Finding into death of Justin Ross Pomery
Deceased
Justin Ross Pomery
Demographics
20y, male
Date of death
2009-04-16
Finding date
2011-03-30
Cause of death
Massive head injuries from motor vehicle accident (bus rollover)
AI-generated summary
On 16 April 2009, a V-Line passenger coach rolled over on the Princes Highway near Heathmere, Victoria, killing Justin Pomery (20 years), Sabrina Brady (7 months pregnant), and her daughter Madison. Three passengers who were unrestrained were ejected; only 5 of 11 passengers wore seatbelts. The coroner found the primary cause was poor road surface conditions (severe bleeding, polishing, rutting, and water pooling) that reduced traction and likely caused aquaplaning. VicRoads had identified this section as needing waterblasting since 2007 but did not act until after the incident. The bus was mechanically sound and the driver was competent. The coroner identified system failures in VicRoads' road maintenance and hazard reporting processes, inadequate seatbelt compliance among passengers, and the absence of child restraints on buses as critical gaps.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Poor road surface conditions (severe bleeding, polishing, rutting, water pooling)
- Reduced skid resistance below VicRoads recommended levels
- Likely aquaplaning due to road surface and wet conditions
- Failure to wear seatbelt
- Inadequate hazard identification and maintenance prioritisation by VicRoads
- Delayed implementation of waterblasting despite identification as necessary since 2007
- Weak public education on seatbelt compliance on buses
Coroner's recommendations
- VicRoads review road maintenance system and implement best practice system for inspecting, monitoring, auditing, funding and repairing road surfaces to minimise crash risk, incorporating considerations for extreme climate events
- Victorian Government ensure VicRoads is adequately resourced to implement recommendations relating to road maintenance and risk
- Bus Industry Confederation of Australia with Transport Safety Victoria develop policy for drivers to play recorded audio message or announcement at intervals advising passengers of seatbelt requirements and emphasising importance in crashes
- Bus Industry Confederation of Australia with Transport Safety Victoria introduce policy for stickers on all bus seats to improve seatbelt compliance emphasising importance and penalties
- Transport Safety Victoria introduce requirement for child restraints to be made available on all buses subject to ADR68/00
- Department of Transport review Road Rules 2009 to define responsibilities for ensuring children are suitably restrained in buses if child restraints become mandatory
- Transport Safety Victoria with Victoria Police and VicRoads ensure comprehensive strategy developed to improve seatbelt compliance and passenger awareness
- Transport Safety Victoria monitor seatbelt compliance rates on buses to evaluate effectiveness of initiatives
- National Transport Commission work with Bus Industry Confederation of Australia to investigate bus occupant safety measures beyond seatbelts including retentive window glazing
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