OnBoard Newsletter - March 2024

Edition 4

Acting Chief Investigator’s message

Welcome to the fourth edition of OnBoard, the OTSI quarterly newsletter.

2024 marks a special year for OTSI as we celebrate 20 years of balanced and impartial investigations contributing to safer outcomes for bus, ferry and rail passenger services in NSW.

For those who aren’t aware, OTSI was first established following the recommendations of the Special Commission of Inquiry into the Waterfall Rail Accident (2003), a tragic accident which claimed seven lives.

OTSI began as part of the Independent Transport Safety and Reliability Regulator (ITSRR) (which has since been integrated into the Office of the National Rail Safety Regulator). In 2004, it was identified that OTSI would benefit by operating independently, leading to the passing of the Transport Legislation Amendment Act 2005, establishing the Chief Investigator as a statutory role, reporting directly to the Minister for Transport.

Two decades later, everyone who has played a role in OTSI’s work can feel proud of the contribution the organisation has made in improving the public safety for bus, ferry and rail journeys in NSW.

To mark the milestone, over the course of the year we’ll be sharing safety lessons from our most significant investigations through the years, starting with the first two in this edition. Some of the investigations we’ll be revisiting are more than 15 years old and highlight just how much progress in safety the transport industry has made in that time.

As the end of the first quarter of 2024 draws near, we have released two investigation reports so far this year – the Dombarton grain train runaway and derailment and Wilsons Valley bus rollaway and collision – along with a CSIRS Outcome report, a Safety Alert on bus and coach rollaways and a Safety Advisory on the importance of considering the risks posed by extreme weather events on rail operations.

During March we are visiting several locations in regional NSW to share insights from our bus safety investigations at the BusNSW member seminars. Meanwhile, excellent progress is being made on several other bus, ferry and rail investigations and I look forward to releasing more reports over the coming months.

As always, your feedback is welcome, and I encourage you to share your thoughts on any issues raised in this newsletter, ideas, and suggestions by emailing engagement@otsi.gov.au.

Investigation reports

Bus rollaway and collision – Wilsons Valley, 5 September 2022 (Short Investigation report)

Our investigation into a rollaway and collision in Kosciuszko National Park identified non-compliant maintenance activity to be a main contributing factor in the failure of the coach’s braking system.

The incident occurred on 5 September 2022 when a coach was transporting 41 passengers, including 36 children, from Smiggin Holes snowfields. The coach lost its brakes and with the vehicle gaining speed, the driver made the decision to veer the coach off the road where it travelled down an embankment before it struck a rock outcrop and came to a stop.

Multiple children and adults were transferred to hospital for observation with some passengers suffering minor injuries.

The investigation identified:

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 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.

Bus and coach operators are urged to:

Ensure their vehicles are maintained by licensed mechanics, in accordance with original equipment manufacturer and National Heavy Vehicle Inspection Manual (NHVIM) requirements. 
Ensure they and their drivers 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.
Remember that 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.

To find out more insights and observations, view the full investigation report

Runaway and derailment of loaded grain train 3966 – Dombarton, 15 December 2020 (Final investigation report)

The investigation into a runaway and derailment of a loaded grain train at Dombarton highlights the importance of effective risk management by rolling stock operators to help train crew safely navigate steep sections of track on their routes.

In the early hours of 15 December 2020, the crew of a grain train, consisting of two locomotives,40 loaded and 1 empty wagon, lost control on the descent into Unanderra on the Moss Vale to Unanderra rail line.

During the runaway, the train reached 100 km/h on a 30 km/h section of steep, winding track. The consist subsequently separated at two points, and 39 of the trailing wagons derailed and were destroyed, causing substantial damage to track infrastructure. There were no fatalities or serious injuries.

Key findings from the investigation include:

Ineffective braking caused by several factors contributed to the runaway.
The train was not over the maximum allowable tonnage limit, but several individual wagons were likely over the allowable limit for a single wagon.
Variability in braking capability between wagons combined with variability in loading likely reduced braking effort on some wagons during the steep descent.
Train handling and locomotive braking was also affected by environmental conditions.
The driver’s operation of the train and braking actions did not always conform to the operator’s instructions.
The train operational procedure for train management between Moss Vale, Unanderra and Inner Harbour did not consider the way the locomotives attached to the train would react during emergency brake applications. This increased the risk of the driver not applying the appropriate combination of normal and emergency braking during a runaway event.
This misunderstanding was also found to be embedded in other rolling stock operator’s procedures with similarly configured locomotives in NSW.

Safety lessons for rail transport operators include:

Rolling stock operators should:

ensure their trains have sufficient braking, are loaded within safe load limits, and are operated in accordance with their procedures.
understand how their locomotive braking systems are configured and the associated error tolerance. Operators must communicate this information through their procedures and training material to ensure train crew have knowledge of and competence in operating locomotive braking systems.

Rolling stock operators and rail infrastructure managers should ensure risk assessments identify critical operational requirements to safely run trains down such steep sections of track, and there is sufficient error tolerance to enable control of trains on sections of rail line that present increased risks from long and steep descents.

OTSI undertook this investigation under a Collaboration Agreement with the Australian Transport Safety Bureau (ATSB).

To know more,read the full investigation report.

Derailment involving Qube freight train 5WB7 – Casino, 17 March 2022 (Investigation discontinuation)

The findings of a discontinued investigation into a 2022 derailment at Casino highlighted vulnerabilities in a rolling stock operator’s axle inspections and maintenance regime and prompted them to implement several safety actions to prevent another incident.

On 17 March 2022, an axle in the rear part of a train broke as it entered the yard at Casino, derailing the wagon. As the train continued to pass through the yard, a further eight wagons derailed. There was significant damage to the track and signal infrastructure in the yard, however there were no injuries.

OTSI undertook an investigation into the incident, under a Collaboration Agreement with the ATSB, which found the derailment was due to a broken axle on the 55th wagon, caused by a fatigue crack on the axle barrel.

Since the incident, the rolling stock operator involved has taken the following safety actions:

Implemented visual inspections and ultrasonic testing of axles on all wagons.
Updated their rolling stock maintenance manual using data from the on-wagon axle testing to provide clear standard for future axle maintenance.
Created a register to ensure all axles have unique identifying numbers.
Made representations to the Rail Industry Safety and Standards Board to consider strengthening the requirements of AS 7515 Axles to mandate the marking of axles with dates and sources of manufacture to align with traceability requirements of AS 7514 Wheels.

In December 2023, due to the work completed by the operator and the nature of the failure, the investigation was discontinued after it became apparent that further investigation was unlikely to identify any systemic safety issues or additional safety lessons.

View the investigation report to find out more about this investigation.

Confidential Safety Information Reporting Scheme (CSIRS) Outcome Report

OTSI recently published a report on a rail safety matter raised by a transport employee under the Confidential Safety Information Reporting Scheme (CSIRS).

The CSIRS gives transport industry employees a confidential way to make a report about a safety issue affecting a bus, rail or ferry service. CSIRS Outcome Reports are published because their findings have the potential to benefit other organisations in the sector.

Long distance passenger train operating with below minimum crew numbers (CSIRS Outcome Report C1021)

OTSI investigated an incident in which a passenger service carrying 177 passengers had operated with only two active onboard crew members. The CSIRS reporter asserted that the service operated with less than the required staff due to staff illness and insufficient replacement coaches.

The operator’s procedures for unplanned staff absences outlines that a minimum of three active onboard crew members are required to operate a service compared to the normally rostered four onboard crew.

Following the investigation, the operator agreed to address key safety issues resulting from the event including:

reviewing and strengthening the procedure for minimum onboard staff during unplanned staff absences
exploring processes to capture and monitor real-time fatigue data to allow crew and management to monitor fatigue more accurately and make more informed decisions.

The investigation is a reminder to operators of passenger trains that the safety of passengers and staff is the most important consideration when deviating from established safety processes.

Risk management principles require that a decision to deviate from an established safe practice should be supported by a formal decision framework that records the assessment of the risk, the risk mitigation strategies, consultation with workers and approval by an authorised officer of the operator.

Read the CSIRS Outcome Report

Safety Alert SAL01/24

Bus and coach rollaways: review your risk controls - 28 February 2024

We issued a Safety Alert to raise industry awareness and encourage action following several reported bus and coach rollaway incidents involving park brake application failures.

The Safety Alert includes information on two incidents involving school bus services, Casino (22 November 2023) and Gundagai (1 February 2024) which highlight the importance of bus and coach drivers assuring themselves that the park brake is applied before they alight the driving position. No injuries resulted from either event, but they are a reminder of the potential risks of serious injury or death in rollaway situations.

Bus and coach operators are strongly encouraged to: 

Ensure that they and their drivers understand the functionality of the park brake systems, and interface with door interlock systems, for all vehicles in their operating fleet. 
Ensure drivers are familiar with any alarms or indications identifying the state of the parking brake if the driver is to leave the driving position.  
Ensure that drivers understand the consequences of external door closure switch activations in circumstances where the parking brake is not applied.
Review driver operating procedures for rollaways, including appropriate responses to abnormal situations, such as door closure issues.
Review the strength and effectiveness of operator risk controls to mitigate vehicle rollaways.

Read the full Safety Alert on the OTSI website.

Safety Advisory SA01/24

Consideration of extreme weather events in safety management systems - 8 March 2024

We issued a Safety Advisory to remind rolling stock operators and rail infrastructure managers that effective rail safety management systems require consideration of external factors like extreme weather events.

The Safety Advisory follows a freight train derailment ion the Ulan line which damaged two kilometres of track infrastructure and sparked a wildfire impacting neighbouring private land and the Wollemi National Park. Temperatures in the area at the time of the incident reached a recorded maximum of 40.1°C.

Rolling stock operators and rain infrastructure managers are urged to:

Ensure risk management for extreme weather events and track stability is current and considers Bureau of Meteorology advice for predicted events throughout the year.
Remind rail safety workers to remain vigilant while operating trains and continually assess the condition of the track and make timely reports of any defects to network control.
Ensure rail safety workers’ induction and refresher training includes sufficient operational information for identifying and traversing track defects (such as buckles).
Ensure rail transport operators’ emergency management plans are current, routinely practised and provide information relating to seasonal hazards and the roles and responsibilities of each rail safety worker during an emergency response, including scenarios where external agencies may assume jurisdictional control over the incident.

Read the full Safety Advisory on the OTSI website.

Safety lessons from our 20 most impactful investigations - 2004 to 2023

Over the past 20 years, OTSI has completed more than 230 investigations, harnessing learnings and insights from bus, ferry, and rail incidents to help stakeholders make informed decisions to improve safety systems and prevent a similar incident from reoccurring.

Throughout this year, we’ll be shining a spotlight on our most impactful investigations from 2004-2023. The safety lessons are just as relevant now and serve as a reminder for stakeholders to regularly assess their safety management systems and risk controls and consider how measures can be applied to further improve safety outcomes.

The following two bus safety investigation reports highlight the importance of risk assessment, effective driver training, compliance with Australian Design Rules (ADR), adequate vehicle repairs and maintenance, and engine bay fire suppression systems in buses.

Jamberoo Mountain Road fatal bus accident

What happened

On 5 September 2005, a 24-seat minibus towing a loaded trailer was descending Jamberoo Mountain Road on the NSW South Coast when the brakes overheated and the driver lost control, causing the vehicle to collide with a guard rail before rolling onto its roof and coming to a stop against a small tree.

Three passengers were fatally injured and 14 sustained injuries that required hospitalisation.

What OTSI found

The accident occurred when the bus’s brakes failed, preventing the driver from safely negotiating a corner on a steeply descending road.
The overheating was caused by the driver’s inappropriate selection of gears and poor braking technique for the condition of the road.
The bus had a defective air brake pressure alarm system. While the defect itself was not found to be an issue in the accident, the fact the operator did not detect the fault, or allowed the bus to operate with such an important safety device disabled, was indicative of poor defect identification.
The driver had held a foreign driving licence for 19 years and had operated heavy vehicles before moving to Australia, but they had limited driving experience in Australia having only obtained their NSW bus licence five weeks earlier.
The operator instructed the driver to use an unfamiliar route.

The existing seats in the bus were not fitted with lap-sash seatbelts and their anchorages would have been incapable of meeting the strength requirements specified in Australian Design Rule 68 once an approved seat belt had been fitted. The bus was registered by the Roads and Traffic Authority (RTA, now Transport for NSW) but was not compliant with the required regulations and should not have been registered.

Safety lessons

Improper maintenance regimes and controls: There was cause to question how the Operator was managing their maintenance regimes considering the defective air brake pressure alarm system went unnoticed and the vehicle was not compliant with the required regulations.
Proper route risk assessment: Operators must proactively and effectively address safety risks, particularly in relation to bus drivers’ route selection and familiarity.
Driver training and experience: The incident highlighted the importance of driver training, route and vehicle familiarisation, and competency testing.

Safety actions taken

The RTA advised OTSI that in October and November 2005 it had:

Inspected the operator’s fleet and identified one bus that did not fully conform to RTA requirements for imported buses being operated for commercial purposes. The RTA issued the operator with a major defect notice which prohibited use of the bus. It issued a similar notice on three other buses operated by another Sydney-based company.
Issued Compliance and Enforcement Notice 44 – Inspection Requirements for Buses – Australian Design Rule (ADR) Compliance to all its vehicle inspectors to clarify its requirements for bus inspections.
Written to all engineering signatories to remind them of the requirements for certifying imported buses. The RTA reviewed all certificates issued for imported buses from 2000-2005.

The NSW Ministry of Transport conducted a full compliance audit of the operator in September 2005 and issued a warning notice requiring it to rectify the deficiencies identified.

This investigation report led to the OTSI Systemic Investigation into the Importation and Registration of Overseas-Sourced Buses in NSW.

Download the Fatal bus accident - Jubo Travel Jamberoo Mountain Road - 05 September 2005 report.

Hillsdale bus fire involving bus MO4878

What happened

On 29 July 2011, a bus powered by compressed natural gas (CNG) caught fire at Hillsdale in Sydney when returning to the Port Botany depot. Despite attempts by the bus driver and Fire and Rescue NSW to extinguish the fire, the bus was destroyed. There were no passengers onboard at the time of the incident and no reported injuries.