Finding into death of Stephanie Louise Meredith

Contributing factors

• failure of road vehicle driver to see flashing warning lights at level crossing despite activation
• level crossing infrastructure inadequate to alert familiar drivers
• inadequate brake maintenance on semi-trailer trailer
• anti-lock braking system on prime mover reducing deceleration rate
• flashing incandescent lights focused at car drivers, not truck drivers
• insufficient human factors research informing level crossing safety systems
• inappropriate triage and transfer of trauma patient by fixed wing aircraft without critical care support
• tension pneumothorax development during pressurized aircraft transfer
• inadequate initial ambulance scene management and situation reporting
• confusion in emergency response coordination between multiple agencies

Coroner's recommendations

1. Systematic approach to collecting routine detailed human factors information about level crossing collisions
2. Investigate and implement new level crossing infrastructure designed to alert drivers unresponsive to current warning signs
3. Joint sophisticated human factors research and innovative technology to alert drivers failing to notice approaching trains
4. Amend standards to require warning signs and train visibility at least 131 metres before level crossing for heavy vehicles
5. National Heavy Vehicle Regulator amend Code of Practice to require inspection of brake pads and push rod extensions weekly or fortnightly
6. Expand National Heavy Vehicle Accreditation Scheme to include all Victorian heavy vehicle operators performing in-house maintenance
7. Code of Practice to ensure mechanics have access to and comply with manufacturers' maintenance instructions
8. Investigate directed sounds from horns and sirens to increase locomotive conspicuity in regional areas
9. Extend development and evaluation of level crossing countermeasures with specific reference to alerting drivers to approaching trains
10. Standards Australia review AS1742.7-2007 to include advice on left turn slip lanes and LED specifications
11. Implement more frequent routine reviews of AS1742.7-2007 for currency and compatibility
12. Establish formal cooperative arrangements between Transport Safety Victoria, VicRoads for sharing information on risk assessment and upgrades
13. Transport Safety Victoria cooperate with National Rail Safety Regulator in establishing root cause analysis system for fatal level crossing collisions
14. Improve accuracy, content and relevance of data in predictive risk analysis for level crossing upgrades
15. Australian Transport Safety Bureau apply systematic analysis procedures in analysis of fatal rail incidents
16. Continue to maintain and improve comprehensive reliable database of level crossing incidents
17. VicTrack, VicRoads, Transport Safety Victoria and rail operators implement innovative in-vehicle warning systems
18. Ambulance Victoria and Air Ambulance Victoria carefully consider risks of tension pneumothorax when triaging trauma patients for fixed wing transfer without Mobile Intensive Care Ambulance support
19. V/Line provide train drivers and conductors with formal instruction and scenario practice for Interim Site Controller role
20. V/Line provide same for all trained conductors to assist in Interim Site Control
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 trapped passengers
23. Victoria Police ensure Incident Commanders include representatives of all support organisations in Emergency Management Team
24. V/Line review management arrangements for trained Rail Incident Controllers within timely access to level crossings
25. V/Line involve train crews and management in local desktop and scenario emergency service training