Bus Safety Investigation - Bondi Junction pedestrian fatality - 16 December 2020

View the Bus Safety Investigation Report

What happened

At 1009 on 16 December 2020, Transit Systems bus m/o 8159 was negotiating a left-hand turn from Grosvenor Street into Grafton Street, Bondi Junction. During the turn, the left (near) side of the bus struck a pedestrian who was crossing Grafton Street in a northerly direction with a green walk signal indication and within the designated pedestrian crossing walk lines. 



As a result of the incident, the pedestrian was fatally injured.

What we found

The investigation found that the bus driver did not see the pedestrian and the bus entered the pedestrian crossing area before the pedestrian was safely clear of the bus’s path. The bus collided with the pedestrian twice.



The investigation found several factors contributed to the incident. These factors included:

• The bus driver positioned the bus beyond the road stop line on approach to turning left into the pedestrian intersection and commenced the left-hand turn about 1 second prior to the intersection lights changing from red to green. These factors culminated in the bus advancing into the turning sequence prematurely. The forward movement of the bus would have placed the pedestrian within the near-side bus blind spot areas as opposed to being positioned in the direct line of sight of the bus driver as the bus approached and entered the pedestrian foot crossing walk lines.
• During the left-hand turn sequence, the position of the bus driver’s head was largely directed on the near-side mirror and front windscreen. In the time taken for the bus to negotiate the left-hand turn into Grafton Street, the potential for the driver to detect the pedestrian via these views would have been minimal.
• The traffic light sequence at the intersection provided for a simultaneous green walk signal for pedestrians and a green signal for vehicle traffic (‘green-on green’) to turn left. An alternate traffic signal phasing design (pedestrian protection) would have held the left-hand turning traffic signal on red for an additional 8 seconds. This delay would have increased the likelihood of the pedestrian being detected in the driver’s front field of vision as the bus negotiated the left-hand turn. This feature is designed to improve pedestrian safety at higher risk traffic intersections aimed at reducing the risk of pedestrian / vehicle adverse interaction.

Actions taken by directly involved parties during the investigation

Transit Systems



The bus operator undertook the following safety actions after the incident

• Updated its mobile phone policy in March 2021 to further define that only certain mobile devices are permitted for use (such as a Driver’s Navigation device being the property of Transit Systems) or any other device approved by Transit Systems management.
• Issued a Safety Alert to its drivers in April 2021 reminding them of the requirement to stay alert when operating in high pedestrian areas, follow the road rules and obey traffic lights, be aware of pedestrian activity around them, wait until pedestrians have completely cleared the intersection before proceeding, always be observant and look before completing a turn. 
• Updated its online driver training materials in April 2021 to include an additional module on Pedestrian Awareness. 
• Issued a Safety Alert to its drivers in December 2021 covering requirements of bus entry into the Bondi Junction Interchange (BJI) from Grosvenor Street. The Safety Alert detailed that when drivers are stopped at the intersection, they must not proceed beyond the stop line in Grosvenor Street and that any following bus wishing to turn left into the BJI from Grosvenor Street will need to wait until the entrance portal to the Interchange is clear to safely enter. The Safety Alert also reminded drivers to be observant and aware of pedestrians around a bus in this area and to always look for pedestrians and other hazards before completing a turn.
• Commenced trialling the use of 360o video camera technology to increase driver visibility of pedestrians, cyclists, and other hazards in close proximity to a bus.

Transport for NSW



TfNSW initiated the following safety actions post incident.

Upgraded the Grosvenor/Grafton Street pedestrian crossing signalling on 21 April 2021 to include:

• Pedestrian activation, where the crossing protection was only activated on the demand of a pedestrian pushing the pedestrian walk button. If the pedestrian activation was not engaged in sufficient time for the light sequencing or was not engaged at all, pedestrians were not permitted to cross the intersection with a red ‘don’t walk’ symbol displayed.
• Pedestrian protection, provides pedestrians with an 8 second head start on left-hand turning road traffic at the intersection when the green walk signal is activated. That was achieved through addition of a red left turn arrow displayed for 5 seconds before the arrow is extinguished to permit traffic to make a left-hand turn giving way to pedestrians into Grafton Street. The upgraded left turn red arrow indication together with green walk signal. 
• The repainting of the stop line and pedestrian cross walk line at the Grosvenor Street intersection.
  
  

Recommendations

OTSI made the following recommendations:



Transport for NSW 

• Review and amend as appropriate its current risk assessment model that assesses signalled pedestrian crossings to identify any additional crossings that may warrant an upgrade to include pedestrian protection. Such a review is recommended to consider the Grosvenor/Grafton Street pedestrian crossing configuration as a means of identifying other like intersections that may be considered for upgrade. The review should also consider assessment of whether the intersection is included in a bus heavy vehicle route and the applicable risk such a route imposes on the intersection. 
• Assess the viability of implementing bus sensors to detect and alert drivers to the presence of pedestrians in proximity to buses and within the bus blind spot areas when they are turning left or right. The assessment of bus sensor viability is recommended to include a human factor review which considers the efficacy and reliability confirmation of the technology including how this new technology could integrate into the NSW road and passenger transport model. 

Transit Systems 

• Review the driver performance monitoring system and consider expanding it to cover a level of random discrete driver performance reviews. These performance reviews could include discrete assessment of driver cornering techniques, compliance with NSW Road Rules on stopping at intersections and road traffic lights, and any other high risk driver situations considered essential. The program should consider higher risk operating areas along the prospective route and include education about and assessments at known risk intersections. 
• Review internal instruction to drivers covering collisions and incidents to consider additional instruction where appropriate on stopping a bus as soon as possible in the event a bus collision. This should include further consideration at busy pedestrian intersections or crossing points and what may be immediate action in the event of a pedestrian collision at an intersection.