Speaking to ABC's Australian Story, survivors and bereaved families said the crash was the product of failures across the system, not one man's actions alone, and called for reforms so it never happens again.
"We need to step in and speak up and prevent these things from happening again," said Jason Junkeer. "There's been some catastrophic errors in judgement."
Jason and his wife Sharyn were among the guests being driven home from a vineyard wedding at Lovedale when the bus veered out of control on a roundabout near Greta, tipped onto its side and smashed into a crash barrier. Jason, thrown into the windscreen, helped other guests free themselves from jammed seatbelts before passing out. Sharyn, who broke her back and pelvis, dragged herself out through the manhole exit and walked about 20 metres barefoot before collapsing.
"That was a very powerful moment when we both realised that we had escaped," Sharyn said. She has had to learn to walk again and is still recovering from a severe hip injury. She was careful to note that she does not claim to speak for the other families. "I never want to be seen to be speaking on behalf of anyone else."
The investigation by the NSW Office of Transport Safety Investigations (OTSI) found the driver, Brett Button, then 58, had taken more than his prescribed dose of the opioid tramadol. The bus was travelling at 56.48 km/h entering the corner, and a speed above 47 km/h was likely to lead to a rollover.
The report documented a chain of missed warnings. Button was sent to a pain management clinic in 2022 as part of a WorkCover claim, which noted "an opiate dependence disorder with features of vulnerability to addiction". His then employer, CDC NSW, suspended him from driving in June 2022, but he resigned that October, the day before an independent medical assessment, and later joined Linq Buslines.
OTSI found CDC NSW did not disclose Button's health issues to Linq because privacy legislation prevented it sharing health information without consent. A judge in a recent court case against Linq described its reference check of Button as "flippant". Twelve complaints upheld against Button during six years at CDC were not passed on, and there is no record of Transport for NSW being advised of his substance misuse. Tramadol is not a banned substance for bus driving.
Matt and Leanne Mullen, whose 26-year-old daughter Rebecca, a junior doctor, died in the crash, share the view that blame extends beyond the driver. "The crash was a result of a perfect storm of mistakes, perfect storm of a lack of accountability, system failures, processes that don't work properly and a whole mismatch of agencies that aren't working together," Leanne said.
Button was originally charged with 10 counts of manslaughter, later downgraded after a plea deal to 10 counts of dangerous driving occasioning death. He pleaded guilty to 25 other charges and was sentenced to 32 years' jail, with a non-parole period of 24 years. Matt Mullen said the sentence left him numb. "It didn't change anything." Button apologised in 2024, saying: "I live with this every day... I can't forgive myself."