The bus that was involved in a crash that ended up killing Barbara Supynuk failed independent inspections both before and after her death.

On Feb. 15, 2013, Regina Transit Bus 548 veered off the road into a sign which hit Supynuk on the head. She died of her injuries just over one month later. The coroner ruled the manner of death as accidental, but Supynuk's family has sued the City of Regina.

Saskatchewan Government Insurance found that all four brake drums were worn below minimum national standards. 

skpic barbara supynuk

The family of Barbara Supynuk has launched a lawsuit against the City of Regina over the woman's death at a bus stop. (Courtesy: Supynuk family)

The coroner concluded "the rear left brake was not operational, which would have caused the bus to veer to the right and leave the roadway."  

When the Regina Police Service removed Bus 548 from the scene, they noted "that the brakes failed during this process."

An independent test was conducted a few days later and found "left rear brake failure; it failed to engage."

The coroner's report also noted that there were warnings about the brakes prior to the crash. 

In her report, Maureen Stinnen points out that in the six weeks leading up to the accident, bus drivers filed 11 vehicle defect reports about Bus 548. Five of those reports raised issues with the brakes. 

The City of Regina says Bus 548 was repaired and put back into service on March 22, 2013.

More problems emerge after the crash

But it wasn't on the road for long.

One month later, SGI conducted an inspection of Bus 548 and found it failed to meet national safety standards.

A copy of the April 23, 2013 inspection report obtained by CBC's iTeam shows a range of concerns including issues with the steering column and the right rear brake. 

Bus crash scene skpic

A bus hit a sign post, resulting in the sign falling on a woman and causing her death. (CBC)

A notation indicates "mechanical aspects to be satisfied prior to resuming service."

This was not the first time Bus 548 failed an SGI audit.

A February 23, 2012 inspection found issues related to an airbag, the front axle and rear brakes. 

SGI wrote that Bus 548 "may be in a condition as to render it unsafe for highway operation or may be in contravention of the Vehicle Equipment Regulations." It also said all repairs had to be made before the vehicle could be put back into service.

City of Regina defends bus maintenance

In September 2013, Regina's deputy city manager, Brent Sjoberg, said  "the brakes were not the cause or a contributing factor to the accident," though he acknowledged that "the brake drums were ready to be replaced."

Regarding the history of failed audits Sjoberg said the City of Regina is in regular contact with SGI. 

"It doesn't require an audit for us to take this stuff seriously. We are working on this on a regular basis."

In an e-mail to CBC News, SGI said Regina Transit has made the required improvements to its maintenance program. "These changes address the concerns SGI had regarding Regina Transit's preventative maintenance program."  

Sjoberg says "safety is paramount" for the city and he says it is continually making improvements to the inspection and maintenance program, to deal with aging vehicles. 

"We're dealing with mechanical equipment. It's going to break down from time to time."

Following the April 23, 2013, audit, Bus 548 was repaired and put back into service.

It was decommissioned and retired from service in November of 2013.

A history of trouble for bus 548

Feb 27 2012 SGI pulls bus 548 out of service, telling the city of Regina: "This vehicle shall not be operated on any public road or highway until it is repaired." » read report     » read letter
Jan 1 2013 - Feb 17 2013 Bus 548 issued 11 defect reports, 5 of them for braking issues » read report
Feb 15 2013 Barbara Supynuk hit in bus accident » read article
Feb 19 2013 - March 5 2013 Series of independent and SGI inspections are done on Bus 548; "The vehicle shall not be operated on any public road or highway until it is repaired." » read letter
Mar 5 2013 SGI officially notifies Regina of its test results; problems with brakes noted » read report
Mar 22 2013 Bus 548 returns to service
Mar 25 2013 Supynuk succumbs to her injuries in a Regina hospital » read article
Apr 23 2013 SGI inspection report raises concerns with Bus 548's steering column and right rear brake, and it is pulled from service until repairs are made » read report
Nov 2013 Bus 548 is decommissioned and retired from service.
Dec 10 2013 Coroner report into death of Supynuk deems Bus 548's "rear left brake not operational" and cites "multiple complaints regarding the brakes" resulting in "multiple defect reports". » read report