Chief Investigator’s message
Welcome to the sixth issue of OnBoard, the OTSI quarterly newsletter.
The last quarter has been a busy time for us, as reflected in this newsletter. Inside, you will find updates on a new investigation we have initiated, and investigation reports we have released.
In August, we welcomed Minster Haylen to OTSI to celebrate our 20th anniversary. This event was also an opportunity to recognise the dedication of our staff with service awards. The Minister emphasised the critical role of ‘no-blame’ independent safety investigation and the importance of learning from past incidents to prevent future occurrences, reaffirming our role in contributing to a safer transport network in NSW.
I was recently invited to present at the Australasian Railway Association’s Light Rail Conference in Sydney. My presentation focused on the importance of effective risk management and quality processes in preventing incidents in light rail operations. With the continued growth in light rail operations, the conference was a great opportunity to put the spotlight on some of the issues we are seeing through occurrence notifications and to raise awareness of the value OTSI provides in sharing safety lessons with the light rail operators, maintainers and other industry members.
Our team attended the International Boat Show in August, where our Director, Investigations Bus, Ferry and Light Rail, Sam Moran delivered ‘Talking Safety’ sessions on the main stage. Our stand at this event facilitated productive discussions with visitors, and we received some useful feedback on how we deliver our services.
In this edition, we continue to share safety lessons from our most insightful investigations over the past 20 years since OTSI was established. Some of these investigations date back more than 15 years and highlight the substantial progress in safety the transport industry has made during this time.
Thank you to all our stakeholders who participated in our recent survey, conducted by Lonergan Research. Your feedback is invaluable and will help us to enhance the value we offer the transport sector. The survey captured your confidential insights on our work, products, and services and we look forward to sharing the key findings in the coming weeks.
In the meantime and 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
July - September 2024
| Investigation launches | - Passengers struck by train on track and fatally injured – Carlton Station – 21 July 2024 |
Number of incident | - 143 |
| Completed investigations | - Rail Worksite Protection in NSW – Report 2 – Cowan – 11 January 2023 - Collision between banking locomotives and grain train 5446 - Werris Creek – 6 January 2022 - Bus collision with road barrier - Belmont North - 13 November 2022 |
| Safety Alerts/Advisories | - RO-2022-001-SAN-01: Automatic coupler operation and design features - RO-2022-001-SAN-02: Assessment of rail safety worker competence |
Recent Investigation reports:
Rail Worksite Protection in NSW - Report 2 - Cowan - 11 January 2023
We released an investigation report on an incident near Cowan in January 2023 where a passenger train was inadvertently allowed to enter an area where maintenance workers were on the track. The incident occurred at night during track work between Cowan and Hawkesbury River, north of Sydney.
An electric passenger train entered a section of track that should have been protected by a Local Possession Authority (LPA) but was not. While there were no injuries or asset damage because of this incident, there was the potential for a collision between the passenger train and workers and equipment.
The investigation found factors that contributed to the incident included:
- misinterpretation of safety rules
- inattention or distraction (possibly due to unauthorised use of electronic devices)
- lack of familiarity with LPA arrangements
- simultaneously issuing multiple LPAs with differing protection requirements increasing the likelihood of critical information or errors being missed.
The investigation highlights the critical importance of rail operators ensuring robust assurance and communication procedures, as well as effective supervision of safety-critical personnel. It emphasises that human error – from non-compliance with rules, procedures, and protocols – along with limitations in worksite protection methods, remains a significant factor in worksite protection incidents involving trains entering protected areas.
We share these safety insights to support rail transport operators, infrastructure managers and their contractors to improve worksite safety and help prevent future incidents.
Read the investigation report
The Cowan investigation is part of a systemic investigation into worksite protection in NSW to be delivered in early to mid-2025. It follows the release of a report in December 2023 on a worksite protection incident at Picton in 2022.
Collision between banking locomotives and grain train 5446 - Werris Creek - 9 January 2022
We published the findings of our investigation into a collision involving a grain train and three banking locomotives near Werris Creek in northern NSW in January 2022 which left a crew member with a minor head injury and caused significant damage to rolling stock.
Three banking locomotives which were to be used to assist the train to travel up a steep section of track separated from and then collided with the rear of the train shortly after leaving Werris Creek.
The cause of the train separation was highly likely due to the knuckle on the lead banking locomotive’s bottom operated coupler – the component which connects the locomotive to the rear of the train – remaining unlocked after coupling.
The investigation found the crew did not perform a ‘stretch test’ which would have identified that the knuckle was unlocked. It also found that:
- The train crew had limited coupler functionality knowledge, and test procedures associated with shunting operations were not clearly defined.
- There was insufficient evidence to determine whether the banking locomotive crew had previously demonstrated a sufficient level of competence in a stretch test procedure, either with their current employer or previous operators.
- Procedures in the event of an emergency during banking operations were absent.
- There was limited effective and meaningful stakeholder engagement during the risk assessment process.
The investigation has highlighted the following safety lessons for rail transport operators:
- Operators should meet certain standards, including collecting sufficient assessment evidence, to ensure a reliable competency decision can be made when delivering assessments for rail safety workers. This applies to both enterprise-based and those that are aligned to the Australian Qualifications Framework.
- When assessing risk, effective and meaningful engagement with stakeholders is key to ensuring risks are identified and appropriate controls are implemented. This is especially important for unique operations and identifying novel risks.
- Operators should pay particular attention to procedures used in past operational environments to ensure they continue to be appropriate in unique operational circumstances.
OTSI carried out this investigation under a Collaboration Agreement with the Australian Transport Safety Bureau (ATSB). A report on the investigation and two Safety Advisory Notices have been published to share the findings with the rail industry.
Read the investigation report and Safety Advisories
Bus collision with road barrier - Belmont North - 13 November 2022
We released an investigation report on the collision of bus MO8219 with a concrete barrier in Belmont North.
On 13 November 2022, at 0347, bus m/o8219 collided with a concrete barrier. At the time, the bus was travelling westbound on Wommara Ave in Belmont North and conducting a passenger service with the driver and six passengers onboard. The collision resulted in the bus rolling over to the left and coming to rest against the side of a drainage channel. Several passengers, including two who were ejected during the bus rollover, sustained injuries requiring medical treatment. The bus sustained significant damage.
The investigation report identified that several factors led to this collision including:
- a low light operating environment with limited visual cues
- the activation of an onboard vehicle speed alert resulting in bus driver distraction at a critical time
- the sloped design of the barrier which also had limited markings and reflectors.
The investigation also identified that the operator was unaware that the driver had a medical condition and was taking prescribed medication. This oversight resulted in a missed opportunity for the operator to assess the potential operational risks associated with a driver with a diagnosed ocular disease.
The investigation identified safety improvement opportunities, including:
- reviewing the road markings and infrastructure in the incident site vicinity
- evaluating onboard vehicle monitoring system alerts to mitigate the potential for driver distraction
- enhancing bus driver awareness of the management of internal glare sources
- assessing bus operator route risk assessment processes
- providing updated guidance to operators on managing driver medical conditions.
Investigation launched into Carlton Station fatalities
We have launched a transport safety investigation into a fatal incident on 21 July at Carlton Station where passengers were struck by a train.
The incident occurred when a pram rolled in an uncontrolled manner towards the platform edge and fell onto the track. The person with the pram jumped onto the track to retrieve the infants and was struck by an approaching passenger train. The person and one of the infants were fatally injured, while the second child sustained non-life-threatening injuries.
Based on findings from our preliminary enquiries, the Acting Chief Investigator determined that the incident warrants investigation and has assigned an Investigator in Charge (IIC) to:
- identify the factors, both primary and contributory, which led to the incident
- determine whether the incident 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 rail operations.
We use a 'no-blame' approach to identify and understand contributing safety factors and underlying issues. The Interim Factual Statement for the Carlton Station investigation is available on our website
Read the Interim Factual Statement
Bus Fire and Thermal Incidents in NSW in 2023
The eleventh annual summary report into bus fires in NSW has been released which shows that fire remains a major safety risk for bus and coach operations. In NSW, both the number of bus fires and thermal incidents have increased in recent years, although the severity of damage caused to vehicles has decreased. The key takeaways from this report are:
- In 2023, there were 24 notifications of bus fires and 148 notifications of bus thermal incidents, marking a 41% increase in fires and a 6% increase in thermals compared to 2022.
- Approximately 66% of bus fires and 60% of bus thermals occurred with passengers onboard, emphasising the potential for physical harm. Although no physical injuries were reported, the incidents caused varying degrees of damage to buses, with one bus destroyed and three significantly damaged.
- Bus fires primarily originated in vehicle engine bay, while thermals generally originated in the wheel well.
- Brake faults were the most common cause of bus thermal incidents (55%), while electrical faults were the biggest cause of bus fires (37%).
- Fire suppression and extinguishing equipment and safety monitoring systems were critical in mitigating damage. Portable fire extinguishers were effective in 81% of bus fires in which they were used, while Engine Bay Fire Suppression Systems activated in 42% of engine bay fires, limiting damage to buses.
Inaugural OTSI Knowledge article launched
We have published the inaugural OTSI Knowledge Article focusing on the topic of fire risks of engine coolant leaks in buses.
Coolant leaks have been highlighted as a potential cause of vehicle fires worldwide. Several OTSI investigations into bus fires in NSW have also identified engine coolant as the likely first fuel for fire prompting further research into this area.
This Knowledge Article is targeted at bus operators and suppliers, including personnel involved with fleet management and safety compliance, and:
- aims to provide a better understanding of the fire properties of engine coolants, the underlying science behind these properties, and the associated fire risks of coolant leaks relating to bus operations
- identifies misinformation regarding engine coolant fire safety in vehicle operational and non-operational (storage and handling) environments.
Knowledge Articles are designed to share OTSI insights on various transport safety topics drawing on literature research and investigation experiences. This article is intended for education and awareness, not necessarily to provide recommendations to transport operators or other stakeholders.
Education animations
We have developed three educational animations about OTSI: who we are, what we do and how we do it. These short animations run for around two minutes each and explain our role as the independent transport safety investigator for NSW and our commitment to improving transport safety.
The animations cover the different types of OTSI investigations, how they are triggered, the investigation process, and how we identify safety issues, and share recommendations and safety lessons.We maintain regular interaction with bus, ferry and rail organisations by participating in events, committees, meetings and developing partnerships to foster safety improvements.
Watch, download or share these videos:
Video 1: Who is OTSI?
Video 2: What does OTSI do?
Video 3: How OTSI investigates
Insights from 20 years of OTSI Safety Investigations
Over the past 20 years OTSI has completed more than 230 investigations, and this series spotlights the most impactful investigations from 2004-2023.
This issue shines a spotlight on two ferry investigations, one concerning a steering failure which is an issue that continues to cause incidents today, and the other related to the importance of emergency drills.
Collision of the MV Louise Sauvage, Rose Bay Wharf (2004)
What happened
On 12 May 2004, the vessel MV Louise Sauvage collided with the wharf at Rose Bay in Sydney Harbour. The crew reported that the vessel had suffered a steering system failure at a critical stage of the approach to berth.
What OTSI found
Earlier in the day of the incident, the vessel experienced a failure of its steering system. The defect was not confirmed during shipyard testing and sea trials, so the vessel was returned to service.
Based on the earlier steering system failure, the extent of disassembly of the system before OTSI could inspect the vessel, and the absence of reliable data recording of vessel parameters, the investigation concluded that the most likely cause of the collision was the failure of the steering system. However, technical investigations by both the vessel operator and OTSI could not establish what caused the steering system failure.
Safety lessons
Risk management
At the time of the incident, the operator lacked a formalised system for managing operational risk. Since then, marine safety has advanced and all vessels are now required to develop and implement a risk management system. This system identifies and implements reliable controls for any operational safety hazards in the vessel design, vessel operations, and the operating environment.
Data recording
The absence of reliable data recording of vessel parameters meant that the cause of the collision could not concluded, the cause of the steering failure could not be determined, and the failure could not be replicated. This report stressed the importance of incorporating data recording facilities into all public passenger service vessels.
Accuracy of operating manual
Effective risk management requires an effective safety management system and an accurate operating manual. Training and procedural information in MV Louise Sauvage’s Vessel Operations Manual Supercat Class was inaccurate or incomplete. As a result, the ability of the crew to implement appropriate corrective action to avoid a collision was limited.
Importance of training
This incident stressed the importance of structured training and ongoing competency programs. The concepts of Crew Resource Management were also highlighted in managing emergency situations to help operational crew improve on communication, teamwork, and emergency response to achieve safe operations.
Systemic Investigation into Training of Ferry Crews Operational Procedures and Emergency Drills, November 2007 – May 2009
What happened
This investigation was initiated following safety concerns reported under the Confidential Safety Information Reporting Scheme (CSIRS). The reporters alleged the number of drills undertaken by onboard ferry crews had decreased since November 2007, when training responsibilities were transferred to a different division within the operator. It was also alleged that some personnel participated in numerous drill practices while others received minimal drill practice.
What OTSI found
The investigation focused on the conduct of drills. At the time, there was a requirement to comply with the Uniform Shipping Laws (USL) Code for drills to be conducted at regular intervals on all ferries. The operator also included a requirement for drills in its Safety Management System (SMS).
The investigation found that a rigorous and systematic approach to meeting the requirements of the USL Code and the SMS was lacking. OTSI observed:
- It was left to individual Masters to design, deliver and assess drill practice, without assistance from the responsible division within the operator.
- Ineffective record keeping practices, with records not identifying the vessel on which the drill was conducted, and the partial completion of drills not being recorded.
- Drills not being conducted at regular intervals.
- Inconsistent rostering of crew members, resulting in some individuals not being involved in a drill practice for long periods while others were involved more often.
- Drill practice performance was not independently assessed.
- No collision drills were undertaken during the relevant period.
- Vessel Operating Manuals (VOMs) did not contain an adequate level of detail and were inconsistent in content common to all vessels.
- There were complexities regarding the timeframes available for scheduling vessels for drills and the limited flexibility, due to the diversity of vessels within the operator’s fleet.
During the investigation, OTSI provided feedback to the CSIRS reporters,who indicated that the new arrangements introduced satisfied the safety concerns raised.
Safety lessons
Onboard emergency drills
The operator responded to OTSI’s findings and instituted several changes which resulted in a restructure of how onboard emergency drills were undertaken and recorded, and remedial action in response to safety issues identified during observations of drill practices and general operations.
The objective of these drills was to ensure the maintenance of a high standard of crew competency in emergency situations and preparedness. A quality control regime was also recommended to ensure the content, conduct, and assessment of drills were maintained at a consistent standard and continued to meet the requirements of the USL Code and SMS.
Crew-based rostering
OTSI recommended crew-based rostering to avoid inconsistencies and assist in meeting the challenge of crew competencies in emergency responses on different vessel classes.