We undertake different types of investigations in response to safety occurrences and risks identified through data analysis.
What we investigate
OTSI investigates safety incident and accidents in NSW involving:
buses seating more than 8 adults and operating a public passenger service for a fare
ferries (vessels) seating more than 8 adults and operating a public passenger service for a fare
railway operations such as the construction of a railway and rolling stock; the management, commissioning and maintenance of rail infrastructure; and the operation or movement of rolling stock for the purposes of operating a railway service.
No-blame approach
The aim of an OTSI investigation is to enhance transport safety by sharing safety lessons and insights with those organisations that can implement actions to improve safety.
We use a 'no-blame' approach to identify and understand contributing safety factors and underlying issues. OTSI does not assign fault or determine liability in relation to the matters it investigates.
An OTSI investigation is independent of any investigation or inquiry that a regulator, NSW Police or the Coroner may undertake into an incident or accident. Additionally, evidence obtained through an OTSI investigation cannot be used in any criminal or civil proceedings. Whilst information gathered in the conduct of OTSI’s work is protected, the Chief Investigator, under the Transport Administration Act 1988 , may disclose information if they think it is necessary for the safe operation of a transport service.
All of our Completed investigations are available online.
Review of operator reports
Reviewing investigation reports prepared by transport authorities and other transport operators is an important OTSI function. It enables the OTSI to better understand safety issues occurring on the network, provide feedback to operators on their reports and to identify safety insights that could be shared to improve safety.
After reporting a bus, rail, or ferry safety occurrence, the OTSI may ask the operator to provide additional information on the incident such as a copy of any technical or operational investigation report.
Information obtained by OTSI is used to enhance its database to identify trends or patterns of safety factors across the network, provide any feedback to operators on the conduct of investigations, to assist in making a decision to investigation or to identify insights or safety lessons that may be shared across the sector.
Incident investigations
OTSI can conduct an incident investigation into a safety occurrence notification received from a rail, bus or ferry operator. OTSI triages these notifications to determine whether to investigate the occurrence considering several factors including:
- severity of incident or accident
- potential for consequences to have been more severe
- potential for new safety learning and how widely it could be applied
- existence of system wide issues
- the suitability of OTSI as the agency to investigate
- alignment with safety trends and priority areas
- public interest in incident or accident
- availability of OTSI resources.
Systemic investigations
A systemic investigation is a ‘deep dive’ into a specific topic or occurrence that examines systems issues and organisational influences on safety. They are often identified through safety trend analysis or from a series of investigations into similar incidents.
Examples of past OTSI systemic investigations include:
- Rail Safety Investigation - Steel sleeper introduction on NSW Class 1 Main line track - 1996-2004.
- Ferry Safety Investigation - Systemic investigation into public passenger ferry services operated by Captain Cook Cruises within Sydney Harbour - 14 September 2010.
- Ferry Safety Investigation - Systemic investigation into ferry close quarter incidents - Sydney Harbour, 2010-2016.
Programmed investigations
Programmed investigations may focus on safety topics or risks that require ongoing monitoring and sharing of information with industry such as the annual Bus Fire Summary Report which examines bus fires and thermal events in NSW.
As part of the OTSI Strategic Plan, we are building our capacity and capability to conduct more programmed and systemic investigations.