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.
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.
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.