Coroner's Finding: VENNING James William

Contributing factors

• gearbox in neutral during descent
• inadequate trailer brake maintenance
• severely worn brake linings (three-eightmm range)
• maladjusted brake assemblies with slack adjuster angles exceeding 90 degrees
• brake failure due to excessive heat from prolonged braking
• driver inexperience on South-Eastern Freeway
• failure to use available safety ramp despite loss of vehicle control
• lack of specific training on Rule 108 mandatory low-gear requirement
• excessive speed for conditions and vehicle control capability

Coroner's recommendations

1. Increase penalties for Rule 108 contraventions to include imprisonment, not just expiation
2. Deem heavy vehicles exceeding 60 km/h on freeway descent as driving dangerously per se
3. Enable third party insurers to recover compensation from driver, vehicle owner, operator, and chain of responsibility parties for preventable deaths
4. Make downhill descent training and Rule 108 competency mandatory for all heavy vehicle licence acquisition
5. Require specific South-Eastern Freeway descent training and competency demonstration for all heavy vehicle drivers, regardless of state of origin
6. Prohibit first-time solo descent of South-Eastern Freeway; require supervision by trained experienced driver
7. Require all heavy vehicle licence holders to demonstrate competency in South-Eastern Freeway descent before licence issue
8. Implement options 1-10 from stakeholder workshop including education campaign, speed limit reduction, improved signage, safety ramp promotion, and maintenance roadworthiness chain of responsibility
9. Reduce heavy vehicle speed limit to 40 km/h and light vehicle limit to 80 km/h on freeway descent on trial basis
10. Add 'heavy penalties apply' to low-gear signage
11. Clarify to drivers that failure to use second safety ramp provides no further recovery opportunity
12. Bring vehicle maintenance and roadworthiness into Heavy Vehicle National Law chain of responsibility regime nationally
13. Implement periodic and frequent heavy vehicle inspections including mandatory pre-registration inspections
14. Further consider feasibility of third safety ramp with traffic management considerations
15. Install speed detection technology with warning signage directing excessive-speed drivers to use safety ramps
16. Create mandatory stopping area between tunnel exit and second safety ramp with requirement to use ramp if unable to stop