Inquest into the death of Maximilian Patrick McDowall
Deceased
Maximilian Patrick McDOWALL
Demographics
20y, male
Date of death
2021-05-27
Finding date
2024-10-24
Cause of death
Multiple injuries due to motor vehicle collision (cyclist)
AI-generated summary
A 20-year-old cyclist was struck and killed by a Brisbane City Council bus at an intersection where both the cyclist and bus received simultaneous green lights. The bus driver, despite checking his mirror, did not see the cyclist who was positioned in an extensive blind spot on the left side of the bus. The collision resulted from a combination of factors: inadequate traffic light sequencing that permitted simultaneous pedestrian and vehicle access to the same lane; extensive blind spots on the bus unknown to the driver; the cyclist's failure to notice the bus's flashing turn indicators despite being within sight; and the inherent difficulty of the dynamic situation. While the bus driver lacked knowledge of the blind spots and the cyclist's head-down pedalling contributed to his situational awareness failure, the principal cause was identified as the traffic light design. Subsequent upgrades installed a red arrow preventing left turns when pedestrians have a green walk signal, creating complete separation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Extensive blind spots on left side of bus preventing driver visibility
- Bus driver lack of awareness regarding extent of blind spots
- Traffic light sequencing permitting simultaneous pedestrian and vehicle access
- Cyclist's failure to identify bus turning despite green light
- Cyclist's head-down pedalling position affecting situational awareness
- Cyclist unable to see or appreciate bus's flashing turn indicators
- Simultaneous green signals for bus and cyclist at same intersection
- Bus driver gave-way position not recognized by cyclist
Coroner's recommendations
- Brisbane City Council review bus driver Incident Report protocol and incorporate in training guidance and criteria to assist drivers in providing appropriate information
- Brisbane City Council incorporate in bus driver training guidance on Blind Spot Mapping to assist identifying hazard awareness of pedestrians and cyclists
- Brisbane City Council and Translink Services install 'mobile eye' and 'camera mirrors' technology in full bus fleet to assist driver awareness of pedestrians and cyclists
- Brisbane City Council and Department of Transport and Main Roads undertake programmed review of every intersection in Brisbane metropolitan area to prioritize installation of red arrow prohibition of vehicles crossing pedestrian lanes with 'green man' light, with assessment of blind spot risks on buses as critical factor
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