Draft:Office of Transport Safety Investigations
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The Office of Transport Safety Investigations (OTSI) is New South Wales's independent transport safety investigator. OTSI is the state-based government body responsible for investigating bus, ferry, light rail and rail transport-related incidents within New South Wales. OTSI is separate from transport regulators, policy makers and service providers.
History
OTSI was established on 1 January 2004[1] as a separate division within the Independent Transport Safety and Reliability Regulator (ITSRR) to investigate and report on rail, bus and ferry safety incidents in NSW.
In response to the recommendations of the Special Commission of Inquiry into the Waterfall Rail Accident, the NSW Parliament passed the Transport Legislation Amendment (Waterfall Rail Inquiry Recommendations) Bill 2005 which removed OTSI from ITSRR and created the Chief Investigator as a statutory position. OTSI began operating independently on 1 July 2005.
The separation of OTSI was designed to reinforce the independence of the Chief Investigator, and to give the travelling public and the transport sector a high degree of confidence in the safety of the NSW transport network through the conduct of fair, impartial and balanced investigations. OTSI investigation reports are tabled by the NSW Minister for Transport in both houses of the NSW Parliament.
Since 2004 and 2024, OTSI has successfully investigated and published over 240 safety investigations, received and triaged over 17000 bus, rail and ferry notifications, reviewed over 1700 operator reports and shared 1000’s of safety insights with the transport sector in NSW. OTSI findings and insights have enabled operators, regulators and agencies to take action to improve safety.
The Chief Investigator
OTSI is led by the Chief Investigator who is appointed by the Governor of NSW on the recommendation of the Minister for Transport. The Chief Investigator is not subject to the direction or control of the Minister in the exercise of the Chief Investigator’s investigative and reporting functions. Jim Modrouvanos is the current Chief Investigator.
The functions of the Chief Investigator are set out in the Transport Administration Act 1988 (s45 to s45DB) and the Passenger Transport Act 1990 (s46A to 46E). These functions include:
• conducting investigations into rail and passenger transport accidents or incidents under the Passenger Transport Act 1990
• determining the causes of those accidents or incidents
• reporting on the outcome of any investigation to the Minister
• reviewing investigation reports prepared by transport authorities and other transport operators
• at the request of the Minister, investigating and advising the Minister about any matters related to the safe operation of transport services.
The Chief Investigator can also give a written notice to the Minister requesting that any transport accident or incident or any other event, occurrence, practice or matter that may affect the safe provision of a public passenger service carried on by means of a bus or ferry be the subject of a transport safety inquiry.
Collaboration with the Australian Transport Safety Bureau (ATSB)
In 2013, the NSW Chief Investigator entered into a collaboration agreement with the Australian Transport Safety Bureau (ATSB) and the Chief Investigator Transport Safety Victoria (CITS). The collaboration agreement sets out arrangements for the conduct of independent rail investigations to support reforms introduced in 2013 for a national rail regulatory framework.
Under the agreement, OTSI may conduct some rail investigations in NSW under the provisions of the Transport Safety Investigation Act 2003 (Cth). The collaboration agreement is reviewed annually.
OTSI Investigations
OTSI investigates safety incident and accidents in NSW involving:
• buses seating more than 8 adults and operating a public passenger service for a fare
• ferries (vessels) seating more than 8 adults and operating a public passenger service for a fare
• railway operations such as the construction of a railway and rolling stock; the management, commissioning and maintenance of rail infrastructure; and the operation or movement of rolling stock for the purposes of operating a railway service.
The Chief Investigator can investigate any transport accident or incident that may affect the safe provision of railway operations or public passenger services on buses or ferries. The NSW Minister for Transport can request that the Chief Investigator investigate and advise the Minister about any matter related to the safe operation of transport services.
The Chief Investigator focuses the agency’s resources on those investigations considered most likely to enhance bus, ferry or rail safety by providing new safety lessons and insights that may be shared.
The Transport Administration Act 1988 empowers the Chief Investigator to conduct investigations into rail and passenger transport accidents under the Passenger Transport Act 1990.
Bus Investigations
OTSI has conducted over 90 bus investigations since its establishment in 2004, including an annual report into bus fires and thermal events in NSW.
Some recent bus investigations include an incident a bus rollaway and collision at Wilsons Valley in 2022, a bus fire at Green Valley in 2022 and a report detailing trends in the causes of bus fires and thermal events between 2013 and 2022.
Ferry Investigations
OTSI has conducted over 35 ferry investigations since its establishment in 2004.
Some recent ferry investigations include a collision between two passenger vessels in Sydney Harbour in 2021 and a passenger fatality on a privately hired passenger vessel in 2019.
Rail Investigations
OTSI has conducted over 130 investigations since its establishment in 2004.
Some recent rail investigations include a derailment of a loaded grain train at Dombarton in 2020, a collision between a passenger train and a motor vehicle at Kembla Grange in 2021 and an ongoing systemic investigation into worksite protection.
Confidential Safety Information Reporting Scheme (CSIRS)
The Confidential Safety Information Reporting Scheme (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, under the provisions of Section 46E of the Passenger Transport Act 1990.