Acting Chief Investigator’s message
Welcome to the third edition of OnBoard, the OTSI quarterly newsletter.
As many people who work with OTSI would be aware, Dr Natalie Pelham, who held the role of OTSI CEO and Chief Investigator since January 2021, has left the organisation to take up the role of Chief Executive at the Office of the National Rail Safety Regulator (ONRSR).
Natalie has left a significant legacy, having implemented a new business operating model for OTSI to deliver more value to transport operators, suppliers, regulators and other organisations which can action safety lessons and make NSW transport networks safer.
Since Natalie joined OTSI in January 2021, OTSI’s core investigation function has been strengthened and it has increased its focus on proactive, data-driven activities which will enable the organisation to better identify risk and share further valuable safety insights more often with the transport industry.
The ONRSR role is a unique opportunity for Natalie to continue her work in transport safety, now at a national level. ONRSR is a key stakeholder for OTSI and we look forward to strengthening our relationship under Natalie’s leadership.
While recruitment activities are undertaken to permanently fill the role of CEO and Chief Investigator, Minister for Transport, Hon Jo Haylen MP, has appointed me to act in the position, an opportunity for which I’m both grateful and excited.
My substantive role is Executive Director with the Point to Point Transport Commission, which regulates the taxi and rideshare industries to achieve safer point to point transport in NSW. I’ve had more than 30 years' experience in the Transport Public Service, holding a diverse range of leadership roles within radio systems, operational technology, signalling control systems, rail engineering, asset management, safety systems, systems assurance, freight and industry regulation.
With Natalie taking some leave in September and October, I’ve been acting in the role at OTSI for several weeks now. Since I began acting as CEO and Chief Investigator in early September, we have released multiple investigation reports including a Confidential Safety Information Reporting Scheme (CSIRS) outcome report, held a webinar on the Bus Fire and Thermal Incidents in NSW 2013-2022 and published a safety alert on bus door serviceability which you can read more about in this newsletter.
The webinar allowed us to share key insights and important safety lessons, as well as OTSI’s top six recommendations. I encourage you to view the webinar recording and share with your network to learn more about how we can work together to achieve greater bus fire and thermal safety in NSW.
In addition to the above, you’ll also see that our Annual Report 2022-23 is now available. The report highlights OTSI’s key achievements for the year including the appointment of three new Transport Safety Investigators along with the completion of six investigations and another ten initiated. We can expect an increase in investigation reports released in 2023-24. The year also saw the expansion of the Systemic Review and Insights team, further enhancing our data analysis and reporting capability.
We’ve also recently published a Safety Promotion and Stakeholder Engagement Strategy 2023-2025 which outlines the principles which will guide our strategic engagement over the next three years, aligning with the OTSI Strategic Plan 2022-2025.
As we approach the end of 2023, we reflect on what an incredibly busy year it’s been, right up to the very end with another investigation report completed and released for the year. I thank all our stakeholders for your ongoing cooperation and wish everyone a safe and joyous end to 2023. I look forward to working with you in 2024.
I hope you find the information in this newsletter insightful 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.gov.au.
Investigation reports
Rail Worksite Protection in NSW – Report 1, Picton, 16 August 2022
OTSI recently published its first report as part of a systemic investigation into worksite protection in NSW. This report focuses on an incident at Picton on 16 August 2022 and provides observations to support the findings of the final investigation.
Worksite protection incidents (trains entering protected worksites) continue to occur in NSW, with the potential for trains encountering hazards on the track and for workers to be struck or killed by rail traffic.
Along with other contributing factors, the report highlights the importance of fatigue and workload management and the need for a detailed procedure on how to manage rail traffic through a worksite.
What happened
On 16 August 2022, NSW Trains Endeavour passenger service SN42 travelling from Moss Vale to Sydney departed Picton platform and encountered an excavator on the Up Main line approximately 300m ahead.
The Protection Officer (PO) had authorised the handsignaller closest to the worksite to permit SN42 to travel unrestricted, however the PO also permitted the excavator operator to occupy the track before the train had passed safely through the work area.
The potential consequence from this action was a loaded passenger train striking a piece of heavy equipment at speed, putting at risk not only the operator of the excavator, but the passengers onboard the train should it derail and overturn.
Find out more about the insights and observations from this report.
View the full investigation report
Articulated bus fire 2169ST – Camperdown – 13 January 2022
OTSI recently released an investigation report into an articulated bus fire at Camperdown on 13 January 2022. The report highlights the importance of routine inspection and replacement of components such as silicone coolant hoses and high amperage electrical circuits to prevent similar incidents from occurring.
What happened
On Thursday 13 January 2022, bus 2169ST caught fire adjacent to the intersection of Parramatta Road and Ross Street, Camperdown. The bus was travelling westbound with the driver and 12 passengers on board. Following a motorist’s attempt to gain the driver’s attention, the driver noticed heavy grey smoke coming from the rear of the bus, leading them to pull over and safely evacuate all passengers. Fire and Rescue NSW extinguished the fire within the extensively damaged engine bay.
The investigation identified several contributing factors to the incident, including:
- the likely initiation of the fire was a perforation in a silicone hose that fed heated engine coolant to the saloon heater.
- coolant leaking under pressure likely contacted hot engine components and ignited.
The investigation also discovered unsecured high amperage wiring, which may potentially lead to an increased risk of an electrical short circuiting, causing fires within the passenger saloon area.
Bus and coach operators should consider the following recommendations:
- Consider initiating component change out programs for silicone coolant hoses based on anticipated replacement prior to failure or serviceable life of such components, within existing scheduled preventative maintenance activities.
- Monitor condition of and replacement of unserviceable silicon hose insulating materials to prevent deterioration of the silicone hoses due to ambient temperature effects.
- Incorporate ongoing routine inspection of high amperage electrical circuits into their maintenance routine, including checks for wiring security and abrasion to reduce the risk of fire. These checks should include cabling and wiring in air conditioning ducting and areas not normally accessed in scheduled inspections.
View the full investigation report
Bus Fire Safety Report
In September, OTSI released the Bus Fire Safety Report – Bus Fire and Thermal Incidents in NSW from 2013-2022. Fire is a major safety risk for bus operations and both the number of bus fires and thermal incidents have increased in recent years.
The OTSI report:
highlights the health, social and economic impacts of bus fire and thermal events in NSW
investigates the causes and potential contributing factors to these incidents
reviews the effectiveness of existing fire safety interventions.
The key findings include:
Bus fire and thermal incidents from 2013 to 2022 are estimated to have cost NSW $203 million – this includes destruction of or significant damage to 52 buses and an average of 30 minutes lost by every onboard bus passenger due to travel delays arising from these incidents.
Without further improvement in bus fire safety, it is projected that these incidents will continue to rise, costing NSW a further $265 million over the next decade.
Most bus fires in the last 10 years originated in the engine bay of the bus. The percentage of engine bay fires, however, has slightly reduced in recent years, likely due to the installation of engine bay fire suppression systems in Transport for NSW (TfNSW) contracted buses and other buses.
Electrical faults were the most common cause of bus fires in the past decade, emphasising the need for proper configuration management, maintenance and inspection of electrical components and electrical design.
Most thermal incidents in the last 10 years were caused by brake problems. Further investigation into brake-related issues is required to develop targeted fire safety solutions.
OTSI made the following six evidence-based recommendations, with the first recommended for the cooperation and consideration of multiple organisations, including the National Heavy Vehicle Regulator, Bus Industry Confederation, and all states’ and territories’ transport and/or bus authorities. Recommendations 2-6 are for TfNSW’s consideration.
Establish a national database to record all bus fire and thermal incidents, and to provide consistent bus fleet data for all states and territories.
Review the average age and age distribution of the NSW bus fleet.
Explore better and smarter fire and smoke detection technologies for buses.
Review the appropriateness of the type, location, installation and maintenance of the existing fire mitigation/fighting technologies fitted in the buses. Review driver training into the use of these technologies and ensure rigorous risk assessment.
Explore additional fire mitigation/fighting technologies for bus fire safety.
Review Australian Design Rules and TfNSW procurement panels for buses.
View the Bus Fire Safety Report
Bus fire m/o9340 – Lane Cove – 14 April 2022
The final investigation report into a bus fire inside the Lane Cove Tunnel in April 2022 was published in August 2023. The report highlights the high risk of fires and emergencies occurring within a tunnel, particularly for buses due to the number of passengers on the vehicle.
What happened
On 14 April 2022, bus m/o9340 caught fire while operating between Sydney and Dural. The bus was travelling westbound in Lane Cove Tunnel with 14 passengers on board when a fire started in the engine bay at the rear. Upon receiving a passenger’s alert of the bus fire, the driver pulled over and observed all passengers exit the bus before attempting unsuccessfully to extinguish the fire.
Lane Cove Tunnel Traffic Control Room Officers (TCROs) discovered the bus on fire via the closed-circuit television, prompting them to update their response from traffic management plan to a fire response plan. The TCROs then deployed the tunnel deluge system to suppress the fire and closed the westbound tunnel.
The investigation identified several contributing factors to the incident including:
- the fire in the engine bay was likely caused by a fluid leak of either hydraulic oil or coolant which was potentially ignited by a hot surface and spread from the engine bay.
- the deluge system implemented by TCROs prevented the spread to the surrounding structure and limited the damage to the tunnel from the fire.
All passengers were safely evacuated from the tunnel with no injuries, however the bus was destroyed.
OTSI made four recommendations to the bus operator, the tunnel operator and Transport for NSW for their consideration:
Hillsbus Co Pty Ltd
- Review driver training to ensure drivers receive training on the indicators for an impending breakdown and emergency evacuation scenarios, aligned to appropriately assessed responses.
- Review driver emergency evacuation training to ensure information on fire and life safety systems in tunnels, including risks and required driver responses for passenger safety, is provided to enhance response to emergencies in tunnels.
Transurban
- Review the configuration and effectiveness of the automatic visual incident detection system for the Lane Cove Tunnel to determine if enhancements can be made to ensure the automatic detection of incidents.
Transport for NSW
- Facilitate coordination between tunnel operators and TfNSW-accredited bus operators to develop and implement updated emergency procedures and preparedness arrangements.
View the full investigation report
Confidential Safety Information Reporting Scheme (CSIRS) Outcome Report
OTSI recently published a report on a rail safety matter raised by transport employees under the Confidential Safety Information Reporting Scheme (CSIRS).
The CSIRS gives employees in the transport industry a confidential way to make a report about a safety issue affecting a bus, rail or ferry service. Reporting under CSIRS is voluntary, confidential and non-punitive.
The CSIRS Outcome Reports are published because their findings have the potential to benefit other organisations in the industry.
CSIRS Outcome Report C1020 – Track Occupancy Authority Safeworking Incident
The CSIRS reporter asserted that during the response and recovery following an infrastructure failure, a Track Occupancy Authority (TOA) was authorised without the knowledge of the adjacent signalling panel who controlled the signal required to protect the worksite. The omission was a serious breach of the operator’s safeworking procedures which created a risk that the signal block could have been removed prior to the TOA being fulfilled, leaving the field teams unprotected.
OTSI Annual Report 2022-23
The OTSI Annual Report 2022-23 is now available online and provides a summary of our activities and performance for the financial year that ended 30 June 2023.
To meet the evolving needs of the industry, OTSI developed and implemented a new business operating model in February 2022. 2022-23 was the first full financial year under the revised business operating model, which saw an increase in our focus on data-driven proactive activities and our core investigation function strengthened.
The new model, which included changes to OTSI’s structure, was designed to help us better identify risk and share more valuable safety insights with the transport industry to further improve transport safety in NSW.
OTSI’s key achievements for 2022-23 include:
- Recruiting three new Transport Safety Investigators, enhancing our future capacity to investigate both standalone incidents and more complex rail, bus and ferry systemic safety issues.
- Receiving and triaging 1,086 rail, bus and ferry incident notifications.
- Completing six investigations (including three investigations in collaboration with ATSB) resulting in 13 safety recommendations.
- Deploying OTSI investigators 11 times to conduct preliminary incident investigations, and initiate 10 investigations into rail, bus and ferry accidents and incidents.
- Conducting nine investigations into Confidential Safety Information Reporting Scheme (CSIRS) reports regarding safety concerns raised by TfNSW employees and publishing three CSIRS Outcome Reports.
- Completing 17 reviews of transport operators to identify potential risks and opportunities for safety improvement.
- Issuing seven Safety Advisories on immediately identified safety issues.
In addition to the above, OTSI leveraged more strategic opportunities including industry events and increased online engagements to share safety lessons and insights with stakeholders.
View the OTSI 2022-23 Annual Report
Safety Alert
Bus door serviceability: a safety critical control system
OTSI recently issued a safety alert on Bus door serviceability: a safety critical control system. The safety alert was developed in response to a recent incident involving a passenger fall from a bus, highlighting the importance of door systems operating in good working order.
While NSW Technical Specifications govern requirements for bus door safety systems, including potential entrapments, operators must ensure doors are serviceable and operate as intended. This includes external passenger doors remaining closed while the bus is in motion.
OTSI recommend the following safety actions:
- Ensure that the serviceability and security of bus doors, in both the open and closed positions, is tested before the ‘first of day’ service of each vehicle, as part of documented checks.
- Ensure that serviceability/safety testing of doors, before the first service of the day, includes placing some physical force on the door panels in the closed position to confirm external passenger doors will not open when the bus corners/moves, or in response to internal force such as a passenger inside the saloon leaning against the door panel/s.
Domestic Commercial Vessels (DCV) induction training
In 2022, OTSI identified a potential safety risk relating to the induction of casual crew on domestic commercial vessels (DCVs). It was observed that crew members were not consistently receiving effective induction training in accordance with legislation to safely operate DCVs.
Following discussion with the Australian Maritime Safety Authority (AMSA), Transport for NSW, Port Authority of NSW and the Commercial Vessel Advisory Group (CVAG), OTSI engaged Taverner Research Group to conduct an industry survey as a safety initiative for DCV owners, operators, masters and crew members to improve safety practices aboard their vessels.
Although the survey sample size included just over 100 participants, the findings indicated that the issue was more prevalent in smaller operators, with only 56% of crew on smaller vessels ‘demonstrating competency in operating equipment’ compared to 86% of crew working on larger vessels.
The research also found that 70% agreed that hands-on practice with demonstrations would be beneficial for trainees to learn emergency drills and procedures.
Based on the findings, OTSI came up with the following recommendations for DCV owners and operators:
- Casual crew members should be provided with more formal induction training, including practical elements such as hands-on practice and longer training longer periods.
- Following induction training, ongoing instruction from experienced crew/masters would be beneficial for new and casual crew members.
- Induction training should be tailored to the vessel and its individual operation, highlighting differences which affect safety such as different layout and capabilities/equipment.
Our safety messaging for DCV owners and operators can be seen on the OTSI website and LinkedIn. AMSA is also promoting these safety messages on Facebook and in their December 2023 newsletter.
We hope to encourage agencies and operators to use the findings to inform their upcoming education activities to improve safety outcomes around DCV crew induction and training.
Additionally, we hope to raise awareness among DCV owners, operators, masters, crew, and peak bodies of the importance of effective and practical induction training to improve the safety of their own operations.
View the research key findings