I am delighted to welcome you to the first edition of the Office of Transport Safety Investigations (OTSI) quarterly newsletter OnBoard. This newsletter is a new way for us to share the latest OTSI news and developments with you, as well as providing you with insights into the way we work and the services we deliver.
In this edition you will find information about our recent investigation report and Safety Advisory releases, new investigations initiated, enhancements to our ‘72 hour report’ for bus operators, and changes to the safety incidents that bus operators must report to OTSI immediately by phone.
You can also read about three reports we have recently released after investigating matters raised by transport employees through the Confidential Safety Information Reporting Scheme (CSIRS). The CSIRS is an important mechanism for helping to shine a light on safety risks on our transport network.
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Revised 72 Hour Bus Incident Investigation Report form
Identifying the root cause/s of a safety incident enhances the ability of a transport operator to prevent the same type of incident from recurring by developing and implementing targeted safety improvement actions.
To support bus operators to undertake their own investigations, OTSI has released a revised version of its 72 Hour Bus Incident Investigation Report form to incorporate the ‘PEEPO’ (People, Environment, Equipment, Procedures and Organisation) investigative model.
In some cases, when a bus operator reports a bus safety occurrence, OTSI may ask the operator to complete a 72 Hour Bus Incident Investigation Report form. OTSI uses the information collected to identify trends or safety factors across the sector, to inform investigation decisions, and to work with individual operators or the regulator to identify lessons or improve safety specific to the incident.
The revised report form includes topic areas under the PEEPO model which can be used as prompts during general bus operations investigations to accurately identify appropriate corrective actions and implement preventative measures.
OTSI has released two investigation reports so far in 2023:
Rockfish 3 collision with John Cadman 3 – Sydney Harbour
This investigation into a night-time collision between two charter vessels on Sydney Harbour on 12 December 2021 highlights the importance of vessel operators maintaining a proper look-out and the need to identify and effectively manage specific risks encountered when operating at night.
The investigation identified several contributing factors to the incident including:
Proper look-out was not maintained which meant neither vessel saw the other and so, were unable to act in time to avoid the collision.
The operators of the involved vessels did not fully consider the risks of operating in the Sydney Harbour Bridge Transit Zone at night, including the increased vessel traffic expected in this area and potential impacts from the backscatter of city lights and other vessel design visibility issues.
OTSI made recommendations to the operators involved in the incident that they review their Safety Management Systems (SMSs) to ensure that:
the risk register includes relevant risks encountered during charter operations, specifically identification and mitigation for night operations and look-out requirements
relevant competency-based crew induction and ongoing refresher training are included.
OTSI also made a recommendation to all DCV operators to review their SMSs to ensure risks unique to their vessel operations (including from operating in the Sydney Harbour Bridge Transit Zone) are identified and assessed for inclusion in their SMSs. Operators are encouraged to implement mitigation strategies to reduce risks for any identified hazards.
Speed restriction not applied, allowing train ST24 to overspeed – Harefield
This investigation highlights the importance of staff training when introducing new procedures and technologies.
On 29 June 2021, a NSW Trains XPT operating between Albury and Sydney passed through a worksite at approximately 100 km/h.At the time, ongoing repairs required that a speed limit of 40 km/h should have been in place.
Key safety lessons for operators from the investigation focus on training and competency assessment, and the information workers require to successfully apply new technology.
When introducing new technology, training regimes should include competency assessments, and content tailored for the workers and their required application of the technology. Training should include practical use of the technology under different scenarios, and include managing foreseeable errors, to promote familiarisation and understanding.
This investigation was carried out by OTSI under a Collaboration Agreement with the ATSB. Read the full investigation report on the ATSB website.
Recent Safety Advisories
SA02/23 – Bus rollaways and incident data collection - 21 April 2023
This advisory focuses on bus rollaway events which present a substantial risk of both serious injury and loss of life. Bus and coach operators need to fully understand the circumstances of the event and likely cause/s, to ensure appropriate and timely safety actions are taken. Using a simple investigative model such as PEEPO (People, Environment, Equipment, Procedures and Organisation) will assist operators to capture better data and identify contributory or underlying cause/s.
SA01/23 – Protection of electrical circuits on buses - 14 March 2023
This advisory focuses on the importance of ensuring fuses are matched correctly to the ampacity of the cables installed when designing and installing electrical circuitry in buses. The inclusion of cables with a lower ampacity than the fuse will significantly increase the risk of a fire in the event of a short circuit. Fuses and circuit breakers should be correctly rated according to relevant electrical standards to protect cabling and the equipment creating the load within a circuit.
On 10 February 2023 Transdev coach TV287A was on Uranus Road, Revesby operating a charter service carrying 39 primary school-aged children and two teachers.
During the journey the coach made a routine stop at traffic lights. On signal and departing from the traffic lights, the driver observed smoke coming from the rear of the coach. The driver, seeking a safe place to stop, continued for approximately 300m along Weston Street where the coach stalled and stopped. All passengers onboard were safely evacuated.
No passengers were injured during the incident, but the coach was destroyed by fire. Nearby vehicles sustained damage from heat and smoke generated by the incident.
Confidential Safety Information Reporting Scheme (CSIRS) releases
OTSI recently published reports on three rail safety matters 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.
CSIRS Outcome Reports were published on three matters in March and April 2023 because the investigation findings have the potential to benefit other organisations in the rail industry.
CSIRS Outcome Report C1016 - Competence assurance and performance management of incident response personnel
The CSIRS reporter made assertions about the competence assurance and performance management of a rail transport operator’s incident response personnel. The operator provided advice about several actions it had taken in relation to matters raised. OTSI is satisfied the actions taken by the operator are suitable to manage the issues raised and has closed the report.
The CSIRS reporter made assertions about potentially unauthorised modifications carried out to accommodate the brake handle on Tangara train sets. OTSI is satisfied with the actions taken by Sydney Trains to address the safety risks arising from unauthorised desk modifications and its intention to determine a long-term solution.
This matter is a reminder to all rail transport operators that any modifications to original design must follow proper engineering and change management processes, including the formal assessment of the requirement for, and risk of, any such changes.
CSIRS Outcome Report C1012B – Response to defects detected during train preparation
The CSIRS reporter made assertions that train units with faults in data loggers resulting in an ‘F’ (failure) flag indication, remained in service after being reported. The report is now closed and although the original claim was found to be unproven, opportunities were identified for Sydney Trains to improve safety through review of its standards and practices to provide assurance that it is satisfying its own minimum train unit operating standards for data loggers.
You can find out more about the CSIRS and make a report (if you are a transport employee) on the OTSI website.
Changes in bus incident reporting to OTSI
OTSI has introduced a revised list of ‘significant’ safety occurrences that bus operators must report to the OTSI Duty Officer immediately by phone.
The reporting changes, which took effect in March 2023, will ensure the OTSI Duty Officer can focus their attention on events that may require OTSI to deploy to a site or undertake other immediate actions. The changes will also help reduce the administrative burden on operators at the time an incident occurs.
The following significant safety incidents are to be reported immediately by phone to OTSI on 1800 677 766:
a person being fatally injured
the driver of the bus being incapacitated
fire or an explosion on the bus
a failure of the steering or brakes of the bus
a bus being in motion while not under the effective control of a driver (e.g bus rollaway)
a person being caught in the doors of the bus while the bus is in motion
a collision where the bus requires towing
a collision where a pedestrian is struck and is seriously injured
a school child being seriously injured (including children in organised care)
a child left on a bus unattended, while in organised care
any other accident or incident likely to generate immediate or intense public interest or concern.
There are no changes to the legislative requirements for what incidents must be reported via the Bus Incident Management Database (BIMD).