Cellphone distraction and confusion over a complex railway crossing caused a Canadian National train to hit an ambulance in Langley, B.C., the Transportation Safety Board says.

Helena Van Gool, 87, was a patient being taken to hospital from a long-term care facility when the crash occurred on Sept. 11, 2015. Van Gool was airlifted to hospital, where she later died.

A paramedic who was in the back of the ambulance with Van Gool was injured.

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The vehicle entered an intersection when a railway crossing bell was ringing, lights were flashing and the gates were descending, Transportation Safety Board investigator-in-charge Peter Hickli said Thursday after the agency issued a report.

He said phone records indicated the ambulance driver, a paramedic, was on a cellphone a number of times during the trip.

Other factors contributed to the driver's distraction, he said, adding the paramedic was intending to turn left at a green light but stopped on the track when a lowered crossing gate appeared to be blocking the way forward.

However, Hickli said the gate had come down for traffic moving in the opposite direction.

"From videos of the incident and all the information it's likely that the driver perceived they were trapped behind the gate as we see two (vehicles') forward movements late, just before the collision," he said.

The report says there were two tracks about 13 metres apart at the crossing, with two different warning systems at the intersection.

Faded road markings added to the confusion, Hickli said.

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Motorists were getting conflicting information because a red signal at the crossing indicated an approaching train required them to stop while a green traffic signal suggested they could proceed when it wasn't safe to do so, an examination of the scene revealed.

Since the crash, a warning system of flashing lights and a gate that protects the main track has been moved to make it more visible and an LED sign alerting drivers of approaching trains has been added to the same area while roadway markings have been painted, Hickli said.

In 2014, the Transportation Safety Board gave road authorities and railways two years to find design deficiencies at all crossings and another five years to bring them up to standard, he said, meaning the changes did not have to be completed until 2021.

Three other incidents had already occurred at the same Langley crossing in the last decade, Hickli said.

"In this case, Transport Canada was actively engaged with both the railway and the road authority in changes that Transport Canada wanted to see made at this crossing. Unfortunately, the change hadn't taken place at the time of the occurrence."

A Transport Canada official was not immediately available for comment.

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Hickli said the investigation also found ambulance drivers lacked training on how to properly use a crossing, such as the need to roll down the windows in order to hear any approaching trains.

"They didn't have a performance management program for drivers, unlike most transportation companies, to ensure drivers are sticking to policies, he said.

Linda Lupini, executive vice-president of B.C. Emergency Health Services, said all ambulance drivers are now being trained on how use railway crossings and their performance is being monitored through a more organized system.

The driver was using a hands free cellphone but it's clear from the multiple studies cited in the report on distraction from any cellphones that mobile devices should not be used behind the wheel, Lupini said.

"We have a policy now that says no cellphone use, hands free or otherwise, when you're with a patient."