Coronial
VICother

Finding into death of Harold Claude Long

Deceased

Harold Long and 10 other train passengers

Demographics

83y, male

Coroner

Coroner Dr Jane Hendtlass

Date of death

2007-06-05

Finding date

2013-10-21

Cause of death

Acute blood loss and shock/trauma in a man with cardiomegaly, myocardial fibrosis and ischaemic coronary artery disease

AI-generated summary

This coronial finding examines the deaths of 11 train passengers in the Kerang level crossing collision on 5 June 2007, where a semi-trailer struck a V/Line passenger train. The investigation found that 6 passengers died immediately from trauma, while others died from severe injuries with poor prognosis despite appropriate emergency response. Harold Long developed a tension pneumothorax during fixed-wing air transport to Melbourne without Mobile Intensive Care Ambulance support, highlighting risks of air transfer in pneumothorax-vulnerable patients. The inquiry also examined 12 additional level crossing fatalities across Victoria to identify preventable factors. Key findings included: drivers unfamiliar with trains despite regular crossing use; failures in level crossing infrastructure to alert drivers to approaching trains; predictive risk assessment systems (ALCAM) that underestimated actual risks; inadequate heavy vehicle maintenance standards; and gaps in emergency response coordination. The coroner emphasised that while the emergency response was generally competent, the tragedy demonstrates the need for improved train detection systems targeting familiar drivers, better infrastructure standards for heavy vehicles, and enhanced multi-agency communication during mass casualty incidents.

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

Specialties

emergency medicineparamedicinetrauma surgeryaviation medicine

Error types

systemprocedural

Drugs involved

morphine

Clinical conditions

tension pneumothoraxcardiomegalymyocardial fibrosisischaemic coronary artery diseaseshockcompound fracture

Procedures

intubationintercostal catheter insertionintravenous accesscardiopulmonary resuscitation

Contributing factors

  • Driver unfamiliar with train warning systems despite familiarity with level crossing
  • Inadequate infrastructure for alerting drivers to approaching trains
  • Unroadworthy trailer brakes
  • Inadequate maintenance procedures for heavy vehicles
  • Transfer by fixed-wing aircraft without Mobile Intensive Care Ambulance support
  • Tension pneumothorax development during air transport
  • Pre-existing cardiac disease and large laceration to lower leg

Coroner's recommendations

  1. Ambulance Victoria and Air Ambulance Victoria carefully consider risks of tension pneumothorax when triaging trauma patients for transfer by fixed wing aircraft without Mobile Intensive Care Ambulance support (Recommendation 18)
  2. Transport Safety Victoria, Public Transport Victoria and VicRoads adopt systematic approach to collecting routine detailed human factors information about level crossing collisions (Recommendation 1)
  3. Transport Safety Victoria and VicRoads investigate and implement new level crossing infrastructure designed to alert drivers to approaching trains unresponsive to current warnings (Recommendation 2)
  4. Transport Safety Victoria and VicRoads commit to joint human factors research and innovative technology for alerting drivers of approaching trains (Recommendation 3)
  5. VicRoads and Standards Australia amend standards to require warning signs and train visibility at least 131 metres before level crossing, more for B-doubles and B-triples (Recommendation 4)
  6. National Heavy Vehicle Regulator amend Code of Practice to require inspection of brake pads and push rod extensions weekly or fortnightly (Recommendation 5)
  7. National Heavy Vehicle Regulator expand National Heavy Vehicle Accreditation Scheme to include all Victorian heavy vehicle operators performing in-house maintenance (Recommendation 6)
  8. Code of Practice ensure mechanics have access to and comply with manufacturers' maintenance instructions (Recommendation 7)
  9. Transport Safety Victoria investigate directed sounds from horns and sirens to increase locomotive conspicuity in regional areas (Recommendation 8)
  10. Transport Safety Victoria, Public Transport Victoria and VicRoads extend development of level crossing countermeasures with specific reference to alerting drivers to approaching trains (Recommendation 9)
  11. Standards Australia review AS1742.7-2007 to include advice on left turn slip lanes and LED specifications (Recommendation 10)
  12. Standards Australia implement schedule of more frequent routine reviews of AS1742.7-2007 (Recommendation 11)
  13. Transport Safety Victoria, Public Transport Victoria and VicRoads establish formal cooperative arrangements for predictive risk assessment, prioritisation and innovative warning systems (Recommendation 12)
  14. Transport Safety Victoria cooperate with National Rail Safety Regulator in establishing system for root cause analysis of fatal level crossing collisions (Recommendation 13)
  15. Transport Safety Victoria improve accuracy, content and relevance of data in predictive risk analysis for level crossing upgrades (Recommendation 14)
  16. Australian Transport Safety Bureau trial root cause analysis procedures in systematic analysis of fatal rail incidents (Recommendation 15)
  17. Transport Safety Director maintain and improve comprehensive reliable database of level crossing incidents (Recommendation 16)
  18. VicTrack, VicRoads, Transport Safety Victoria and rail operators cooperate to implement innovative in-vehicle warning systems (Recommendation 17)
  19. V/Line provide train drivers and conductors with formal instruction and scenario practice for role as Interim Site Controllers (Recommendation 19)
  20. V/Line provide trained conductors with equipment, instruction and scenario practice to assist in Interim Site Control duties (Recommendation 20)
  21. V/Line provide first aid supplies including blankets and bandages for major emergencies on regional trains (Recommendation 21)
  22. V/Line provide tools and gloves on regional trains for removing seats and freeing trapped passengers (Recommendation 22)
  23. Victoria Police ensure Incident Commanders include representatives of all support organisations in Emergency Management Team (Recommendation 23)
  24. V/Line review management arrangements to ensure Rail Incident Controllers accessible to all level crossings in timely manner (Recommendation 24)
  25. V/Line involve train crews and management in local desktop and scenario emergency service training (Recommendation 25)
Full text
Official source Archived copy

Related cases from VIC

VICcommunity2026-05-07

Finding into death of Elizabeth Susan Edwina Ferris

44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…

Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…

psychiatryintensive carediagnosticcommunicationheroin
VICaged care2026-05-06

Finding into death of Cornelia Groot

87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…

An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…

geriatric medicineemergency medicinediagnosticcommunicationoxycodone
VIChome2026-04-30

Finding into death of Nick Panagiotopoulos

47y · Male·Acute myocardial infarction due to thrombotic occlusion of the right coronary ar…

Nick Panagiotopoulos, a 47-year-old man, suffered a fatal acute myocardial infarction (heart attack) on 16 October 2021 at home in Preston, Victoria. His family made five calls to Triple Zero (000) requesting emergency a…

cardiologyemergency medicinesystemdelay

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.