BUS SAFETY INVESTIGATION REPORT - OTSI...BUS SAFETY INVESTIGATION REPORT BUS DRIVER TRAINER FATALITY...

BUS SAFETY INVESTIGATION REPORT

DRIVER TRAINER FATALITY PRAIRIEWOOD, NSW 07 JUNE 2018

BUS SAFETY INVESTIGATION REPORT BUS DRIVER TRAINER FATALITY

PRAIRIEWOOD NSW

07 JUNE 2018

Released under the provisions of Section 45C (2) of the Transport Administration Act 1988 and

Section 137 of the Passenger Transport Act 2014

Investigation Reference 04802

Published by: The Office of Transport Safety Investigations

Postal address: PO Box A2616, Sydney South, NSW 1235

Office location: Level 17, 201 Elizabeth Street, Sydney NSW 2000

Telephone: 02 9322 9200

Accident or incident notification: 1800 677 766

Facsimile: 02 9322 9299

E-mail: [email protected]

Internet: www.otsi.nsw.gov.au

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contained in this Report, its contents may be copied, downloaded, displayed, printed,

reproduced and distributed, but only in unaltered form (and retaining this notice).

However, copyright in the material contained in this Report which has been obtained

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individuals or organisations, belongs to those agencies, individuals or organisations.

Where the use of their material is sought, a direct approach will need to be made to

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Subject to the provisions of the Copyright Act 1968, no other use may be made of

the material in this Report unless permission of the Office of Transport Safety

Investigations has been obtained.

THE OFFICE OF TRANSPORT SAFETY INVESTIGATIONS

The Office of Transport Safety Investigations (OTSI) is an independent NSW agency whose

purpose is to improve transport safety through the investigation of incidents and accidents in

the rail, bus and ferry industries. OTSI investigations are independent of regulatory,

operator or other external entities.

Established on 1 January 2004 by the Transport Administration Act 1988 (NSW), and

confirmed by amending legislation as an independent statutory office on 1 July 2005, OTSI

is responsible for determining the contributing factors of accidents and to make

recommendations for the implementation of remedial safety action to prevent recurrence.

Importantly, however, OTSI does not confine itself to the consideration of just those matters

that contributed to a particular accident; it also seeks to identify any transport safety matters

which, if left unaddressed, might contribute to other accidents.

OTSI’s investigations are conducted under powers conferred by the Transport Administration

Act 1988 (NSW) and Passenger Transport Act 2014 (NSW). Additionally, all OTSI

publications that are considered investigation reports are also conferred by these Acts.

OTSI also conducts rail investigations on behalf of the Australian Transport Safety Bureau

under the Transport Safety Investigation Act 2003 (Cwlth). OTSI investigators normally seek

to obtain information cooperatively when conducting an accident investigation. However,

where it is necessary to do so, OTSI investigators may exercise statutory powers to

interview persons, enter premises and examine and retain physical and documentary

evidence.

It is not within OTSI’s jurisdiction, nor an object of its investigations, to apportion blame or

determine liability. At all times, OTSI’s investigation reports strive to reflect our balanced

approach to the investigation, in a manner that properly explains what happened, and why,

in a fair and unbiased manner.

Once OTSI has completed an investigation, its report is provided to the NSW Minister for

Transport and Infrastructure for tabling in Parliament. The Minister is required to table the

report in both Houses of the NSW Parliament within seven days of receiving it. Following

tabling, the report is published on OTSI’s website at www.otsi.nsw.gov.au.

http://www.otsi.nsw.gov.au/

OTSI Bus Safety Investigation

Trainer Fatality, Fairfield City Showground, Prairiewood, NSW, 07 June 2018 5

CONTENTS

GLOSSARY 6

EXECUTIVE SUMMARY 8

PART 1 FACTUAL INFORMATION 9

Introduction 9

The Bus Operating Company 9

Transport for NSW 10

Roads and Maritime Services 10

Location of Accident 11

Environmental information 12

Bus MO5127 12

Driver Recruitment, Induction and Training 13

The Driver 14

The Accident 15

PART 2 ANALYSIS 21

Familiarity with Critical Bus Controls 21

Driver’s Cognitive Load 23

Preparation for new Bus Operating contract 25

Risk and Safety Management Systems 27


Transport for NSW 29

PART 3 FINDINGS 30

PART 4 RECOMMENDATIONS 31


Transit 31

Bus Operators/Industry 31

PART 5 NOTABLE ACTIONS TAKEN POST EVENT 32

PART 6 APPENDICES 33

Appendix 1: Sources, Submissions and Acknowledgements 33

Appendix 2: BOAS (TfNSW reference) 34



GLOSSARY

Accident An unwanted outcome, which includes a collision or crash

Active Failure The acts or conditions precipitating the incident situation. They usually

involve the frontline staff, the consequences are often immediate and can

be prevented by design, training or operating systems

Bus Operating

Company

Also known as the bus Operator whom for the purposes of this report is

Transit (NSW) Liverpool Pty Ltd. The parent company being Transit

Systems Pty Ltd

BOM The Australian Bureau of Meteorology

CCTV Closed circuit television

Cognitive Overload A situation where there is too much information or too many tasks for an

individual resulting with inadequate processing and/or response

Driver Trainer Person who delivered bus driving training/induction

Driver Mentor Qualified bus drivers with experience who are considered by Transit

Systems to be role models for peer bus drivers. Provide guidance and

advice to other bus drivers

FCS Fairfield City Showground

Hand Brake Lever A lever that is used to apply the parking brake. The lever is moved in the

rearwards direction to apply the hand brake. When the lever is moved to

the forward direction the park brake is off or released. The hand brake is

typically operated with the drivers’ right hand

Human factors The scientific discipline concerned with the understanding of interactions

among humans and other elements of a system, and the profession that

applies theory, principles, data and methods to design in order to optimize

human well-being and overall system performance

Individual Action,

Error – Slip

A slip is skill-based, a failure in execution of an action, an attentional

problem in a familiar situation



New Recruit Qualified Heavy Vehicle licence holders being inducted into Transit

Systems’ procedures and methodologies

RMS Roads and Maritime Services

Throttle Used by the bus driver to control engine power, also known as an

‘accelerator’

Transit Systems References the Transit Systems group of companies collectively including

Transit Systems Pty Ltd, Transit (NSW) Liverpool Pty Ltd, Transit Systems

West Pty Ltd and Transit (NSW) Services Pty Ltd

Transit Liverpool References Transit (NSW) Liverpool Pty Ltd, which has a NSW

Government contract for operating buses in Western Sydney known as

Region 3

Transit West References Transit Systems West Pty Ltd, which has a NSW Government

contract for operating buses in Western Sydney known as Region 6

Transit Services References Transit (NSW) Services Pty Ltd, which recruits, trains and

employs the Driver Trainers, Driver Mentors, New Recruits and other

employees that provide the services for the performance by Transit

Liverpool of the Region 3 contract and by Transit West of the Region 6

contract

Transmission Rotary

Selector

Also known as the ‘gear selector’. A round shaped switch that, when

rotated, will change the state of the drive transmission from Drive to

Neutral to Reverse. On a MAN Model A69 bus, this rotary selector is on

the right hand side of the drivers’ dashboard and typically operated by the

driver’s right hand

Stress A gap between the demands of a situation and an individual’s ability to

deal with that situation

Stressor An event or situation which induces stress

WHS Workplace health and safety



EXECUTIVE SUMMARY

At approximately 0950hrs on Thursday 07 June 2018, a bus with registration number

MO5127 was being used for inducting drivers into Transit Systems processes at

Fairfield City Showground. This bus was involved in an accident that resulted in one

of the trainers being struck and fatally injured. The accident occurred whilst a new

recruit was driving the bus as part of an assessment manoeuvre in the parking lot

adjacent to Smithfield Road, Prairiewood.

Under the instruction of a number of trainers, the driver of the bus made some

unintended errors that resulted in the bus moving forward instead of reversing. A

trainer that was providing instruction from the kerb in front of the bus was struck and

fatally injured.

The trainer was employed by the Transit Systems subsidiary company known as

Transit Services. He had many years of experience working in the bus industry.

The driver was an experienced driver with prior bus driving history working for other

companies primarily on long haul interstate routes. The driver was medically unable

to attend any post-accident interview to give his account. The bus was fitted with on-

board CCTV which provided some of the evidence for this investigation.

The investigation found that even though Transit Systems was recruiting additional

drivers at an elevated rate, it followed a documented process for recruitment and

induction.

The investigation has made recommendations which can be found in Part 4 of this

report.



PART 1 FACTUAL INFORMATION

Introduction

1.1 The accident occurred on the final day of Transit Systems’ bus driver training-

induction course which required newly recruited drivers to demonstrate their

competencies in controlling the bus through various low speed manoeuvres in

the forward and reverse directions.

1.2 Under the instruction of a number of trainers, the driver of the bus made some

unintended errors that resulted in the bus moving forward instead of moving in

reverse. One of the trainers, while providing instructions to the driver from the

kerb in front of the bus was struck and fatally injured.

The Bus Operating Company

1.3 The bus was being operated by Transit Liverpool at the time of the accident.

Transit Liverpool is a subsidiary company of an Australian-based multi-

national public transport company known as Transit Systems Pty Ltd.

1.4 At this time, Transit Liverpool had a NSW government contract for operating

buses in Western Sydney known as Region 3 which comprised of two bus

depots.

1.5 Also, at this time Transit Systems was mobilising for a new contract known as

Region 6, due to commence in July 2018 for which additional drivers were

required. Region 6 comprised of four bus depots.

1.6 Transit Liverpool had been accredited by Roads and Maritime Services (RMS)

to operate Long Distance, Tourist, Charter and Regular Passenger Services

by RMS on 19/07/2013 under the Passenger Transport Act 19901 for a

maximum of 250 buses. The Certificate of Accreditation number was 38743.

1.7 Transit Liverpool was certified by Bureau Veritas to AS/NSZ4801

Occupational Health and Safety Management Systems and AS/NZS 9001

(Quality Management Systems).

1 The Passenger Transport Act 1990 has been superseded by Passenger Transport Act 2014



Transport for NSW

1.8 Transport for NSW (TfNSW) is responsible for the delivery of public transport

services awarded a Sydney Bus Service Contract (SBSC) in accordance with

NSW Government procurement policy through either competitive market

processes or direct negotiation.

1.9 TfNSW awarded Transit West a contract for Region 6 with an operational

commencement date of 1 July 2018.

1.10 Clause 35.3 of the SBSC stipulated that Transit Systems were required to

develop, implement, and maintain a Safety Management System (SMS).

1.11 Additionally, Clause 35.7 the contract required Transit West to comply with

certain WHS requirements. In particular, undertake assessment of risks and

risk control measures relating to the performance of the operation.

Roads and Maritime Services

1.12 At the time of the accident, RMS was the regulator for buses accredited under

the Passenger Transport Act 2014 to operate in NSW. Since this time, RMS

has combined with TfNSW although the regulatory function of RMS still exists.

1.13 Bus Operator Accreditation Scheme (BOAS) is an accreditation process that

has evolved since 1990 to include aspects of the RMS Bus Reform Process

and requirements under the Passenger Transport Act. Specifically this

included the need for the following key aspects:

SMS including risk management

driver health monitoring, drug and alcohol programs

improve quality and safety through an enhanced auditing program

enhance the safety culture of the NSW bus industry.

1.14 In March 2018, RMS audited Transit Liverpool’s compliance with BOAS in

March 2018, with no deficiencies identified.



Location of Accident

1.15 The accident occurred in the south eastern parking lot adjacent to Fairfield

City Showground (FCS) which is accessible to the public off Smithfield Road

Prairiewood, see Figure 1.

1.16 This site was occasionally used by Transit Systems for training purposes and

was known internally to Transit Systems as the Fairfield Showground Driving

Skills Circuit. The particular driver skillsets evaluated at this site included the

low speed manoeuvring of a bus around commonly found suburban features

such as kerbing and median strips.

1.17 The circuit comprised of a series of turns and straights around various

features of the parking lot. This commenced with the bus being driven in the

forward direction, and finished with a reversing manoeuvre. There were a total

of 32 turns involved to complete this circuit. New recruits were evaluated on a

number of parameters including their ability to avoid the bus from contacting

any of the raised median strips, signposts, or kerbs.

Source: Google Maps, annotated by OTSI

Figure 1: Map showing the accident site at Prairiewood

1.18 The induction program showed that new recruits also attended this location on

day five of the induction course. Post incident interviews confirmed that all



new recruits were introduced to the FCS circuit prior to the day of the

accident.

Environmental information

1.19 The weather was clear at the accident location on the morning of 07 June

2018. The Bureau of Meteorology recording a maximum temperature that day

of 19.6 degrees C and a wind speed maximum of 19 km/h from the ENE

direction.

1.20 The nearest weather station at Horsley Park measured 12 mm rain on the day

prior and 5 mm rain earlier on the day. Overnight rain had left the bitumen

surface slightly damp, however it was not raining at the time of the accident.

The weather was not determined to be a contributing factor to this accident.

Bus MO5127

1.21 MO5127’s chassis was designed and manufactured by MAN with a build date

of August 2010. The bus’ body was built on the MAN chassis by Volgren

Australia in August 2013. The bus was registered in NSW with a fleet number

of 1109.

1.22 The bus was owned, registered and operated by Transit Liverpool under a

NSW state government contract. Registration was current at the time of the

accident with an expiry date of 15 August 2018.

1.23 The bus had all its mandatory safety checks and there were no outstanding

maintenance items. In particular, its brakes were inspected on 20 April 2018

with a pass result recorded.

1.24 The bus had inbuilt closed circuit television (CCTV) with seven cameras

recording colour footage. Audio was also recorded from the driver’s seat

position. The CCTV system also recorded GPS position, road speed, heading

direction, date, and time.

1.25 The most recent HVIS (Heavy Vehicle Inspection Scheme) inspection was

completed on 23 January 2018 with no ‘Fail’ results recorded, no defects

recorded, and an overall ‘Passed’ result given. As a result of damage



sustained during the accident, the bus was issued a defect notice on 7 June

2018.

1.26 Testing carried out on the bus by RMS and Police Crash Investigators

following this accident showed no defects were found that could have

contributed to the accident.

1.27 On the day of the accident, enroute to the FCS, the trainer whom was driving

the bus reported he felt the brake pedal response was firmer than usual to

operate. This led to the trainer conferring with another trainer whom was

asked to drive the bus and independently review this issue. This trainer drove

the bus and determined that the bus was suitable for use and there was no

need to get a mechanic to assess this issue.

Driver Recruitment, Induction and Training

1.28 Transit Systems has a documented process known as ‘Operations Instruction

R1001’ which describes the methods used to recruit, induct, and train new

bus drivers. R1001 outlines the methodology used to evaluate applications for

the role of bus driver including assessment of pre-requisites, experience,

qualifications, referees, and medical history.

1.29 Prior to this occurrence, Transit Systems was preparing for the Region 6

contract which meant the demand for additional bus drivers was higher than

usual. Transit Systems was recruiting additional bus drivers at the rate of

approximately four times higher than its usual rate.

1.30 The role of the trainers when conducting driver inductions at FCS was to

supervise and evaluate the performance of new recruits as they drove the bus

through the skills circuit. Trainers also gave directions to the driver via hand

signals and verbal instructions, if needed. As the parking lot was a public

road, the trainers were also required to be on the lookout for any members of

the public who might enter the area, in which case they would stop the bus,

for safety reasons, until the member of the public was moved out of the way.

1.31 Based upon information gathered during interviews with Transit Services

employees, the intent of the final day of the induction was to bring key driving

skillsets together and reaffirm the finer points of bus control. This included an



understanding of situational awareness, while manoeuvring the bus at low

speed around traffic islands, kerbs, and raised median strips.

The Driver

1.32 The driver had been identified as having a valid heavy vehicle (Heavy Rigid)

driving licence as well as an Authorised Bus Driver qualification2. The licence

had a condition that spectacles or contacts were required while driving. In

court proceedings subsequent to the accident, the driver stated that he was

wearing contact lenses at the time of the accident. The driver stated on the

Transit Systems job application that he had 10 years of experience with some

interstate driving.

1.33 The driver was originally from Turkey. In his job application he said that

although he could communicate successfully in English, he did indicate that

‘an English course can be required’ (sic). The driver immigrated to Australia in

2013, therefore approximately half of his 10 years’ bus driving experience

would have been in jurisdictions outside of Australia.

1.34 The driver had accrued 7 demerit points for traffic infringements such as

exceeding the speed limit and disobeying traffic lights over the period

between 2015 and 2017. During the induction at Transit Systems, the driver

had been involved in an incident where a bus side mirror had collided with

another bus.

1.35 The driver successfully completed a pre-employment health assessment on 7

May 2017 as part of the Transit Systems recruitment process. In this

assessment it was noted that the visual acuity test identified the need for

distance vision and near vision glasses. The driver’s licence had included the

condition that spectacles or contacts were needed while driving. At the time of

the accident no spectacles were being worn. NSW Police were provided

information that the driver in compliance with his licence conditions at the time

of the accident.

2 Details obtained by OTSI from the Bus Operator as requested under terms of Passenger Transport Act 2014, provided by RMS.



1.36 The driver had passed the company pre-employment hearing assessment

test.

1.37 The driver was taken to Liverpool Hospital immediately after the accident for

mandatory drug and alcohol testing. The tests provided negative results.

1.38 The driver was unable to attend a post-accident interview with OTSI due to

medical reasons. OTSI requested information from the driver via his medical

specialist about this incident. A written response was provided by the driver’s

medical specialist and was considered during the analysis of this report.

The Accident

1.39 There were two buses at the FCS site at the time of the accident, only one

bus was being used on this skills circuit. The other bus was not involved in

matters that led to the accident.

1.40 The accident occurred on the final day of a nine day training course described

in a Transit Systems document entitled ‘9 Day Training Course Induction

Training’. Prior to this day, the course comprised of classroom based

instruction, route awareness, driving on public roads, and, familiarisation with

the features and controls of various bus models utilised by Transit Systems.

Records indicate the driver received a vehicle familiarisation with each of

seven different bus types.

1.41 There were three trainers delivering the induction for 14 drivers using bus

MO5127. There were also eight experienced bus drivers working as mentors

providing on the job support for the new recruits. Additionally, the mentors

provided guidance and advice to all drivers in Transit Systems to support the

formal induction.

1.42 New recruits awaiting their turn to drive the skills circuit, were given the choice

to travel on-board the bus, or to stand on the kerb nearby.

1.43 At the time of the accident, there was one mentor driver on-board the bus,

one new recruit driving, and one other new recruit on-board the bus observing

and next in line to drive.



1.44 The bus’ inbuilt CCTV showed the driver involved in the accident had been

aboard bus MO5127 observing the previous driver successfully complete the

skills circuit on his first attempt that day.

1.45 When the driver involved in the accident took the driving position on the bus,

he made adjustments to the seat height, mirrors, and, he fastened the seat

belt.

1.46 The driver then commenced driving through the skills circuit, however at Turn

4 of the circuit (Refer to Figure 2 below), he turned the bus left and

approached on a path that may have resulted in the rear left hand side wheel

driving up on a raised median strip.

Source: Transit Systems, annotated by OTSI

Figure 2: Diagram showing Driving Skills Circuit

1.47 At this time, one of the trainers recognised that the bus was on a path to

mount the median strip (Refer to Figure 3). The trainer stepped off the kerb,

walked towards the front of the bus and gave hand signals to the driver to

stop the bus. The driver observed the hand signals and brought the bus to a

halt. Another trainer approached the driver’s side window and gave verbal

instructions to reverse and start the sequence again.

Turn 4

Turn 5

Turn 3

Turn 1

Turn 2



1.48 The driver then selected reverse which activated the reversing buzzer, the

foot brake was released and the bus moved in the reverse direction away

from the median strip. Then, the driver brought the bus to a stop with the foot

brake, selected forward, the reversing buzzer now deactivated, the foot brake

released and the bus moved in the forward direction around the parking lot to

re-join the circuit at Turn 2.

Source: OTSI

Figure 3: Diagram showing rear left wheel proximity to median strip

1.49 The driver’s 2nd attempt through the skills circuit started at Turn 2 and

successfully negotiated Turns 3 and 4. As the bus approached Turn 5, the

front left hand side wheel tracked on a path where it would have driven up and

mounted the kerb (Refer to Figure 4).

1.50 Then the following sequence of events occurred in a short space of time. The

timestamp at the beginning of the following paragraphs is in 24hr time.

1.51 At 9:49:34, Trainer 1 who was standing near the ‘No Stopping’ sign walked

along the kerb to a position in front of the bus and was providing the driver

hand signals, most likely indicating to rotate the transmission selector to the

Turn 2

Turn 3

Turn 4



Reverse position. At this time, the transmission selector remained in the Drive

position.

1.52 At 9:49:44, the driver brought the bus to a halt to avoid mounting the kerb.

The mentor on-board the bus was positioned behind and to the left of the

driver. This mentor was recorded as saying ‘reverse’ to the driver.

1.53 At 9:49:46, the driver selected Reverse position.

1.54 At 9:49:48, this mentor gave an additional verbal instruction to the driver to

‘apply hand brake’. The driver applied the hand brake with his right hand.

1.55 At 9:49:49, by this time the reversing buzzer sounded indicating reverse was

selected and engaged.

1.56 At 9:49:50, the driver straightened the steering wheel by turning it in the

anticlockwise direction.

Source: OTSI

Figure 4: Position of Trainers just prior to the accident

1.57 At 9:49:54, the driver changed the transmission selector from the Reverse

position to the Forward position which deactivated the reversing buzzer. At

this time the mentor says ‘reverse’ again.

1.58 At 9:49:56, the driver released the hand brake.



1.59 At 9:49:59, the driver applied the hand brake and the mentor says ‘reverse,

reverse’.

1.60 At 9:50:01, Trainer 2 has moved to the driver’s side window and is heard

giving verbal instructions,

‘put your foot on the brake to put (sic) reverse, otherwise it won’t go

into reverse’.

1.61 At 9:50:05, the engine can be heard on the audio recording as having

increased in revolutions per minute (engine speed) which indicated the

accelerator was being pressed.

1.62 At 9:50:06, the driver released the hand brake with his right hand and the next

action observed was when the bus propelled forward, mounting the kerb

towards Trainer 1. The trainer attempted to move out of the way, however as

the bus progressed rapidly forward. The trainer was unable to escape and

was struck by the bus.



1.63 The incident location is shown in Figure 5.

.

Source: OTSI

Figure 5: Yellow arrow shows the approximate path taken

1.64 The bus continued in the forward Easterly direction at an approximately 50

degree angle to the kerb line until it came to rest approximately 18 metres to

from the point of mounting the kerb.

1.65 The other staff responded to the accident however the trainer had received

fatal injuries during the collision.



PART 2 ANALYSIS

2.1 The investigation focussed principally on the factors that contributed to the

accident and associated human factors issues.

2.2 Accidents are mostly the result of a combination of organisational factors,

local workplace factors, individual actions, and absent or failed defences3. In

this accident there were several factors that fell under the above mentioned

categories, these include:

Familiarity with critical bus controls

Driver’s Cognitive Load

Preparation for new bus operating contract

Risk and Safety Management Systems.

Familiarity with Critical Bus Controls

2.3 The driver’s dashboard layout of this model of MAN bus was configured with

the transmission selector and the hand brake lever both located on the right

hand side of the console (Refer to Figure 6). This configuration would require

the driver to use the right hand to operate both of these controls.

This configuration is similar but not the same as other buses, some buses in

this fleet have the transmission selector on the left hand side of the console.

2.4 Experienced bus drivers would be familiar with the function and position of

these controls. New recruits were given an initial familiarity with the controls

and over time they are expected to improve their working knowledge of the

controls.

2.5 While Transit Systems training program includes detail about the function of

transmission selectors, the specific training record sheet includes many other

3 Reason, J (2004). Managing the Risks of Organizational Accidents. Burlington USA. Ashgate Publishing Company.



aspects of bus controls, however, the sheet does not include confirmation that

each driver has been deemed competent in this critical detail.

2.6 The driver’s experience was mostly with interstate driving, therefore it is

reasonable to expect that it would take some time for the driver to gain

competency and cater for the different driving environment. Interstate bus

driving has some key differences to suburban route driving in that the need to

manoeuvre the bus at low speeds is more prevalent in suburban route driving.

Other significant differences noted are the higher frequency of driver control

inputs which includes the operation of the hand brake and gear selection from

forward to reverse and back again.

2.7 In other transport domains such as the airline industry where the

consequences of an accident can be higher, it is common practice to certify

flight crew to operate a particular model of aircraft. This is a method of

ensuring operators achieved and maintained adequate levels of competence

with critical controls. The level of familiarisation with controls is particularly

relevant when the operator is challenged with competing cognitive tasks such

as just prior to this accident.

Source: OTSI

Figure 6: Transmission Selector & Hand Brake Lever



2.8 On the day of the accident the bus model used was a MAN A69. Records

show that the driver had been given a familiarisation session on a MAN bus

prior to the accident. Transit Systems subsequently presented evidence to

support the driver had previously driven the MAN bus, however this evidence

was inconclusive.

2.9 Upon observing the CCTV recording of the driver’s activity during the

sequence of the accident, the driver appeared to be uncertain of the position

of the transmission selector prior to commencing the drive around the skills

circuit. This was confirmed when the on-board mentor pointed to the

transmission selector and verbally instructed the driver to select ‘D’ for drive.

Once the driver was reminded where the transmission selector was, the

appropriate transmission selection was made and the driver demonstrated his

ability to drive in an environment where cognitive stimuli4 were relatively low.

Driver’s Cognitive Load

2.10 There are various human factors models and studies such as that by

Wickens5 that outlines how an individual’s Short-Term sensory store has finite

capacity and if overwhelmed by stimuli, attention resources can be depleted

and poor responses and/or slips in attention could result.

4 Refer to Wickens & Flach model in Figure 7. 5 Wickens, C.D., Engineering Psychology and Human Performance, Harper Collins, New York, 1992.



Source: Wickens

Figure 7: Wickens & Flach - Human Factors Information Processing

2.11 Wickens’ Model of information processing can assist with the analysis of this

accident and help us to explain the driver’s observable unintended errors in

the moments prior to the accident.

2.12 As described in the occurrence during the minutes before the accident, the

driver was required to process multiple stimuli in quick succession:

The driver was given instructions in English from the trainer outside the

drivers’ window (visual and verbal from the right hand side of the bus);

The driver was given additional verbal instructions in English from the

mentor inside the bus on the left hand side of the driver;

The driver was given hand signals from another trainer (the deceased)

standing in front of the bus.

2.13 It is likely the driver was in a heightened state of stress due to a number of

factors including making an error in the skills course, and was required to

make a response to rectify the path of the bus in order to continue with the



remainder of the skills course. In this situation, it is possible his cognitive

processing ability was in overload, and the driver made an unintended

acceleration6 error.

2.14 There have been many global studies into accidents such as this that are

termed Unintended Acceleration (UA) accidents. Many of these studies were

relating to drivers mistaking the brake pedal with the accelerator pedal. In this

accident, the driver made three key errors that led to the UA. They are the

selection of drive instead of reverse, the application of the accelerator instead

of the foot brake, and lastly the release of the park brake instead of selecting

reverse. These errors in combination, most likely contributed to driving the bus

rapidly in the forward direction.

2.15 After reviewing Transit Liverpool’s recruitment documentation, it became

evident that the driver struggled with the English language. This evidence

cited how the driver could speak and understand English at a very basic level.

It is possible that the driver’s limited ability to speak and comprehend English

added to the required mental workload to process the instructions being given

to him by the trainers and the mentor, leaving little attention resources to

make the correct response to reverse the bus.

Preparation for new Bus Operating contract

2.16 Transit Systems followed a standard recruitment process for new bus drivers.

This process incorporated documented methods for screening new applicants

and records kept that included application forms, qualifications, prior work

experience, and referee checks. Risk was mitigated by the recruitment of

qualified heavy vehicle licence holders with commensurate experience. That

is, Transit Systems did not recruit unqualified drivers. This was an induction

course, not a driving licence course. The purpose of the induction course was

to take qualified bus drivers with relevant experience, and familiarise them

with the various bus configurations, routes, behaviours, and performance

expectations of Transit Systems.

6 Frontiers in Psychology, Original Research Article published 25 Nov 2010, Cars gone wild: the major contributor to unintended acceleration in automobiles in pedal error, Richard A. Schmidt and Douglas E. Young.



2.17 Similarly, Transit Liverpool followed a standard process for inducting newly

recruited drivers and training them in the systems and processes deployed at

Transit Systems. Whilst the bus operator was not a Registered Training

Organisation, a standardised method was followed with various bus

configurations, records kept for each bus driver as they progressed through

the induction course.

2.18 The trainers had training qualifications recognised by Transit Systems and

additionally held considerable experience in bus driving and bus operations.

Bus driver training had been conducting at FCS over many years for

approximately 2,000 runs at this skills circuit with no reported prior incidents.

2.19 A key test often used in human factors is a substitution test. This test may

consider the performance of another similarly qualified individual in the same

situation and assesses whether or not there would be differing outcomes. In

this case, many other similarly qualified new recruits had driven the skills

course successfully.

2.20 At the time of the accident, the bus operating company was recruiting drivers

at approximately four times its usual intake rate. This had the potential to put

the trainers under greater stress than usual.

2.21 The induction course comprises of different streams based on bus driving

experience. One stream was for experienced bus drivers, and another stream

was for new heavy vehicle licence holders. Among the differences in these

streams was the detailed exposure to the different bus models. The

experienced stream were given ‘dash-only’ familiarisation of six models of bus

(including MAN), however the new heavy vehicle licence holders were given

additional time undertaking driver training with each of the same six models of

bus. Records kept by Transit Systems show the driver at the time of this

accident had been given ‘dash only’ familiarisation with all other models of bus

except for the MAN model. It is possible that the driver had driven the MAN

bus previously, however there were no conclusive records presented to

confirm this.

2.22 The driver was initially placed in the experienced-drivers’ induction course due

to having 10 years of prior bus driving experience. Early in this stream, the



trainers acknowledged this driver’s prior driving experience. However due to

the driver’s ability and competence in the English language, the driver was

placed in the basic induction stream and given additional attention with

language and driving skills.

2.23 Records kept through this development showed that at the commencement of

the induction course, the driver’s performance was rated as poor, then

reassessed as fair, then towards the end, just prior to the accident,

performance was recorded as good. In some other instances, other new

recruits did fail to progress to the driving phase which indicates Transit

Systems were exercising due diligence and not just passing all new recruits.

2.24 The selection criteria for new drivers included the need for relevant

experience and qualifications. Referee checks were made to confirm the

experience of the driver.

2.25 The induction exercise at FCS on the day of the accident was consistent with

similar exercises conducted over many years at this site. The methods used

were realistic and gave drivers exposure to the handling of a bus during slow

speed manoeuvring. At times the pressure of numerous people talking or

making announcements around the bus driver are also realistic, the task for

the bus driver is to remain calm and perform duties in a safe and reliable

manner.

Risk and Safety Management Systems

2.26 Contemporary risk management practice is to assess risk and adequately

implement and document controls, which is at the core of an SMS.

2.27 The bus industry in NSW is required by a number of regulations and

guidelines, including BOAS, to use risk management techniques. This needs

to be regarded as a live process and implemented in day-to-day operations.

The requirements encompass the need to conduct and document risk

assessments and this should extend to the management of safety of the driver

induction program, such as that conducted at FCS. Transit Systems followed

a process documented in their ‘Business Management System (BMS)’. The

BMS document makes reference to mitigating risk, however Transit Systems



did not document the hazards and risks for the skills testing at sites such as

FCS.

2.28 The specific requirements of clause 35.7 of the SBSC require the Operator to

undertake an assessment of the work, health and safety risks associated with

the performance of the operator activities and implement control measures to

eliminate or minimise such risks. Compliance with the full requirements of

clause 35.7 were not evident in the information provided during this

investigation.

2.29 The deceased trainer was an experienced bus driver who was described by

his peers as passionate for sharing his skills and training others. His

experience spanned five years with Transit Systems, two years as a driver,

and one year as a mentor. He had completed all training to be an

instructor/trainer on 18 October 2017.

2.30 Just prior to the accident, the trainer was standing in a position on the kerb

adjacent to the ‘No Stopping’ sign. This was considered a safe place during

driver assessment and usual practice by Transit Systems at that time.

2.31 Transit Systems issued documentation to their staff on the hazards of

person/vehicle interaction (SWP003). The CCTV footage indicated the

trainers interacted with the driver of the bus whilst it was in motion. The

trainers interacted with the bus driver of an operating bus, not fully

acknowledging the risk and danger this represented.

2.32 The trainer would not have been expecting the driver to release the hand

brake with the transmission in forward. It was likely he expected the bus move

in the reverse direction. This is supported by the CCTV footage which showed

the trainer pointing to the transmission rotary selector and giving hand signals

to rotate towards the reverse setting.

2.33 When the bus commenced moving forward, the trainer attempted to move out

of the way, however the bus accelerated too rapidly for him to avoid the

impact.




2.34 RMS is responsible for accrediting bus operators and auditing against the

defined BOAS (refer to Appendix 2) criteria. This criteria includes the need for

a Safety Management System. RMS has a published document entitled

‘Safety Management System (SMS) Guidelines for Bus and Coach Operators

in NSW’. Whilst Transit Systems held accreditation to AS4801, the system in

place did not identify higher risk business activities such as those present

during skills circuit testing at FCS. These higher risk activities should be either

eliminated or mitigated to acceptable lower levels of risk.

Transport for NSW

2.35 TfNSW awarded the SBSC to Transit Systems. Clause 35.7 of this contract

required risk assessments and risk control measures relating to the

performance of the operation. There was insufficient evidence found that

Transit Systems met the requirements of clause 35.7 in relation to skills circuit

evaluation at FCS.



PART 3 FINDINGS

3.1 RMS and NSW Police conducted post accident inspections of the bus. These

agencies advised the bus MO5127 was roadworthy at the time of the

accident.

3.2 The driver’s level of familiarity with the use of the transmission selector and

park brake on the MAN A69 was not sufficient to demonstrate competence in

a high workload situation.

3.3 The Transit Systems’ records were inconclusive in confirming the driver had

previously driven the type of bus (MAN A69) involved in the accident.

3.4 The trainers and mentor were giving verbal and non-verbal instructions to the

driver moments before the accident, possibly placing additional stressors on

the driver which likely depleted his attention resources.

3.5 The driver made an unintended acceleration error.

3.6 RMS had conducted BOAS audits with Transit Systems with no deficiencies

found. The Transit Systems risk register (Hazard and Environmental

Identification Risk Control Status register) did not include hazards associated

with skills testing such as that at FCS.

3.7 Transit Systems held the correct certification to operate buses and provide

induction training for new recruits. The training records, such as the

dashboard familiarity form, did not included details about the operation of the

transmission selector.

3.8 The trainers were qualified for the role undertaken during the circuit training.

There were no reported significant accidents from circuit training prior to this

accident.

3.9 The trainers interacted with an operating bus at FCS in a manner that placed

them in dangerous positions.

3.10 The deceased trainer was experienced in the bus industry. At the time of the

accident, he was standing in a location on the kerb that allowed clear visibility

between the bus mirror and the ‘No Stopping’ sign. For many years, trainers

stood at this position without any reported accidents.

3.11 Transit Systems did not demonstrate they had met the full WHS requirements

of clause 35.7 of the SBSC.



PART 4 RECOMMENDATIONS


RMS to review its approach during BOAS audits to ensure that the Annual

Self Assessment Report and the Independent Audit process incorporate all

aspects of a bus operator’s business into the SMS. This review should identify

any associated risks and hazards and develop procedures to eliminate or

mitigate those risks. The review should focus on the following areas:

• the bus operator’s key operational tasks/training conducted on a designated

or planned route offsite from their normal place of business

• the need to review and update the SMS when any significant changes occur

within the operator’s business.

Transit Systems

4.1 Transit Systems to review the induction/training system including records kept

to ensure the system adequately captures the competence of their drivers in

all aspects of bus control. For example, the training record should include the

assessment of competency in the use of the transmission selector.

4.2 Transit Systems to conduct formal risk assessments to cover activities such

as skills circuit evaluations at sites like FCS including documented risk

controls. Hazard and Environmental Identification Risk Control Status register

updated with learnings from this accident.

Bus Operators/Industry

4.3 Bus operators to conduct formal risk assessments to cover activities such as

skills circuit evaluations at sites like FCS including documented risk controls.

4.4 Bus operators to conduct formal risk assessments when mobilising for new

contracts. Bus operators to manage this change process with a focus on risk

identification and mitigation.

4.5 Bus operators to review training/induction methodologies to minimise the

opportunity for excessive driver workload.



4.6 Bus operators consider the need for competency based assessments to

confirm each driver has (and retains) competencies for each type of bus they

are required to operate.

PART 5 NOTABLE ACTIONS TAKEN POST EVENT

5.1 Transit Systems reiterated to all relevant staff about the importance of being

vigilant to the hazards of working around buses.

5.2 Transit Systems stopped skills circuit testing at FCS.

5.3 FCC has conducted a Job Safety & Environment Analysis for Trainer

Conducting Bus Driving Training Activity, JSEA #089. This document requires

the trainer to be inside the bus while observing or training or assessing the

driver.



PART 6 APPENDICES

Appendix 1: Sources, Submissions and Acknowledgements

Submissions

The Chief Investigator forwarded a copy of the Draft Report to the Directly Involved

Parties (DIPs) to provide them with the opportunity to contribute to the compilation of

the Final Report by verifying the factual information, scrutinising the analysis,

findings and recommendations, and to submit recommendations for amendments to

the Draft Report that they believed would enhance the accuracy, logic, integrity and

resilience of the Investigation Report. The following DIPs were invited to make

submissions on the Draft Report:

Transport for NSW


NSW Police Service

The driver at the time of the accident

Transit Systems

Fairfield City Council



Appendix 2: BOAS (TfNSW reference)

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