Chief Investigator’s message
I would like to welcome you to the second edition of the Office of Transport Safety Investigations (OTSI) quarterly newsletter, OnBoard.
The last quarter has been a busy time for us and is reflected in this newsletter where you will find information on new investigations we have initiated, and investigation reports and safety advisories released.
We launched our webinar series in July. This is another way we are sharing important safety lessons from key investigations to provide in-depth understanding of complex and emerging issues facing the transport industry.
Another key focus for this year is to further develop engagement and partnerships with the transport industry to achieve safety improvement. OTSI recently co-hosted the Rail Resilience Forum 2023 along with the Transport Asset Holding Entity of NSW. The event was attended by representatives from across NSW, Australia and internationally. The forum covered a range of important topics including climate change resilience and the role of rail in a sustainable future. We are continuing to develop partnerships and collaborations to identify solutions and drive positive change.
I hope you find the information in our latest issue informative and engaging. As always, your feedback is valuable to us, and we encourage you to share your thoughts, ideas, and suggestions by emailing engagement@otsi.nsw.gov.au.
Implementation of investigation recommendations and safety actions for operators
We have implemented a new step in our investigation process in response to stakeholder feedback which indicates that awareness of the actions taken by transport regulators, agencies, operators and others in response to safety incidents can benefit other organisations in the sector to improve their own safety practices.
This new step will affect organisations identified as ‘directly involved parties’ (DIPs) in OTSI investigations who we will ask to advise on the work they have carried out to implement safety actions or recommendations. This applies to any investigation report released from August 2023. Information about these outcomes will be included on the investigation report page on the OTSI website.
This new step is consistent with approaches used by other agencies in Australia and overseas including the Australian Transport Safety Bureau and US National Transport Safety Bureau.
Information on how organisations respond following an OTSI investigation will also be valuable to assist us to continue to ensure our recommendations are realistic and achievable.
Find out more about the OTSI investigation process.
Investigation reports
Derailment of freight train 4BM4 - Nana Glen
OTSI recently released an investigation report into the derailment of freight train 4BM4 at Nana Glen on 25 February 2021 during an extreme weather event.
A passenger train travelled through this area 27 minutes prior to train 4BM4’s derailment, which underscores the risk of more serious life-threatening incidents in inclement conditions.
This investigation highlights the importance of understanding the impact of extreme weather events like flooding on rail infrastructure and the need for rail network managers and users to have effective risk management processes so they can respond in a timely manner and with suitable responses given the significant risk such events pose to rail infrastructure, and which are likely to increase in frequency and intensity in the future.
In summary, rail infrastructure managers should assess their networks to understand where their rail assets are vulnerable to extreme weather events, consider what monitoring equipment, data, and information they require to understand the severity so they can respond adequately.
The investigation identified several contributing factors to the incident including:
- The rail infrastructure manager’s (ARTC) process for monitoring and responding to extreme weather events had significant limitations.
- Rail network users were not aware of the extent of the severe weather event and had not been advised of an amber alert issued by the weather monitor prior to the derailment.
- Alerts issued by the weather monitor did not reliably meet the requirements of ARTC’s extreme weather monitoring procedure or the service agreement under which the information was provided.
- ARTC was installing remote weather monitoring stations but had not undertaken formal assessments to determine the need for these stations or their locations.
- ARTC could not reliably determine the risk of flooding along the Telarah to Acacia Ridge corridor or risks associated with inadequate capacity cross drainage systems.
- The culvert located nearest to the derailment did not have sufficient capacity to discharge the runoff from the rain event on the night of 24-25 February 2021.
- Neither the network manager (ARTC) or the operator (Pacific National) provided guidance for train crew on how to respond to extreme wet weather events or floodwater in the rail corridor.
This investigation also highlights that extreme weather events can affect the integrity and exceed the design of rail infrastructure so infrastructure managers must ensure they have effective systems in place to identify, assess and manage the risks so that trains are prevented from entering sections where the design of the infrastructure will be exceeded.
Following this investigation ARTC have completed, or are in the process of implementing these proactive safety actions:
- Installed an additional 20 remote weather stations along the Telarah to Acacia Ridge corridor, with plans to install an additional 50 remote weather stations and 500 stream flow monitors across their network in the next two years.
- Developed and implemented a work instruction for the management of flooding and special locations. Introduced an enterprise-wide special locations register (to capture infrastructure such as non standard culverts) which is maintained through their asset management system.
- Release of a safety bulletin which increased the rainfall and flooding alerts by one category (i.e., red alerts treated as black alerts) as a preventative measure based on the cumulated conditions impacting on the network including saturated catchments and the La Niña weather pattern.
- Initially reviewed the contract with the Early Warning Network (EWN) to revise inconsistencies between the contract and extreme weather monitoring procedure (OPE PR 014) and ensured that monitoring for the Hunter Valley commenced.
While ARTC has taken various actions to improve safety since the incident, recommendations have been made both to ARTC and Pacific National to develop guidance for train crew to respond to and report extreme wet weather events or floodwater in the rail corridor. Guidance provided to train crew to respond in these situations is vital for quick action to prevent or reduce the risk of serious incidents.
OTSI conducted this investigation under its Collaboration Agreement with the ATSB.
Read the full investigation report
Safety Advisories
SA03/23 - Securing bus batteries, cabling and protective covers – 8 June 2023
This advisory focuses on the importance of risk assessment and effective maintenance and inspection processes to manage risks to safety. It recommends that operators provide their mechanics with sufficient training and instruction for the inspection of batteries, their mounting brackets, cabling and protective covers. This is because rubbing and the resulting abrasion of electrical cables can lead to electrical faults that cause fires.
Bus fires present a significant risk of serious injury, loss of life and assets. OTSI data from 2013 to 2022 indicates that about 34 per cent of fires are caused by electrical faults. Consequently, operators must have an effective maintenance and inspection process to improve the management of risks to safety arising from the placement and maintenance of batteries.
Read the advisory on the OTSI website at SA03/23 - Securing bus batteries, cabling and protective covers.
SA04/23 – Managing fire risks on domestic commercial vessels – 29 June 2023
This Safety Advisory highlights the importance of risk identification and emergency management plans, including training/induction, emergency preparedness and the use of emergency equipment in responding to fires.
It recommends that domestic commercial vessel (DCV) operators should conduct regular risk assessments of emergency response procedures paying attention to the location of emergency equipment and how to access it under different scenarios.
It was developed in response to a vessel fire operating on Sydney Harbour where essential emergency equipment was stored in the area of the fire and so not accessible. All 20 passengers and two crew were safely evacuated.
Read the advisory on the OTSI website at SA04/23 – Managing fire risks on domestic commercial vessels.
SA05/23 – Close quarters situations in the Sydney Harbour area – 13 July 2023
This advisory focuses on the importance of DCV operators understanding and applying the rules to avoid a collision with another vessel, such as monitoring appropriate radio frequencies and maintaining a proper lookout. This applies particularly in congested areas, such as Sydney Cove and the Sydney Harbour Bridge Transit Zone especially at night when background shore lighting can impact visibility of vessels. A recent close quarters situation in Sydney Harbour involving two passenger ferries highlights the importance for all operators to understand and apply these rules.
Read the advisory on the OTSI website at SA05/23 – Close quarters situations in the Sydney Harbour area.
SA06/23 - Bus driver fitness to drive – 11 August 2023
This advisory was developed following a recent incident where a driver suffered a medical episode. The driver was incapacitated for approximately 45 seconds, which led to the bus mounting a concrete divider and colliding with an oncoming utility vehicle.
Bus operators are reminded about the importance of assessing risks related to driver fitness to drive and implementing driver health and safety management processes and procedures. Operators should promote a working environment which provides support for employees and encourages the self-reporting of ill health without fear of discrimination.
Read the advisory on the OTSI website at SA06/23 – Bus driver fitness to drive
New investigations underway
Two transport safety investigations have recently been initiated:
Children overboard at Riverview College Ferry Wharf - Riverview
On 16 February 2023 two school students went overboard from a passenger ferry after the vessel drifted away from the wharf causing the gangway to fall in the water. A third student jumped into the water to assist the other two.
The passengers were retrieved from the water before the vessel was repositioned alongside the wharf. The remaining passengers (including the three persons overboard) were then safely disembarked.
The scope of the investigation includes, but is not limited to:
• locations where similar ferry docking circumstances and associated risks may be present
• examining the systems, the ferry operator had in place to manage risks associated with wharf design and tidal considerations
• ferry operator crew training and procedures, including emergency response
• the response to the incident by relevant parties.
Read the Interim Factual Statement
Rollover of coach 4666MO – Greta
Late in the evening of 11 June 2023, Linq Buslines coach number 4666MO departed the Wandin Estate winery in Lovedale for Singleton. It was reported to be carrying 35 passengers who were returning to Singleton after attending an event at the winery.
The coach travelled through Greta township before joining Wine Country Drive in a southbound direction. At about 2330, on approach to the Hunter Expressway westbound onramp, the coach entered a roundabout, and overturned onto the left-hand side. The rollover and subsequent collision resulted in 10 fatalities, significant injuries to multiple passengers, and major damage to the coach.
The scope of the investigation includes, but is not limited to:
• sequence of events leading up to the rollover/collision
• road design, condition, signage and visibility
• passenger restraint devices and usage
• vehicle condition, roadworthiness and design
• vehicle crashworthiness and survivability
• emergency exit access, awareness and operability
• operator accreditation, and safety management systems.
Read the Interim Factual Statement
Inaugural OTSI webinar – Nana Glen investigation
On 5 July 2023, OTSI hosted a one-hour webinar to share insights into the lessons learned from the investigation into the 2021 freight train derailment at Nana Glen.
The webinar covered:
- investigation safety analysis, key findings and recommendations
- the importance of risk identification and management
- implications for the rail sector in managing and responding to extreme weather events and improving rail infrastructure resilience.
If you were unable to attend the webinar, you can watch a video of the event on the OTSI website. You can also find answers to some questions from attendees that we were unable to be answered during the event.
We are planning more webinars in 2023 to share insights from OTSI investigations and our other safety improvement initiatives. To receive information about these events, subscribe via our website.