Bus Safety Investigation Report - Bus rollaway and collision - Wilsons Valley - 5 September 2022

View the Bus Safety Investigation Report

Based on a review of the available evidence for this incident, OTSI undertook a short investigation to capture factual information and to identify safety lessons to be shared with the industry.

What happened

On 5 September 2022, a coach was transporting 41 passengers (36 children and 5 adults) from Smiggin Holes snowfields for a school excursion. During the trip, the driver was unable to change gears or brake, causing the coach to roll backwards down Kosciuszko Road. With the coach gaining speed, the driver made the decision to veer the coach off the road where the coach travelled 250 m down an embankment before it struck a rock outcrop and came to a stop.

What was found

The investigation identified: 

• Unlicensed and non-compliant maintenance work was a main contributing factor in the failure of the coach’s braking system.
• The air system compressor head was replaced by the owner who was not a licensed mechanic.
• The coach had several defects that did not comply with the requirements of the heavy vehicle standard of the Heavy Vehicle National Law (HVNL) with driver alerts covered, removing a safety critical indication to the driver that there was a brake system fault.
• The driver was not usually employed by the operator and was not familiar with the vehicle, its system alerts and recent maintenance history. 

What has been done as a result

In 2023, Transport for NSW (TfNSW) undertook a joint road safety operation with the NHVR and NSW Police to conduct assurance activities in the NSW snowfields. 

TfNSW staff inspected 71 buses and coaches, to ensure operators were accredited, drivers were authorised under the Bus Operator Accreditation Scheme (BOAS) and had undertaken snow driver training.  

Safety message

There are several key considerations for bus and coach operators:

• Operators must ensure all maintenance and repairs are completed by licenced mechanics in accordance with original equipment manufacturer (OEM) and National Heavy Vehicle Inspection Manual (NHVIM) requirements.
• Operators and drivers should understand that alarm displays serve as important cues indicating issues with safety critical systems and require an appropriate response. Covering an alarm from display removes the opportunity to identify issues with a safety critical system, increasing risk for mechanical failure.
• Pre-departure checks and driver handover procedures provide opportunities to identify system faults and should be a standard practice included in the operator's safety management system.