Bus Safety Investigation Report - Bus collision with road barrier - Belmont North - 13 November 2022

Read the Bus Safety Investigation Report

What happened 

Early on the morning of Sunday 13 November 2022, at 0347 AEDT, bus m/o8219 collided with a concrete barrier. At the time of the incident, the bus was conducting a west bound, public passenger service on Wommara Avenue in Belmont North with the driver and six passengers onboard. The collision resulted in the bus rolling over to the left and coming to rest against the side of a drainage channel.

Several passengers, including two who were ejected from the bus in the rollover, sustained injuries requiring medical treatment. The bus sustained significant damage. 

What we found 

The investigation determined the driver of bus m/o8219 likely experienced several factors which reduced their visual acuity and contrast sensitivity in a low light operating environment with limited visual cues. This resulted in the driver being unable to effectively identify the road and concrete barrier ahead, and a loss of situation awareness leading to the bus being steered onto a travel path misaligned with the road. It was also identified that the driver may have been distracted by an onboard system speed warning as the bus approached the barrier, which led to them looking down at the bus’s dashboard. This removed the opportunity for the driver to identify the imminent collision and take evasive action.  

The design of the barrier involved had a sloped leading/front edge, resulting in the barrier acting as a ramp when impacted by the heavy vehicle, with the bus becoming airborne before rolling over into the drainage channel directly adjacent. The barrier had limited markings and reflectors to provide increased driver visibility of its position.  

The investigation also identified that the involved operator was unaware that the driver had a medical condition and was taking prescribed medication. This resulted in a missed opportunity for the operator to assess the potential operational risks associated with a driver with a diagnosed ocular disease, in the operational environment, and determine if additional risk control measures should be considered and/or applied, such as no night driving.  

Actions taken by directly involved parties during the investigation 

Keolis Downer Hunter (KDH) 

Since the incident, KDH updated its employee onboarding process to include mandatory medical assessments for all new employees, conducted exclusively by medical assessors designated by KDH. Additionally, KDH implemented an in-house review system to determine the suitability of employees being onboarded. KDH reported that since implementation of these additional controls, issues not identified in the Bus Driver Authority commercial licensing process had been detected and these persons were subsequently not employed. 

Lake Macquarie City Council 

Lake Macquarie City Council conducted a review of the road conditions along Wommara Avenue , including the involved concrete barrier and advised the following safety actions: 

• Council will review the line marking and delineation along Wommara Avenue and, if improvements are identified, recommend changes for consideration by the Lake Macquarie Traffic Facilities and Road Safety Committee. 
• Council has included the replacement of the concrete barrier with a barrier that meets current TfNSW standards in its future infrastructure register for consideration of funding priority against competing road safety projects city wide. The replacement is not identified in the current 2024/25 Council Operational Plan, and the location does not meet TfNSW requirements for consideration of Australian Government Black Spot funding. 
• Council will improve the delineation/reflectorisation of the barrier to improve nighttime awareness until such time as it is able to be replaced. 
• Council will review the street lighting on Wommara Ave. If changes are required, upgrades will be considered for funding priority against competing projects city wide. 

Recommendations  

Keolis Downer Hunter 

• Review the involved onboard vehicle monitoring system driver alert activation mechanisms, to ensure that the potential for driver distraction at a safety critical moment, is effectively considered.  
• Ensure that bus drivers are aware of the means of effectively managing glare from internal lighting sources, including saloon lighting in various body configurations.  
• Review current route risk assessment processes to ensure that areas of potential increased operational risk are identified and incorporated into driver route training. 

Lake Macquarie City Council 

• Review the road markings and infrastructure in the incident site vicinity to identify any potential safety improvement opportunities, including consideration of the risks to road users, associated with the design and visibility characteristics of the involved barrier, and streetlight positioning.  

This recommendation has already been adequately addressed by Lake Macquarie City Council. 

Transport for NSW 

• Amend guidance provided to operators under the Bus Operator Accreditation Scheme for consideration of extra preventative measures for the medical assessment of bus drivers beyond the current assessment content by General Practitioners, potential referrals for further evaluation, and self-reporting of existing medical conditions.