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Chief Investigator’s message
Welcome to the 10th edition of OnBoard, the OTSI quarterly newsletter.
At OTSI our mission is to improve safety across New South Wales’ transport networks. This is an endeavour that we pursue with clarity and purpose. This edition demonstrates the breadth of work and our commitment to investigating incidents, learning what occurred, engaging with stakeholders, and sharing insights that prevent future occurrences.
Our recently released investigation report into the structural fractures affecting Sydney’s Urbos 3 light rail vehicles underscores how design, maintenance, and global learnings intersect to shape safety outcomes.
We’ve also launched an investigation into a serious freight train separation incident on the Sydney Trains network at Eastwood.
OTSI issued a Safety Alert for Scania buses following a fire at Bella Vista. The Safety Alert contained clear and practical actions operators can take to prevent similar incidents.
We continue to proactively engage with the sector through our participation in the BUSted emergency response exercise, connecting with operational teams during our visit to the Rail Operations Centre, or sharing key learnings in our recent masterclass during National Rail Safety Week.
In addition, I recently presented at the Australian College of Road Safety’s Behind The Data forum about the importance of no-blame investigations. It was an excellent opportunity to share to discuss how data is used to identify systemic and persistent issues and to highlight and make recommendations to prevent future occurrences.
As with everything that OTSI does, the common thread is collaboration. Safety is a shared responsibility, and it’s through working together across industry, operators, and regulators that we can ensure the transport system remains safe, resilient, and responsive.
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
June - September 2025 (as of 11 September)
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| Completed investigations | |
| Safety Alerts and Advisories |
Investigation report released: Inner West Light Rail Urbos 3 Light Rail Vehicle Underframe fractures – 21 March 2025
We recently published our investigation report into the fractures on the Sydney Inner West Light Rail Line.
In late September 2021 fractures were identified in the underframe of Sydney Urbos 3 light rail vehicles (LRV) operating on the Inner West Light Rail (IWLR) line. The fractures were identified by maintenance staff in the underframe rotation bump stop (RBS) during a routine maintenance inspection.
Additional inspections carried out in October 2021 identified multiple fractures on all LRV C modules within the underframe bogie box area, with the presence of those fractures representing a safety risk. Sydney Urbos 3 services were subsequently suspended in late October 2021 as a precautionary measure to eliminate the potential of a safety incident.
𝗪𝗵𝗮𝘁 𝘄𝗲 𝗳𝗼𝘂𝗻𝗱
The investigation identified the following factors contributed to the potential incident:
- The 2013 Sydney Urbos 3 underframe design was not sufficient to last the required 30-year operation considering cyclic loading at key structural locations.
- The maintenance regime detected the presence of LRV underframe fractures. However, there was insufficient time to take any action that would have permitted the fleet to remain in service.
- The knowledge of similar factures identified in overseas Urbos 3 vehicles was not acted on by any of the parties in a timely fashion to permit some proactive action to take place.
Read the full investigation report
Launch of investigation: Train separation and runaway involving freight train 1WB7
OTSI have launched a transport safety investigation into an incident where a freight service consist (made up of 3 locomotives and 64 wagons) separated.
On 6 July 2025, freight service 1WB7 was travelling north on the Sydney Trains network, carrying steel from Port Kembla, NSW to Acacia Ridge, QLD. At 0433, the consist separated at the southern end of Eastwood Station due to a broken knuckle between the locomotives and the lead wagon. The train was travelling up a 1:40 gradient. The separated wagons rolled backwards, down the main line towards Meadowbank Station where they came to a standstill.
The aim of the investigation is to improve rail safety by identifying and sharing lessons to prevent similar incidents from occurring in the future. A final report will be released at the conclusion of the investigation.
Bus Safety Alert SAL02/25 - Risk of fire on Scania K and N series buses (2004 onwards)
We have issued Bus Safety Alert SAL02/25 - Risk of fire on Scania F, K and N series buses (2004 onwards) based on a preliminary investigation into a bus fire at Bella Vista on 6 July 2025. A 2008 model Scania bus was destroyed by the fire originating at the engine bay, likely the result of an engine oil leak. A similar incident also occurred on 23 March 2021, where a 2007 model Scania bus was involved in an engine bay fire, likely due to the same cause.
Key points for operators
Bus and coach operators are strongly encouraged to:
- Inspect your fleet of Scania F, K and N series buses fitted with centrifugal oil cleaner assemblies to ensure that the outer covers and rotor shafts are correctly fitted, tensioned and that housing outer cover sealing O-ring is in serviceable condition.
- Follow Original Equipment Manufacturer (OEM) instructions when cleaning and servicing centrifugal oil cleaner assembly and rotor assembly including fitment of rotor housing outer cover and sealing O-ring.
- Follow OEM instructions when replacing rotor shafts ensuring specified torque settings are used.
- Review servicing instructions to reflect OEM servicing intervals for these components.
Rail Safety Week masterclass highlights systemic issues and worker competency assessment responsibilities
National Rail Safety Week was held from 11 to 17 August and is a national reminder that we all play a part in staying safe around trains and tracks.
As part of Rail Safety Week, the Rail Industry Standards and Safety Board (RISSB) held a series of masterclasses. Our Director, Investigations Kerry Russell and Senior Transport Safety Investigator Marty Meles delivered a masterclass on the Werris Creek investigation.
The presentation centred on key learnings from the investigation, shedding light on worker competency obligations under both national and enterprise-based frameworks. It also offered practical guidance for enhancing assessment practices within organisations. A core focus of the session was to highlight systemic issues identified during the investigation and reinforce the responsibilities of those involved in nationally recognised (VET) and enterprise-based (internal) assessments.
The session attracted a strong audience of 228 participants and sparked a thoughtful and engaging discussion.
Watch a recording of the webinar
OTSI in action at BUSted
On 21 June, our Senior Transport Safety Investigator Reiner Mangulabnan, took part in a large-scale emergency response exercise led by the Illawarra LEMC. The scenario simulated a serious bus crash on Mount Ousley Road, with agencies responding in real time at a training site in Albion Park.
During the exercise, OTSI was notified by the Bus Operator as the incident unfolded and deployed to the scene. Once there, we connected with the operator representative, attended the command post briefing, and coordinated with Crash Investigations Unit (CIU) and NHVR. Thanks to strong collaboration, we were able to shadow CIU during evidence collection—ensuring consistency and efficiency in the process.
The day ended by OTSI and CIU briefing the first responders on how their initial actions can affect our investigations. It was a valuable opportunity to raise awareness of OTSI’s role and reinforce the importance of inter-agency coordination at crash sites.
Visit to the ROC
On 17 June, a team from OTSI visited the Rail Operations Centre (ROC) in Alexandria.
The ROC is the nerve centre of Sydney’s rail network, and the visit offered us a valuable behind-the-scenes look at how real-time operations, passenger information, and incident management are coordinated across the network.
Visits like these give us an opportunity to engage directly with operational teams and strengthen our understanding of the systems and challenges they face daily. This kind of collaboration is essential to our work investigating rail safety incidents and developing insights that contribute to a safer transport network for all.