[Peetwo]

OTSI Safety Alerts, Advisories and investigative disconnections?? - 

Reviewing the OTSI investigation pages for all three modes (rail, ferry & buses), there are some strange disconnections that IMO deserve some serious contemplation.

Q/ Unlike any safety transport investigative body that I know of, why does the OTSI published investigative process omit the original IFS (interim factual statement) once the investigation and final report has been tabled in Parliament by the Minister and published on the OTSI website? Shirley in the interests of public transparency and accountability it would be much better to have published both the IFS, subsequent interim updates, media statements, links to safety advisories, alerts, recommendations and ultimately the final report all on the same webpage?

Q/ It was my limited understanding that an IFS was issued preferably within days of the Chief Investigator's decision to continue inquiries into a transport safety incident to a full blown investigation. However there are multiple examples, since the present CI took up the position, of instances where IFS have been issued up to a month after serious safety incidents have occurred? Benefit of the doubt but maybe the CI has already made the decision to investigate and dispatched her investigators well before the IIC has issued the official IFS? If that was the case maybe it would be better if the CI issued a media release stating the fact that OTSI is going to investigate a serious transport safety incident and then subsequently issuing a IFS on a set timeframe, say within 30 days after the incident occurred - again all in the interest of transparency, accountability and proper transport safety investigative processes  

Q/ Also in context with the above, the following is an extract from the 2020 OTSI Annual Report:
 

OTSI has established and provides the following services and functions:

• A 24 hour on call duty officer to whom NSW bus and ferry operators and regulators report the occurrence of accidents and incidents. Notifications of serious (Category A) rail accidents and incidents are provided to OTSI by the ATSB via the Office of the National Rail Safety Regulator, in accordance with the provisions of the Rail Safety National Law (NSW), and the Collaboration Agreement.
  
• A 24 hour investigation response team capable of providing immediate deployment to an accident or incident site.
  

 
So did the '24 hour on call duty officer' automatically deploy the '24 hour investigation response team' to the Revesby school Coach fire? If not, why not?  

 Item next, I was interested to discover that, much like the ATSB, OTSI now have webpages (for all three transport modes) that have published links for Safety Alerts and Advisories. Ref: https://www.otsi.nsw.gov.au/bus-safety-a...advisories & https://www.otsi.nsw.gov.au/ferry-safety...advisories & https://www.otsi.nsw.gov.au/rail-safety-...advisories

Here is the bus version:   

Bus Safety Alerts & Safety Advisories

OTSI supports transport operators, regulators and the broader industry to improve safety by identifying immediate and longer-term risks through its investigations and data analysis. In addition to its investigation reports, OTSI produces and disseminates:

Safety Alerts
A Safety Alert suggests action to be taken by bus, ferry or rail operators to address an issue that could pose an immediate safety risk to operations. An alert may be issued in response to a risk that is identified through the course of an OTSI investigation or following the review of an operator’s investigation report.

20 January 2021 - Safety Alert: Risks of Electrical Fires on Volvo Buses with Volgren CR228L bodies (rigid and articulated)

Safety Advisories
 
A Safety Advisory provides advice to operators and other industry stakeholders about longer-term safety issues that have been identified through an investigation or data analysis.

25 November 2022 - Safety Advisory SA05/22: Bus fire safety and emergency incidents in tunnels
15 August 2022 - Safety Advisory SA03/22: Commissioning and servicing of bus and coach fire suppression systems
5 November 2021 - Safety Advisory: Risk of air conditioning system electrical fires on buses
3 June 2021 - Safety Advisory: Accidents involving buses and pedestrians on and near designated crossings

Because of the relevant context (Revesby Coach fire) I extracted the following from the 15 August 2022 SA:

The incident

On Friday 26 June 2022, the driver of a northbound tourist coach operating in NSW was alerted to an active fire within the vehicle’s engine bay by both the Original Equipment Manufacturer (OEM) fire alarm and the Engine Bay Fire Suppression System (EBFSS). Although there was an alarm and panel notification of discharge, the EBFSS did not discharge the suppressant as designed. The driver subsequently extinguished the fire with the assistance of another driver from the same company.

The Office of Transport Safety Investigations (OTSI) later inspected the vehicle and found an isolation device which should have been removed when the fitted system was commissioned. The isolation device remained secured in place to both EBFSS agent tank valve bodies. This device rendered the system unable to discharge the suppressant agent.

Records of the installation and information provided by the EBFSS supplier identified that the system was installed by an organisation known to the supplier that was authorised to service their systems but was neither trained nor authorised to carry out installations of their systems (which included the initial commissioning of the system)

Ok so the serious transport safety incident that precipitated this occurred on the 26 June 2022, yet bizarrely OTSI do not appear to be investigating? Ref: https://www.otsi.nsw.gov.au/bus/investigations

Which brings me to the next bizarre aberration...

Ref: 31 August 2021 - Safety Advisory: Domestic Commercial Vessel (DCV) Steering Systems

Extract:

The incident

On 12 May 2021, a passenger ferry experienced a steering system component failure resulting
in an uncommanded steering input and temporary loss of directional control.

A return spring broke in the helm steering mechanism and when the helm’s wheel was
released, it rotated towards port and engaged the rudder. The vessel was travelling at 14 knots
at the time of the incident. The master unsuccessfully attempted to use alternative steering
controls to correct the uncommanded turn. The master then slowed the vessel before
disengaging the primary steering pumps and engaging the pneumatic backup steering system.

The rudder remained to port for 199 seconds before backup systems were engaged. During
this time the vessel deviated from the intended course and turned to port by approximately 90
degrees across a channel.

The class of vessel involved in the incident had experienced similar return spring failures in
recent times although the causes of such failures along with the appropriate responses to
them were not known to all operational personnel.

Operator follow up

The Chief Investigator requested further information from the operator including their internal
investigation reports, risk assessments, risk registers, training and maintenance records and
vessel data. Following a review of this information and other recent similar incidents, OTSI
wishes to highlight several areas where safety management processes could be improved.

Key points for operators

In 2021, a total of eight incidents relating to problems with DCV vessel steering systems have
been reported to OTSI with varying failure modes. These include mechanical and electrical
component failures, corrosion within primary control switches and maintenance induced faults.
The steering system is critical for safe navigation and ought to be designed and maintained to
ensure its continued safe operation throughout the vessel’s lifecycle. Operators’ safety
management systems (SMS) are the primary means to ensure risks are assessed and
controls are implemented for managing steering system failures. Marine Order 504 sets out
relevant SMS requirements and can assist in SMS design.

Training and emergency response procedures are also essential. They must be developed,
implemented and reviewed at appropriate intervals to ensure failure modes are understood
and appropriate responses are applied. As limitations in design or understanding can result in
delays or unintended consequences when responding to emergencies.

Safety message

DCV operators should ensure that failure modes associated with critical steering systems
(including backup systems) are assessed and appropriate risk controls are implemented.
Maintenance regimes should also effectively monitor asset condition and regular refresher
training should be provided to operational personnel so they are able to successfully respond
to failures should they occur.

Again there is apparently no active or completed investigation that was conducted by OTSI - WTF? 

Although the identity of the operator is not actually stated, not helped by not having an investigation report to refer to, the number of operators that have that level of redundancy on steering systems etc in Sydney could be counted on one hand. But IMO the giveaway here is:   "In 2021, a total of eight incidents relating to problems with DCV vessel steering systems.."

And IMO this part of the statement absolutely nails it:

"..The steering system is critical for safe navigation and ought to be designed and maintained to
ensure its continued safe operation throughout the vessel’s lifecycle. Operators’ safety
management systems (SMS) are the primary means to ensure risks are assessed and
controls are implemented for managing steering system failures. Marine Order 504 sets out
relevant SMS requirements and can assist in SMS design..."

Yet here we are 18 months later and the suspected operator is still IMO having very real systemic operator safety issues that should have been captured and effectively safety risk mitigated by the operator's SMS. Or if not responsibly by the operator, it should have been addressed by the national regulator AMSA, with the assistance of OTSI's firm evidence and recommendations (like the above excellent Safety Advisory) established in a systemic investigation into the operator...  

MTF...P2