The city's ombudsman says that a TTC investigation into allegations of misconduct and racial discrimination by fare inspectors was "not sufficiently fair, thorough or transparent to justify its conclusions."

"The investigation did not adequately probe what happened during the incident and why," Susan Opler said in a statement that accompanied the release of her office's report on Thursday.

"It was important for the TTC to get this investigation right," she said.

In February 2018, three TTC fare inspectors tackled and pinned Reece Maxwell-Crawford, a black man, to the ground on a streetcar platform near St. Clair Avenue West and Bathurst Street. Maxwell-Crawford, who was 19 at the time, was forcibly detained before eventually being released by Toronto police officers who had arrived at the scene.

2 staff involved still employed by TTC

A widely-shared video of the incident was posted to Facebook, sparking calls for a probe into whether the inspectors "used necessary force and whether anti-black racism was a factor," the ombudsman's report said.

Video shot by streetcar rider Bethany McBride shows two TTC fare inspectors pinning the teen to the ground 0:10

The TTC and the Toronto Police Service both conducted separate investigations into the incident. Police decided not to lay criminal charges against the fare inspectors involved — one no longer works at the transit agency though two others do.

The TTC's 95-page report, released in early July 2018, found insufficient evidence of any misconduct, with one exception. Namely, one of the inspectors had smiled at the man during a particularly tense verbal interaction.

The transit agency's analysis relied heavily upon two videos captured by security cameras.

The investigation also accepted the account of one fare inspector that before the takedown, Maxwell-Crawford stared at him for a prolonged period.

Opler says that's just one discrepancy she noticed watching the video. Another was that the teen had his hands in his pocket.

"The first fare inspector as well as an independent witness said that they felt uncomfortable because this young man had his hands in his pockets and might have a weapon. In fact, he does not have his hands in his pockets at any point on the video," she said.

Opler added the ombudsman investigation wasn't into the incident itself.

"What we focused on was ensuring that the TTC is investigating incidents like this and public concerns like this in a way that the public can have confidence and trust in," she said.

"We did not believe that it was adequately fair, thorough or transparent."

TTC to develop anti-racism strategy

While the ombudsman's office said parts of the TTC's probe were adequate, it also found a "number of other problems," including:

The TTC investigation did not consistently identify important facts in dispute and make clear findings of fact.It did not acknowledge and analyze the fact that fare inspectors are expected to disengage when there is a potential for conflict.

The investigation applied an inappropriate standard of proof in some of its analysis.

The TTC's corporate structure does not adequately ensure the independence and impartiality of the primary internal investigator of complaints about fare inspectors.

The TTC's expert witness for its investigation was not sufficiently independent and did not review all the relevant evidence.

There was no analysis of evidence that might have suggested unconscious racial bias.

The ombudsman's report made six recommendations, which the TTC has said it will try to implement by the end of this year. The steps include:

It will take steps to ensure that all investigations are independent and impartial.

Internal investigators will receive additional training.

It will clarify the standard of proof investigators should use in making findings.

Expert opinions will be appropriately independent and thorough.

TTC CEO Rick Leary said in an email statement that the agency is developing a "broad and comprehensive anti-racism strategy" in the wake of the ombudsman's report.

"We are moving without delay to implement a system-wide anti-racism strategy, aimed directly at preventing racial profiling, and covering all aspects of the TTC's operation. We need to ensure that all of our customers feel safe and secure when dealing with our employees," Leary said.

The TTC will hold public consultations with "impacted communities" this year, establish an anti-racism task force and update its training programs for fare inspectors and special constables, Leary said.

'Profoundly disturbing'

For Maxwell-Crawford's lawyers, the ombudsman report only backs up the argument that the TTC's investigation was a "white wash" of what happened that day.

"Taking the evidence of someone that's contradicted by the videotape evidence as if it's a fact ... [is] profoundly disturbing and especially when that stuff relates to whether there was racial profiling happening," said lawyer John Phillips.

Lawyer John Phillips says his client, Maxwell-Crawford, is still recovering from the injuries. (Spencer Gallichan-Lowe/CBC)

As for the anti-racism strategy being developed by the TTC, Phillips said, "that doesn't change the fact that today, were it not for the videotaped evidence we have in this, this cover up would have been complete, and nothing would have come to the fore."

For his part, more than a year later, Maxwell-Crawford is still recovering from the injuries, Phillips says.

"He still struggles with trust of law enforcement and even the TTC. So it's an ongoing problem," Phillips said. Maxwell-Crawford has launched a multi-million dollar lawsuit against the TTC and police.

In March 2018, the man who was forcibly confined launched a civil lawsuit against the TTC, the three fare inspectors, the police officers who attended the scene and the Toronto Police Services Board.