCC) is not activated. 2. Validate and adopt the Incident Response Protocol based on OC Transpo Incident Levels provided in this report (Annex A5) to assist in mitigating some of the challenges encountered in the response to the February 7th incident; most notably in relation to on scene management, incident command and control and communications; 3. Develop and implement a robust communications plan that supports the timely, appropriate and accurate flow of transit and operational information from the scene up to the operational levels of management and City Government, ridership, the public and media. Efforts to be in a position to provide a detailed first statement within 30 minutes of an incident to all key stakeholders (internal and external) should be considered with due regard for the proliferation of technology with email, text, social media and video capability; and 4. Conduct initial and ongoing refresher training sessions based on the updates to the Transit Services EM Plan and approved Incident Levels and Integrated Response Protocol for key OC Transpo staff (Transit Law; Transit Operations, Communications and Senior Management). In order to complete the After Action Review and Lesson Learned process, OC Transpo is encouraged to review and manage the recommendations captured in this report using Annex B.

5

Roles and responsibilities and key activities associated with this protocol will also be developed and validated during a Table Top Exercise planned for May 2012

30

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

9 Conclusion
Overall the incident response on February 7th, 2012 resulted in a timely response by both OC Transpo and City of Ottawa first responders. This multi-agency response proved generally effective and resulted in the restoration of normal transit operations on the Transitway without undue delays. Notwithstanding the general effectiveness of the response, this review has identified a number of potential lessons to be learned specifically in the areas of scene management and communications (internal communications, public notification and media relations). It should be noted that a number of post incident initiatives have been implemented by OC Transpo to include a No Surprises Communications approach and the ongoing development of a Transit Law Checklist for the First Officer on the Scene. In addition to the operational and communications enhancements these two initiatives address, this report provides a series of recommendations and a proposed Incident Response Protocol Process Map to supplement current plans and procedures. Training and exercises are planned for Fall 2012 to validate and support the implementation of the lessons learned from this incident.

31

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Annex A – OC Transpo Incident Response Protocol
Annex A consists of an incident response protocol overview and three separate protocols for Level 3, 2, and 1 incidents on subsequent pages

32

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

33

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

34

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

35

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Annex B – OC Transpo Transit Way After Action Review Recommendations Management Table
Key Recommendations: Recommendation 1. Review and update current plans, protocols and procedures based on the results of this report and the approval and implementation of the recommendations presented in this report. Priorities should be placed on; i. Validating and integrating OC Transpo Incident levels and City of Ottawa Escalation Notification Levels in the Transit Services Emergency Management Plan and associated plans and procedures; and Draft: Approved: Implemented: Deferred/Not Approved: Status Management Comment

ii. Clarifying the roles of Program Managers/Chiefs in support of Incident Response when the SCC is not activated.

36

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendation 2. Validate and adopt the Incident Response Protocol based on OC Transpo Incident Levels provided in this report (Annex A) to assist in mitigating some of the challenges encountered in the response to the February 7th incident; most notably in relation to on scene management, incident command and control and communications. Draft:

Status

Management Comment

Approved: Implemented: Deferred/Not Approved:

3.

Develop and implement a robust communications plan that supports the timely, appropriate and accurate flow of transit and operational information from the scene up to the operational levels of management and City Government, ridership, the public and media.

Draft: Approved: Implemented: Deferred/Not Approved:

37

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendation 4. Conduct initial and ongoing refresher training sessions based on the updates to the Transit Services EM Plan and approved Incident Levels and Integrated Response Protocol for key OC Transpo staff (Transit Law; Transit Operations, Communications and Senior Management). Draft:

Status

Management Comment

Approved: Implemented: Deferred/Not Approved:

By Functional Areas: Recommendation 5. The Transit Services EM Plan or associated procedures/ protocols should clearly establish the process to determine the OC Transpo scene/incident commander. Draft: Approved: Implemented: Deferred/Not Approved: Status Management Comment

38

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendation 6. Establish a protocol to have a common OC Transpo incident command channel at the scene of major incidents Draft:

Status

Management Comment

Approved: Implemented: Deferred/Not Approved:

7.

Transit Law to develop a checklist and targeting training for the first Transit Law officer on scene

Draft: Approved: Implemented: Deferred/Not Approved:

8.

Prepare a vehicle to be used as an Incident Command Post (ICP) with spare radios, plans and materials to allow the vehicle to be the basis of the ICP.

Draft: Approved: Implemented: Deferred/Not Approved:

39

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendation 9. Re-examine and clarify the roles and responsibilities of Branches and key appointments with the Transit Services EM Plan or applicable procedures. Draft:

Status

Management Comment

Approved: Implemented: Deferred/Not Approved:

10.

Review current triggers for OC Transpo incident levels and associated triggers for City of Ottawa Escalation Notification

Draft: Approved: Implemented: Deferred/Not Approved:

11.

OC Transpo incident levels should trigger an associated command and control structure to further clarify the role of the Duty Officer and Program Managers/Chiefs during incident response.

Draft: Approved: Implemented: Deferred/Not Approved:

40

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendation 12. Update and maintain duty rosters/fan outs lists for incidents to ensure key staff can be contacted during an incident regardless of their location. Draft:

Status

Management Comment

Approved: Implemented: Deferred/Not Approved:

13.

Create and maintain a Transit Services Duty Officer package to include key plans, protocols and procedures, contact information, and report templates (based on the City of Ottawa EMIS).

Draft: Approved: Implemented: Deferred/Not Approved:

14.

Traffic Management and Traffic Operations should be notified by OC Transpo of any accident or incident that has the potential to disrupt traffic.

Draft: Approved: Implemented: Deferred/Not Approved:

41

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendation 15. Ensure that applicable plans and procedures include a succession plan outlining delegated authorities. Draft:

Status

Management Comment

Approved: Implemented: Deferred/Not Approved:

16.

Validate the emerging No Surprises approach against the Integrated Response Protocol.

Draft: Approved: Implemented: Deferred/Not Approved:

17.

OC Transpo should consider having a dedicated or delegated media representative on the scene of serious and major incidents.

Draft: Approved: Implemented: Deferred/Not Approved:

18.

Review the delegation of authorities to release incident related information so that it can be released in a timely manner following a serious or major incident.

Draft: Approved: Implemented: Deferred/Not Approved:

42

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendation 19. Develop an incident reporting format to facilitate standardized information sharing and notification. Draft:

Status

Management Comment

Approved: Implemented: Deferred/Not Approved:

20.

Actively promote the OC Transpo Twitter account to increase the number of followers

Draft: Approved: Implemented: Deferred/Not Approved:

21.

Establish protocols to make maximum and timely use of social media, web based tools, 311 services and the media to inform the public and key stakeholders.

Draft: Approved: Implemented: Deferred/Not Approved:

43

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendation 22. Continue with IMS 100 individual training and IMS 200 training for supervisors. Draft:

Status

Management Comment

Approved: Implemented: Deferred/Not Approved:

23.

Conduct refresher/updated training based on the approved Transit Services EM Plan. This training should be confirmed by period drills and annual exercises.

Draft: Approved: Implemented: Deferred/Not Approved:

24.

Conduct refresher post accident investigation training for maintenance staff.

Draft: Approved: Implemented: Deferred/Not Approved:

44

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendation 25. OC Transpo should review escalation triggers and provide a scaled set of criteria for both Enhanced Operations and Activated. OC Transpo should consider any closure of the Transitway as a trigger for Enhanced Operations with closures in excess of 60 minutes with major impacts to traffic and services as a potential trigger for Activated. The Transit Services EM Plan should be updated to reflect OC Transpo support to other law enforcement partners who may have primary jurisdiction for select incidents. Draft:

Status

Management Comment

Approved: Implemented: Deferred/Not Approved:

26.

Draft: Approved: Implemented: Deferred/Not Approved:

27.

Augment the Station Closure Plan with graphics and a supporting crowd control plan detailing the necessary resources

Draft: Approved: Implemented: Deferred/Not Approved:

45

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Recommendation 28. Augment the existing Accident and Incident Investigation and Reporting SOP to ensure the chain of custody of vehicles or equipment involved in an accident. Draft:

Status

Management Comment

Approved: Implemented: Deferred/Not Approved:

29.

Augment the station detour plan to provide the necessary detail to close a station to prevent passengers from using the stations and effectively reroute traffic and buses around the closed station. Insert a clear statement in the Transit Service Emergency Management Plan emphasizing that the first priority is the safety and security of passengers and employees.

Draft: Approved: Implemented: Deferred/Not Approved:

30.

Draft: Approved: Implemented: Deferred/Not Approved:

46

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Annex C – Interview/Session Participants
No.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

Name
Donna Belanger Kim Weston-Martin Jane Wright Jocelyn Begin Trudy Norton Russ Hill Cynthia Bush Dave Newman Nigel Morris Cliff Edlin David Robinson Sabina Majury Jonathan Desnoyers Chris Villeneuve Jim McInytre Roch Roy Denis Racine Jim Greer Pete Simard Project Lead - Safety Coordinator

Title

Manager - Transit Safety and Enforcement Chief, Customer Service and Innovation Manager, Strategic Initiatives and Business Services Transit Superintendent Lead Transit Supervisor Lead Transit Controller Transit Supervisor Transit Supervisor Transit Supervisor Transit Supervisor Special Constable Special Constable Special Constable Staff Sergeant Transit Law Communications Centre Special Constable Manager Maintenance Operations Superintendent Maintenance

47

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

No.
20. 21. 22. 23. 24. 25. 26.

Name

Title

James Shepheard Alizera Fattahi-Ghazi Charmaine Williams Ben Proulx Anna Begin Devon Dupuis Bus Operators

Program Manager Maintenance Section Manager Maintenance Manager, Customer Service Program Manager Customer Information Program Manager Customer Info Systems Strategic Coordinator

External to Transit: 27. 28. 29. 30. 31. 32. 33. 34. 35. Phil Landry Gil Tait Jeff Larocque Joel Jonnson Chris Brinkmann Leng Ha Caroline Barriere Jocelyn Turner Jim Montgomery Manager, Traffic Management Program Manager, Traffic Management Inspector, Traffic Management Inspector, Traffic Management Manager Traffic Operations Coordinator, Traffic Operations Corporate Communications Strategist Media Relations Officer Office of Emergency Management

48

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

Annex D – Interview Guide

City of Ottawa - OC Transpo INTERVIEW GUIDE for CONSULTATIONS, GROUP AND INDIVIDUAL INTERVIEWS

NAME OF INTERVIEWER: _________________________________ NAME OF PERSON(S) INTERVIEWED: ________________________ ___________________________________________________ BRANCH/DIVISION/UNIT: ________________________________ DATE/TIME OF INTERVIEW: _______________________________

49

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

Background
On Tuesday, February 7, 2012, a bus-on-bus collision occurred on the Transitway at the Tunney’s Pasture Transitway station, resulting in several injuries and significant damage to two OC Transpo buses. OC Transpo responded to the incident as per established response procedures and practices.

Objective
The objective of this initiative is to review and assess OC Transpo’s emergency response processes/practices, measure the responses against industry best practices and provide recommendations for improvement. The After Action Review will form the framework for OC Transpo’s Incident Response Plan.

Scope
The After Action Review has been requested to review the following: Scene management Incident escalation/notification Response – Transit response; Emergency Services response Decision-making processes Media relations Public notification The formal debriefing of the incident will also include a review of interagency relations with the intent of identifying opportunities to maximize interoperability and minimize potential interagency misunderstanding.

Stakeholders
The proponent will meet with all approximately 20-25 stakeholders who were involved, either directly or indirectly, in the emergency response to this incident. This may take the form of group sessions and/or individual sessions as appropriate.

Deliverables
The After Action Review will include a: Detailed overview of the incident including timelines; Stakeholder interviews including observations and recommendations; Review of Transit Services emergency response roles and responsibilities and a gap analysis based on industry “best” or “smart” practices;

50

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

Review of Transit Services emergency plans/procedures and a gap analysis identifying areas for improvement (if applicable); Review of Transit Services’ Emergency Management Training Program and a gap analysis based on “best” or “smart” practices; Review of Transit Services’ “continuity of evidence” protocols/practices and a gap analysis identifying areas for improvement (if applicable). Process Stakeholder input will be gathered through a series of interviews and group sessions administered by Lansdowne. Interviews and group sessions with key stakeholders, as identified in consultation with OC Transpo are slated to be conducted during the period 12 – 30 March 2012. If individuals are not available for interviews and/or group sessions, electronic or hard copy competed questionnaires may be submitted. Data will be gathered without specific individual attribution although attribution will be requested, on a voluntary basis, at a group/organizational level (e.g. City department). The individual results will not be disseminated and will be used for analysis in the review and refresh of the current plan.

Questions
Interviewees and session participants will be invited to answer and provide input on questions associated with the following: Roles and Responsibilities Plans and Procedures Training and Exercises Scene management Incident escalation/notification Response – Transit response; Emergency Services response Decision-making processes Media relations Public notification Contact Information: Mr. Chris Davis Project Team Leader Lansdowne Technologies Inc Office: 613.236.3333 ext 309 c.davis@lansdowne.com Roles and Responsibilities Mr. Gary Dawson Deputy Team Leader Lansdowne Technologies Inc

51

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

1. Describe your regular / principal role with the OC Transpo/City of Ottawa.

2. Describe the core functions provided by your organization/group.

3. Do you have a designated Incident Management Role? If so please describe your Incident Management function?

4. What was your involvement with the incident on 7 Feb 2012?

5. What First Impressions of the incident do you have:

52

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

What went well? Is there one “take away” that stands out? What could be improved?

Plans and Procedures 1. Identify plans and key references that were used as part of the planning for the incident response. In terms of operations manual, guidelines, policies and SOPs; are copies readily available to all key staff?

2. What plans or directives are you aware of for expediting the care, handling and removal of passengers from an incident? Are there plans and procedures for accident scene evidence and management?

3. When was the last time key plans and procedures were reviewed and/or tested?

4. Identify methods or processes defined within current plans and procedures that worked well.

53

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

5. Identify methods or processes defined within current plans and procedures that were difficult or challenging to follow.

6. How often are the plans reviewed and amendments disseminated? How do you manage updates/changes to the plan during the implementation phase?

Training and Exercises

1. Describe any recent individual and / or collective emergency / incident management training. Have you participated in or how often do you have any specific accident response training?

54

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

2. Has your team participated in any incident response training, table top exercises or reviewed the response activities to previous events? Have relevant outside agencies been involved?

3. With regard to training in Emergency Management and other related incident response activities - Is there a need for additional training and exercises to simulate situations that could impact the OC Transpo’s ability to respond to similar incidents?

Scene management 1. When were you first advised of the Transitway incident? How and when? Did you advise anyone else of the incident? Who, how and when?

55

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

2. Describe your role and activities in support of the response to the accident.

3. Were the right people assigned to key roles? If no, how can you make sure that you get the right people assigned to the proper role the next time?

4. Were the right people assigned appropriate decision-making authority? What key decisions were made, by who and how were decisions communicated?

5. What other organizations were at the incident site? Was it clear who was designated the on scene commander?

56

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

6. To the best of your knowledge how is the incident On Site Commander in an OC Transpo incident designated or determined? If there is not an SOP to determine the on site commander who do you think should be based on your knowledge of the operation?

Incident escalation/notification 1. What information did you have and / or receive during and immediately following the response to the accident?

2. What formal escalation plans and processes are in place to deal with this type of event and / or major incidents?

57

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

3. To the best of your knowledge were the incident escalation plans and processes followed? Were there any areas where this did not occur as it should have or could be improved?

4. Describe any early warning signs of problems that were identified after the incident that it would not be resolved quickly? Were concerns escalated and communicated appropriately? How

5. Does OC Transpo have access to the City of Ottawa Emergency Information System? If so was it used for this incident? By who and how was it used?

Response – Transit response; Emergency Services response 1. Were the responses timely and with the appropriate equipment and personnel?

58

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

2. Were any necessary resources lacking that are reflected in current plans?

3. Did observe or hear of any jurisdictional issues hampering or impeding response?

4. Can you comment on the overall emergency response and the collaboration between all responding agencies?

Decision-making processes 1. What decision/emergency response centers were activated in during this incident?

59

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

2. Comment on the frequency and nature of communications in support of escalation and decision making. Did the right people have the right information to make timely decisions and to take appropriate actions? How was this information shared?

3. Was there appropriate communication between departments / units and key stakeholders? In your view, what communication approaches worked well? How can communications be further improved?

Media relations 1. When was the media contacted and by whom?

2. Who was designated to contact the media and are there benchmarks or metrics for issuing service disruption notices and holding statements etc?

60

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

3. Was there anyone designated to go to an incident site to handle the media? Who is/was authorized to talk to the media at an incident site?

Public notification 1. When was the public and ridership informed of the incident and how?

2. What means (methods) of communications where used? What others ways could the message to the public be promulgated?

3. Do think the effort had the desired effect?

61

OC Transpo Transitway Traffic Incident After Action Review and Lessons Learned Report

April, 2012

Other issues

Are there any other comments or observations that you would like to make and that have not been asked during this interview/session?

62

Sign up to vote on this title
UsefulNot useful