WHEN EVERYONE OWNS SAFETY, NOBODY DOES
The Fragmented Governance System Behind Britain’s Bus Industry
For months now, I have been trying to answer what initially appeared to be a relatively straightforward question:
Who actually governs bus safety in Britain?
What started as a series of Freedom of Information requests around bus safety transparency, franchising accountability and operational governance has gradually evolved into something much bigger.
Because the deeper I have dug into:
- Combined Authorities,
- franchising structures,
- bus reform,
- autonomous vehicle trials,
- safety reporting systems,
- operational oversight,
- regulatory structures,
- Parliamentary evidence submissions,
- and transport governance arrangements,
the more one uncomfortable pattern has repeatedly emerged:
Britain’s bus safety governance system appears deeply fragmented.
Responsibility is spread across:
- operators,
- regulators,
- local authorities,
- Combined Authorities,
- government departments,
- police forces,
- Traffic Commissioners,
- technology providers,
- highways authorities,
- and commercial partnerships,
yet no single clearly visible national framework appears to bring the entire operational safety picture together in the way many people might reasonably assume.
And that matters enormously.
Because buses are not a niche transport mode.
They are:
- Britain’s most used form of public transport,
- relied upon by millions daily,
- operating continuously within densely populated public environments,
- interacting with pedestrians, cyclists and vulnerable road users,
- carrying children, elderly passengers and disabled passengers,
- and increasingly forming the centrepiece of regional transport reform, franchising and devolution policy.
Yet despite this, the deeper question increasingly appears to be:
Has Britain’s bus sector ever developed the same integrated safety governance architecture seen elsewhere in transport?
Because after months of evidence gathering, the answer increasingly appears to be:
not fully.
And the implications of that may be far more serious than many people realise.
THE QUESTION THAT CHANGED EVERYTHING
One of the most striking comments I have received during this work came recently from transport campaigner Tom Kearney, who has spent years examining bus safety governance and transparency issues.
He said:
“Every local authority, bus operator and regulator thinks Bus Safety is someone else’s problem.”
The more I examine the evidence, the harder that observation becomes to ignore.
Because across:
- Combined Authorities,
- operators,
- government departments,
- regulators,
- and transport partnerships,
the same themes repeatedly appear:
- fragmented ownership,
- distributed accountability,
- inconsistent transparency,
- unclear governance responsibility,
- and differing levels of visibility into operational safety performance.
What becomes particularly striking is that almost every organisation involved appears able to point somewhere else:
- operators point toward regulators,
- authorities point toward operators,
- regulators point toward legal responsibilities,
- government points toward local delivery,
- and safety information itself often sits fragmented across multiple bodies.
The result is a system where:
- oversight exists,
- governance exists,
- reporting exists,
- regulation exists,
yet the overall structure can still appear fragmented and difficult to navigate publicly.
And critically: the fragmentation becomes most visible precisely at the point where safety governance should arguably be most integrated.
THE RAIL AND AVIATION COMPARISON
This issue becomes even more significant when compared against rail and aviation.
Across multiple evidence streams, senior transport figures have independently raised remarkably similar concerns.
During conversations relating to bus reform and safety culture, TfGM’s Danny Vaughan observed:
“the bus industry in general is years behind the rail industry”
particularly in relation to:
- safety culture,
- near-miss reporting,
- organisational learning,
- and just culture principles.
That is an extraordinary statement from a senior transport executive.
Because rail and aviation did not accidentally develop mature safety systems.
They evolved them through:
- institutional reform,
- independent investigation,
- mandatory reporting,
- systems-safety thinking,
- human factors analysis,
- and deeply embedded safety governance cultures.
Rail has:
- RAIB,
- independent investigation,
- structured learning frameworks,
- and highly visible safety governance systems.
Aviation has:
- AAIB,
- mandatory occurrence reporting,
- confidential reporting systems,
- and internationally integrated safety structures.
Maritime transport has:
- MAIB,
- formal investigation systems,
- and nationally integrated governance frameworks.
But buses?
The deeper question increasingly becomes:
where is the equivalent integrated safety architecture for Britain’s bus sector?
Because while buses remain regulated, monitored and investigated in various ways, responsibility itself appears fragmented across numerous institutions rather than integrated into a single coherent safety governance framework.
And importantly: multiple senior figures now appear to recognise this.
In September 2024, Transport for London Commissioner Andy Lord stated:
“There is no such body that does that for road fatalities…”
when comparing road transport against rail and aviation investigation structures.
He continued:
“I would welcome the DfT looking at how some form of independent body could undertake similar reviews in the way the RAIB and the MAIB do.”
That is not a fringe observation.
That is one of the most senior transport leaders in Britain openly questioning whether the governance architecture surrounding road passenger transport remains structurally underdeveloped compared with other safety-critical transport modes.
THE STATS19 PROBLEM
One of the biggest structural issues repeatedly emerging through this work concerns Britain’s reliance upon STATS19 collision data.
For years, STATS19 has effectively become one of the primary national datasets referenced in discussions around bus safety.
But STATS19 was never designed to function as a comprehensive operational bus safety governance system.
The Department for Transport itself has confirmed through FOI correspondence that STATS19 is:
- a police-recorded collision dataset,
- retrospective,
- statistical in nature,
- and not a real-time operational safety management framework.
It does not comprehensively capture:
- fatigue,
- scheduling pressure,
- welfare conditions,
- operational stress,
- near misses,
- passenger falls not reported through police systems,
- assault reporting,
- infrastructure pressures,
- or wider organisational safety culture indicators.
Tom Kearney’s Parliamentary evidence submission raises remarkably similar concerns, arguing that STATS19 is:
- incomplete,
- insufficiently granular,
- and incapable of fully representing the operational bus safety picture.
That matters enormously.
Because if the primary national dataset itself only captures part of the picture, then:
who is monitoring the rest?
And increasingly, the answer appears fragmented.
THE OPERATIONAL PRESSURE QUESTION
Perhaps the most important issue now emerging through this work is this:
operational conditions themselves are part of the safety system.
That may sound obvious. But historically, bus safety discussions have often focused heavily on:
- collisions,
- prosecutions,
- compliance failures,
- maintenance defects,
- and enforcement outcomes,
while paying comparatively less visible attention to:
- cumulative operational pressure,
- fatigue,
- welfare access,
- recovery time,
- staffing pressures,
- congestion,
- unrealistic schedules,
- and organisational reporting culture.
Yet these are precisely the areas repeatedly raised by frontline workers and safety campaigners.
Parliamentary evidence submitted by Lorraine Robertson and Kevin Mustafa repeatedly highlights:
- long shifts,
- welfare failures,
- break erosion,
- fear culture,
- operational pressure,
- driver churn,
- and fatigue
as direct public safety issues — not merely employment grievances.
That distinction is hugely important.
Because mature safety-critical industries increasingly recognise:
- workload,
- fatigue,
- staffing pressure,
- psychological safety,
- reporting confidence,
- and operational stress
as core parts of safety governance itself.
Rail does. Aviation does. Healthcare increasingly does.
Bus governance historically appears far less developed in this area.
And this is where one of the most uncomfortable questions in the entire debate begins to emerge.
Because modern bus systems are under enormous pressure to deliver services that are:
- cheap,
- convenient,
- reliable,
- punctual,
- frequent,
- and financially sustainable.
But what operational pressures are quietly normalised underneath those expectations?
That question matters enormously because operational pressure itself can shape:
- driver behaviour,
- reporting culture,
- fatigue,
- stress,
- concentration,
- recovery,
- and ultimately safety outcomes.
And yet much of this remains comparatively under-discussed within mainstream public transport reform debates.
THE “JUST CULTURE” GAP
One of the most striking observations from Danny Vaughan was his comment that:
“There seems to be a bit of a blame culture, not really a just culture…”
That is an extremely important observation.
Because “just culture” is not simply management jargon.
It is a foundational principle within mature safety-critical systems.
The idea is relatively simple:
- staff must feel safe reporting concerns,
- near misses,
- operational risks,
- fatigue,
- procedural failures,
- and unsafe conditions
without fear of disproportionate blame or punishment.
Because systems only learn effectively when information flows honestly.
And repeatedly, across:
- Parliamentary evidence,
- union submissions,
- operational testimony,
- and industry commentary,
concerns continue emerging around:
- underreporting,
- fear culture,
- blame allocation,
- and weak confidential reporting mechanisms.
This is one reason why proposals for:
- CIRAS-style confidential reporting systems,
- independent reporting structures,
- and stronger whistleblower protections
continue appearing throughout Parliamentary submissions and safety discussions.
Because many within the sector increasingly appear to recognise that bus safety culture may still lag behind the more mature systems-safety environments seen elsewhere in transport.
THE SANDILANDS WARNING
The importance of integrated safety governance and mature reporting culture is not theoretical.
Britain has already seen the consequences of fragmented safety understanding and insufficiently mature safety management systems within public transport.
The 2016 Sandilands tram disaster in Croydon, which killed seven people and injured many more, exposed serious systemic weaknesses relating to:
- fatigue management,
- operational risk understanding,
- reporting culture,
- organisational learning,
- and wider safety governance maturity.
The Rail Accident Investigation Branch identified concerns relating to:
- weak incident learning,
- insufficient appreciation of operational risk,
- limited reporting culture,
- and inadequate integration of safety management processes.
One of the most striking themes emerging afterwards was that multiple organisations, governance structures and oversight arrangements existed simultaneously, yet critical safety risks still evolved within the system.
That matters enormously because many of the same broad themes now continue emerging elsewhere across bus governance discussions:
- fragmented responsibility,
- weak systems integration,
- operational pressure,
- insufficiently mature safety culture,
- and uncertainty around where ultimate safety ownership truly sits.
This is not to suggest direct equivalence between buses and trams, nor to retrospectively simplify the causes of Sandilands.
But it does demonstrate something critically important:
Transport systems do not become safer simply because multiple organisations are involved in oversight.
Safety governance only becomes effective when responsibility, reporting culture, operational learning and accountability are genuinely integrated across the system itself.
FRAGMENTATION IN THE DEVOLVED ERA
At the exact moment Britain is accelerating:
- franchising,
- devolution,
- integrated ticketing,
- automation,
- and regional transport reform,
the governance picture itself appears increasingly fragmented.
Across my FOI work:
- Greater Manchester,
- EMCCA,
- West Midlands,
- North East,
- Cambridgeshire,
- and other Combined Authorities
have all revealed differing levels of:
- safety transparency,
- governance maturity,
- accountability visibility,
- reporting frameworks,
- and publication commitments.
In some areas:
- systems are still “being developed.”
In others:
- safety publication is delayed.
In others:
- information is not centrally held.
In others:
- governance responsibility appears split between multiple organisations.
And increasingly: the same structural question keeps emerging:
Who ultimately holds the complete operational safety picture?
Because without clear integrated governance:
- fragmentation itself becomes a safety governance issue.
AUTONOMOUS TRANSPORT EXPOSES THE GAP EVEN FURTHER
This fragmentation becomes even more visible when autonomous transport enters the picture.
Recent Environmental Information Regulation disclosures relating to autonomous bus trials in Greater Cambridge revealed:
- safety committees,
- project boards,
- governance structures,
- safety sign-off systems,
- and operational oversight arrangements
existing alongside repeated statements that:
“the Council does not hold this information.”
That is hugely significant.
Because autonomous transport introduces:
- AI systems,
- distributed technical responsibility,
- software governance,
- public/private accountability overlap,
- and increasingly complex operational relationships.
Yet the disclosures appear to reveal many of the same themes already emerging elsewhere:
- fragmented oversight,
- distributed accountability,
- unclear ownership,
- and incomplete public visibility.
Which raises an even bigger future question:
Is Britain’s governance system evolving as quickly as its transport technology?
Because technology is now advancing rapidly. Governance maturity may not be advancing at the same pace.
THE BIGGER QUESTION NOW
This work has gradually convinced me that Britain may now be approaching a pivotal moment in bus safety governance.
Because the sector is changing rapidly:
- franchising,
- devolution,
- automation,
- integrated transport systems,
- AI,
- digital optimisation,
- and performance-driven operational management
are all accelerating simultaneously.
But governance itself still appears comparatively fragmented.
And ultimately, the question now emerging may be this:
Can Britain continue modernising bus operations without equally modernising bus safety governance?
Because increasingly, the evidence suggests the two cannot be separated.
WHAT NEEDS TO HAPPEN NEXT
At minimum, serious national discussion now appears necessary around:
- integrated national bus safety governance,
- independent investigation structures,
- standardised safety reporting,
- confidential reporting systems,
- just culture principles,
- operational pressure monitoring,
- fatigue and welfare integration,
- governance transparency,
- and nationally consistent safety performance frameworks.
Not because buses are uniquely unsafe. But because:
- Britain’s bus sector increasingly appears to lack the integrated safety architecture already embedded elsewhere in transport.
And that matters.
Because buses are not peripheral to national life. They are essential infrastructure.
Which means safety governance itself should arguably be treated as essential infrastructure too.
Every day across Britain, millions of people place trust in bus systems without ever seeing the governance structures sitting behind them.
Children travelling to school. Elderly passengers accessing healthcare. Disabled passengers dependent upon accessible transport. Cyclists and pedestrians sharing increasingly congested urban environments. Drivers operating under significant operational pressure while carrying public responsibility continuously throughout their working day.
The public understandably assumes that somewhere behind all of this sits a mature, integrated and coherent national safety governance system comparable to those operating elsewhere in transport.
The deeper question increasingly emerging from this work is whether that assumption is entirely correct.
FINAL THOUGHT
The deeper I have gone into this work, the more one conclusion continues emerging:
Britain does not appear to have a single coherent national bus safety governance system comparable to rail or aviation.
Instead, it appears to operate through a fragmented network of:
- operators,
- authorities,
- regulators,
- police systems,
- government departments,
- commercial partnerships,
- and distributed oversight structures
without a single clearly visible integrated framework capable of holding the complete operational safety picture together coherently.
And perhaps the most important question now is no longer:
“Who is responsible for bus safety?”
But instead:
“What happens when everyone believes somebody else already is?”
KEY SOURCES & EVIDENCE
- Parliamentary evidence submissions to the Bus Services Bill Committee
- Department for Transport correspondence regarding STATS19 limitations
- Freedom of Information and Environmental Information Regulation disclosures from Combined Authorities and public transport bodies
- Rail Accident Investigation Branch findings relating to Sandilands
- Public statements from Transport for London Commissioner Andy Lord
- Governance disclosures relating to autonomous bus trials in Greater Cambridge
- Operational evidence and frontline testimony from bus workers and transport professionals
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