A bus industry safety overhaul billed as the largest in 20 years will come into force following the release of a Greta bus crash investigation report on Friday, the state government says.
A centralised record of NSW bus drivers' fitness was among more than 40 recommendations from an Office of Transport Safety Investigations (OTSI) probe into the Hunter Valley bus crash that killed 10 passengers and injured 25 more on June 11, 2023.
The no-blame investigation was designed to identify potential systemic safety changes, and noted that "widespread change is required".
The government tabled the final report on Friday and accepted, at least in principle, all 21 recommendations made to Transport NSW.
Chief investigator Jim Modrouvanos said the OTSI probe found multiple safety systems had not worked effectively that night to protect passengers.
His investigation involved reconstructing the crash through a visual simulation "to better understand the crash sequence".
The report notes there were "limited" engineering measures that could help reduce the risk to passengers, and that "the driver in most instances [is] the first and last line of defence".
"My report found the driver should not have been behind the wheel that night, given a history of likely misuse of the opioid prescription painkiller Tramadol, including likely impairment at the time of the crash," Mr Modrouvanos said.
"The applicable system of driver health oversight and standard drug testing did not appropriately identify the likely misuse of the painkiller and escalate it to the driver licensing authority for action."
Greta bus driver Brett Button had an appeal against his 32-year jail sentence dismissed on all grounds in November.
He pleaded guilty to 35 offences, including 10 counts of dangerous driving occasioning death.
The OTSI report found complaints against Button had not been disclosed when he changed employers, prompting its recommendation to ensure driver performance data was better carried between companies.
It found that at the time of the crash there was in NSW "no industry-wide driver management system to track bus driver authorities or record metrics related to driver performance such as complaints, compliments, breaches, and passenger feedback".
"This would enable more effective management of driver health and performance and would support the early detection of at-risk behaviour and ensure drivers remain fit and suitable for the role, especially when transitioning between operators," the report notes.
Safety systems on board failed to prevent passengers being ejected from their seats, Mr Modrouvanos said.
"Not all passengers on the coach wore seatbelts and they were not issued with a pre-trip safety warning as was the coach company's policy," he said.
"Although the coach was fitted with seatbelts and it is a legal requirement to wear them, they are generally not worn in NSW - highlighting a broader community issue around seatbelt wearing on coaches and buses where they are fitted."
Other recommendations included greater guidance and support in designing non-circular roundabouts.
NSW Minister for Transport John Graham said the investigation provided a "clear path" towards safer buses.
"We can't undo the immense loss and trauma caused by this crash, but we learn and change from it - and we are doing that," he said.
