The deaths of 10 wedding guests in the 2023 Greta bus crash must drive lasting change across the coach industry and among passengers, according to the state’s transport safety investigator.

A report into the Hunter Valley tragedy found the limited use of seatbelts contributed to the scale of the disaster, while a series of warning signs surrounding the driver were not acted upon.

The mostly young passengers were travelling from a wedding at a Hunter Valley wine estate when the bus rolled at a roundabout near Greta on 11 June 2023.

Ten people died and another 25 were injured in one of the region’s most devastating road crashes.

The Office of Transport Safety Investigations found few passengers were wearing the mandatory seatbelts fitted to the coach.

Chief investigator Jim Modrouvanos said the failure to wear seatbelts on buses and coaches reflected a broader cultural problem.

“If you are travelling on a coach and there is a seatbelt fitted, please wear it. It could save your life,” he said.

“We must act on the lessons from this investigation to improve road safety and minimise the chances of a similar event happening again.”

The investigation found only one fine had been issued in NSW for failing to wear a seatbelt on a coach during the previous five years.

Mr Modrouvanos said the finding showed greater awareness and enforcement may be needed among passengers, operators and police.

The report also found passengers were not given a safety briefing before the journey.

Driver Brett Andrew Button was later sentenced to 32 years in prison over the crash.

The court heard Button was affected by the opioid painkiller Tramadol and was travelling too fast when the bus entered the roundabout before rolling and striking a guardrail.

The report identified several missed opportunities that may have prevented him from driving that night.

Investigators found his medication use was known to a doctor and there had been substantiated passenger complaints about his previous behaviour behind the wheel.

“There were opportunities to report it,” Mr Modrouvanos said.

“There were a series of substantiated passenger complaints about the driver’s general behaviour that could have been acted upon as well.”

The investigation delivered 41 recommendations aimed at improving coach safety across NSW.

They include strengthening the management and reporting of medication use, improving the way complaints about drivers are recorded, and creating a database to provide operators with more information when drivers change employers.

Government agencies, regulators and industry organisations have accepted the relevant recommendations either fully or in principle.

NSW Transport Minister John Graham said the government was committed to learning from the Hunter Valley tragedy.

“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.

Transport for NSW has already begun implementing a number of the recommendations.

Mr Modrouvanos said he hoped the report would provide some reassurance to survivors and the families of those who died that every part of the tragedy had been examined.

“We have looked at every conceivable area, and the loss of their loved ones is not for no gain,” he said.

The findings place a renewed focus on personal responsibility, industry accountability and the simple act of wearing a seatbelt.

For the Hunter community, the report is another difficult chapter in the aftermath of a tragedy that continues to be deeply felt across the region.

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