Chief Investigator’s message
Welcome to the 8th edition of OnBoard, the OTSI quarterly newsletter.
In the first months of the year we have released a Ferry Safety Investigation Report into an incident where two children went overboard at Riverview College Ferry Wharf in 2023, and a short report into a coach fire at Kiama in November 2024. We have also initiated two new investigations, a derailment of a passenger train at Clarendon and an incident where a bus crashed into a house at Bonnyrigg Heights. Further details of these investigations can be found in this newsletter.
As part of Bus Safety Week (17-23 February), I attended an awards ceremony celebrating safe drivers hosted by CDC NSW. The event was also attended by Transport for NSW, the National Heavy Vehicle Regulator (NHVR) and members of NSW Police.
At this event I had the opportunity to look at the new eye movement tracking systems that have now been installed on over 10% of CDC buses. It is pleasing to see innovations like this that improve transport safety for the people of NSW.
I also attended a regulator forum hosted by NHVR which was attended by SafeWork NSW, Comcare and the NSW Police. It was a great opportunity to create strong relationships with other agencies that work to improve safety.
As always, I welcome your feedback. Please share your thoughts on issues raised in this newsletter, ideas and suggestions by emailing engagement@otsi.nsw.gov.au
Jim Modrouvanos
CEO and Chief Investigator
Office of Transport Safety Investigations
Key investigation activity
January- March 2025 (as of 14 March)
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| Completed investigations |
Recent Investigation reports:
Children overboard at Riverview College Ferry Wharf - Riverview - 16 February 2023
We recently released an investigation report into an incident on 16 February 2023 where two students fell into the water when disembarking from the passenger vessel Violet McKenzie at Riverview College Wharf. All students were safely retrieved from the water.
Some factors that contributed to this incident were:
- The crew did not effectively manage the disembarkation of students at Riverview College Wharf, with ineffective crowd management and late identification of the movement of the vessel away from the wharf, resulting in gangway displacement and students falling.
- The vessel operator did not adequately identify and subsequently control risks associated with Riverview College Wharf ferry operations for the Super Rocket Class vessels.
The investigation identified safety improvement opportunities including:
- Improvements to the Operator’s Safety Management System (SMS) to ensure that the hazards and risks associated with the berthing and embarkation/disembarkation of passengers at wharves on individual operators' services are identified and assessed, and effective risk control measures implemented to ensure safe passenger operations.
- Improvements to the Operator’s SMS to provide assurance that crew members have achieved and maintain competency in safe berthing and gangway operations.
- Review of risk control measures in place for student ferry services, including consideration of backpacks or other articles carried by students across gangways.
Coach fire – Kiama – 28 November 2024
On 28 November 2024, coach 5711MO operated by Kiama Coaches Pty Ltd, caught fire while conducting a scheduled school service on Route S491, from Kiama Downs to Kiama, NSW. After being alerted by a student to the smell of smoke and subsequently observing smoke in the engine bay, the driver brought the coach to a halt and evacuated all 33 students on board. The coach sustained significant damage before NSW Fire and Rescue extinguished it.
Factors that contributed to the fire were:
- A high resistance connection in a high amperage electrical cable terminal lug created significant overheating leading to the thermal decomposition and ignition of the polymer insulating material around the high resistance connection.
- The wiring harness comprising of continuously energised high current cables, supplied a continuous heat source. Additional combustible insulation materials inside the engine bay acted as fuel.
- The ampacity of the cable was exceeded due to it being connected to a fuse in excess to the cables carrying capacity.
- Adequate circuit protection in the event of an electrical fault was not present.
- It was discovered that switching off the ignition and activating the battery isolation switch in the engine bay of exemplar coaches, did not isolate power.
- Coach 5711MO was also not fitted with an Engine Bay Fire Suppression system (EBFSS) under the TfNSW Bus Operator Accreditation Scheme (BOAS) because it was not used for regular scheduled services operated in regional NSW and was used primarily to carry school students.
Safety improvement opportunities identified by this investigation include:
- Operators should consider reviewing maintenance regimes to ensure inspections adequately address and remedy any issues with high amperage cabling and terminals.
- Operators should also review their current fleet of buses to ensure electrical circuits are adequately protected and can be effectively isolated as required.
- Consider the fitment of engine bay fire suppression systems in buses and coaches to improve fire detection and prolong available evacuation time in the event of an engine bay fire, thus reducing safety risk to occupants.
New investigations initiated:
IRoute bus m/o5367 crash into a house, Bonnyrigg Heights, NSW – 4 February 2025
OTSI has launched a transport safety investigation into an incident where a bus crashed into a house at Bonnyrigg Heights, NSW.
A bus travelling on a route between Liverpool and Cabramatta crashed into a house, causing significant damage. 6 passengers on the bus were reportedly uninjured.
Emergency services conveyed the driver to the hospital.
Read the Interim Factual Statement
Read the Interim Factual Statement
Derailment of passenger train 172C - Clarendon - 16 January 2025
OTSI has launched a transport safety investigation into a signal passed at danger and derailment incident at Clarendon Station, NSW.
A passenger train overshot the platform, derailing the lead car. There were no injuries to passengers or crew, who safely evacuated from the train at the platform.
Read the Interim Factual Statement
The Chief Investigator has determined that these incidents warrant investigation and has assigned Investigators in Charge (IIC) to:
- identify the factors, both primary and contributory, which led to the incidents
- determine whether the incidents might have been anticipated and the effectiveness of any controls that were in place to manage the related risks
- advise on any matters arising from the investigation that would enhance the safety of bus and rail operations.
The aim of an OTSI investigation is to enhance transport safety by sharing safety lessons and insights with organisations that can implement safety actions. We use a 'no-blame' approach to identify and understand contributing safety factors and underlying issues.
Jim Modrouvanos profile
Our Chief Investigator and CEO was appointed to the role by the Governor of NSW in August 2024 following a recruitment process run by the Public Service Commission and after acting in the role since September 2023.
Jim has qualifications in engineering and public administration and has more than 35 years' experience in the Transport public service encompassing several senior Executive roles. He has led teams in areas such as radio systems, operational technology, signalling control systems, rail engineering, asset management, safety systems, systems assurance, freight and industry regulation.
In the NSW government rail sector, he has held significant positions including General Manager Communications and Control Systems, General Manager Strategic Asset Management, General Manager Chief Engineer, Executive Director Asset Standards Authority and Executive Director Point to Point Transport Commission.
Jim led the development and establishment of the Asset Standards Authority (ASA) as well as its first 5 years of operations. The ASA was an independent unit of TfNSW that undertook a key internal engineering and safety regulatory role across heavy rail and light rail. Jim also led the Freight Branch at Transport for NSW through a complex period of policy, regulatory and operational change including the delivery of the NSW Freight and Ports Plan 2018 – 2023.
Jim is focused on working with stakeholders to develop practical solutions that improve safety and operational outcomes. Most recently as an Executive Director working with the Point to Point Transport Commissioner to improve the operations of the Commission and with the Taxi and Rideshare industries to improve their understanding of safety obligations as well as practical solutions that manage their risks.
Jim’s extensive experience and unwavering commitment to safety will be instrumental in driving OTSI’s growth as a leading centre of transport safety excellence. His deep understanding of the evolving transport safety landscape, combined with his dedication to fostering a culture of accountability and continuous improvement, will ensure that safety remains at the core of every decision—from daily operations to long-term strategic planning.