eBulletin | March 2024 | Safety lessons from OTSI

Important safety lessons from the OTSI rollaway and collision investigation at Wilsons Valley
The Office of Safety Transport Investigations (OTSI) recently released an investigation report into a coach rollaway and collision incident at Wilsons Valley. The investigation highlighted observations and key considerations that may assist operators in enhancing safety measures and preventing a similar incident from reoccurring. 

What happened 
The incident occurred on 5 September 2022 when a coach was transporting 41 passengers (36 children and 5 adults) from Smiggin Holes snowfields during a school excursion.  

On the return trip from Smiggin Holes, the driver was unable to change gears or brake, causing the coach to roll backwards down Kosciusko Road, requiring the driver to swerve to avoid oncoming traffic. With the bus gaining speed, the driver made the decision to veer the coach off the road where the coach travelled 250 m down an embankment before it struck a rock outcrop and came to a stop. 

Multiple children and adults were transferred to hospital for observation with some passengers suffering minor injuries. The coach sustained damage to the rear of the vehicle.  

What was found 
The investigation identified several safety factors in the incident:

  • Unlicensed and non-compliant maintenance work was a main contributing factor to the failure of the coach’s braking system, with the air system compressor head replaced by the owner who was not a licensed mechanic.
  • The coach had several defects that did not comply with the requirements of the heavy vehicle standard of the Heavy Vehicle National Law (HVNL) including air brake system faults, and disabled driver alerts.
  • The driver was not usually employed by the operator and was not familiar with the vehicle, its system alerts and recent maintenance history.

Safety messages for bus and coach operators… 

  • Ensure your vehicles are maintained by licensed mechanics, in accordance with OEM and NHVIM requirements. 
  • Ensure you and your drivers understand that alarm displays serve as important cues indicating issues with safety critical systems and require an appropriate response. Covering an alarm from display removes the opportunity to identify issues with a safety critical system, increasing risk for mechanical failure.
  • Pre-departure checks and driver handover procedures provide opportunities to identify system faults and should be a standard practice included in your safety management system.  

 Visit the OTSI website to download the full investigation report: Bus rollaway and collision – Wilsons Valley – 5 September 2022 >>