Coronial
QLDcommunity

Leonardi, Christine Nan and Leonardi, Samuel John

Deceased

Christine Nan Leonardi and Samuel John Leonardi

Demographics

37y, female

Date of death

2013-09-16

Finding date

2017-10-11

Cause of death

Christine Nan Leonardi: massive soft tissue and bony injury due to motor vehicle collision with Franna AT-20 crane. Samuel John Leonardi: multiple injuries (surgically treated) due to motor vehicle collision with Franna AT-20 crane.

AI-generated summary

A 37-year-old mother and her 6-year-old son died when struck by a Franna AT-20 mobile articulated steering crane that lost control on a downhill stretch of road. The crane operator, an experienced driver, was travelling at 80-95km/h when the vehicle began 'fishtailing'. He attempted to regain control by accelerating and steering sharply, but the crane crossed into oncoming traffic and collided with the family's vehicle. The coroner found that speed was a primary cause, compounded by the crane's unique handling characteristics: frame steering (which rapidly rotates the driver), twitchy hydraulic steering with poor feedback, front wheels that don't self-centre, and harsh suspension. The driver's response (accelerating rather than gentle braking) was influenced by mistaken beliefs about how to recover control. Critical gaps identified: no speed limitations despite known lateral stability issues; inadequate driver licensing requiring no on-road assessment in mobile cranes; missing guidance on emergency procedures in operators manuals and codes of practice. The coroner made extensive recommendations for 60km/h speed restrictions, road access restrictions, enhanced driver training and licensing, and development of electronic stability control systems.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Error types

systemdelay

Contributing factors

  • Speed (80-95km/h on downhill section)
  • Lateral instability of mobile articulated steering crane
  • Inappropriate driver response (acceleration instead of gentle braking)
  • Over-steering by driver
  • Unique handling characteristics of frame-steered mobile articulated cranes
  • Inadequate driver training and licensing requirements
  • Lack of guidance in operators manual regarding emergency procedures
  • No speed restrictions imposed despite known lateral stability issues
  • Twitchy hydraulic steering system with poor feedback
  • Harsh suspension making the vehicle sensitive to road undulations

Coroner's recommendations

  1. National Heavy Vehicle Regulator: Urgently amend National Class 1 Special Purpose Vehicle Notice to impose 60km/h speed restriction on all mobile articulated steering cranes (until electronic stability control systems developed) and restrict access to roads/motorways where 60km/h speed restriction would be unsafe
  2. National Heavy Vehicle Regulator: Propose amendment to Heavy Vehicle National Law to ensure internal speed limiters set to 60km/h on all mobile articulated steering cranes (or 80km/h with electronic stability control)
  3. National Heavy Vehicle Regulator: Conduct independent testing of each make and model mobile articulated steering crane to determine inherent lateral stability issues
  4. National Transport Commission: Amend national licensing scheme requiring practical on-road assessment in mobile articulated crane and theoretical assessment on unique handling characteristics and emergency procedures before driver authorization on public roads
  5. All State and Territory road regulators: Support amendments by National Heavy Vehicle Regulator and National Transport Commission regarding speed restrictions, road access restrictions, and licensing requirements
  6. Safe Work Australia: Amend national workplace licensing scheme requiring practical road assessment and theoretical assessment on unique handling characteristics and emergency procedures before authorization to drive mobile articulated steering cranes
  7. All State and Territory work health and safety regulators: Support Safe Work Australia amendments and amend mobile crane Codes of Practice to include guidance on unique handling characteristics and emergency procedures
  8. Terex Australia Pty Ltd: Develop electronic stability control systems for retrofitting to mobile articulated steering cranes
  9. Terex Australia Pty Ltd: Amend Owners Manuals for all mobile articulated cranes with guidance on unique handling characteristics and emergency procedures
  10. Terex Australia Pty Ltd: Issue Safety Bulletin with guidance on unique handling characteristics and emergency procedures for loss of control
  11. Standards Australia: Update relevant mobile crane Australian Standards (noted as out of date)
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