Finding into death of Nicholas William Parker

Contributing factors

• driver failure to see flashing level crossing warnings due to familiarity and non-expectation of train
• inadequate level crossing infrastructure to alert drivers familiar with the crossing but not expecting a train
• flashing red-filtered incandescent lights focused at car driver height, not truck driver height
• heavy vehicle maintenance defects - trailer brakes unroadworthy
• anti-lock braking system on prime mover reduced deceleration rate
• insufficient stopping distance available when driver became aware of train
• inadequate emergency response coordination and inter-agency communication
• inappropriate triage and air transport decisions for severely injured patient

Coroner's recommendations

1. Transport Safety Victoria, Public Transport Victoria, and VicRoads adopt a systematic approach to collecting routine detailed human factors information about level crossing collisions
2. Transport Safety Victoria and VicRoads investigate and implement new level crossing infrastructure designed to alert road vehicle drivers to an approaching train who are unresponsive to current level crossing warning signs
3. Transport Safety Victoria and VicRoads commit themselves to joint sophisticated human factors research and innovative technology to determine how best to alert drivers who will not notice an approaching train
4. VicRoads and Standards Australia amend standards to require warning signs and train visibility at least 131 metres before level crossing, more on B-double and B-triple routes
5. National Heavy Vehicle Regulator amend Code of Practice to require inspection of brake pads and push rod extensions weekly or fortnightly
6. National Heavy Vehicle Regulator expand National Heavy Vehicle Accreditation Scheme to include all Victorian heavy vehicle operators who perform their own maintenance in-house
7. National Heavy Vehicle Regulator ensure Code of Practice ensures mechanics have access to and comply with manufacturers' maintenance instructions
8. Transport Safety Victoria investigate way in which directed sounds from horns and sirens can increase conspicuity of locomotives in regional areas
9. Transport Safety Victoria, Public Transport Victoria and VicRoads extend development and evaluation of new level crossing countermeasures with reference to their capacity to alert drivers of approaching trains
10. Standards Australia review AS1742.7-2007 to include advice on left turn slip lanes and LED specifications
11. Standards Australia implement schedule of more frequent routine reviews of AS1742.7-2007
12. Transport Safety Victoria, Public Transport Victoria and VicRoads establish formal cooperative arrangements for predictive risk assessment of level crossings
13. Transport Safety Victoria cooperate with National Rail Safety Regulator in establishing system for undertaking and analysing root cause analyses for fatal level crossing collisions
14. Transport Safety Victoria improve accuracy, content and relevance of data used in predictive risk analysis for level crossing upgrades
15. Australian Transport Safety Bureau through Transport Safety Victoria continue to apply systematic analysis procedures in analysis of fatal rail incidents
16. Transport Safety Director continue to maintain and improve comprehensive reliable database of all level crossing incidents in Victoria
17. VicTrack, VicRoads, Transport Safety Victoria and rail operators cooperate to implement innovative in-vehicle warning systems
18. 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
19. V/Line provide train drivers and conductors with formal instruction and scenario practice on their role as Interim Site Controllers
20. V/Line provide equipment, formal instruction and scenario practice for all trained conductors to assist in Interim Site Control duties
21. V/Line provide first aid supplies on regional trains including blankets and bandages for major emergencies
22. V/Line provide tools and gloves on regional trains for removing seats and freeing passengers trapped in debris
23. Victoria Police ensure Incident Commanders are aware of importance of including representatives of all support organisations in Emergency Management Team
24. V/Line review management arrangements to ensure trained Rail Incident Controllers are accessible to all level crossings in regional Victoria
25. V/Line involve train crews and management staff in local desk top and scenario emergency service training