Coronial
VICother

Finding into death of Jaesok Lee

Deceased

Jaesok Lee

Demographics

26y, male

Coroner

Coroner Dr Jane Hendtlass

Date of death

2007-06-05

Finding date

2013-10-21

Cause of death

Multiple injuries from collision between semi-trailer and train at level crossing

AI-generated summary

On 5 June 2007, a semi-trailer collided with a V/Line passenger train at the Kerang level crossing, killing 11 passengers. The driver had crossed this crossing hundreds of times without seeing a train, was familiar with the intersection, and failed to see the flashing red incandescent lights or hear the train horn. This coronial investigation examined the full system: the driver's human factors, the vehicle's braking and maintenance (including unroadworthy trailer brakes), the infrastructure's effectiveness (flashing lights were poorly conspicuous for truck drivers; LEDs had been recommended but not upgraded pre-collision), the risk assessment model's failures, and emergency response issues. The investigation emphasises that level crossing safety involves coordinated attention to multiple system failures: poor human awareness despite infrastructure, vehicle maintenance lapses, and tension pneumothorax risk from inappropriate air transfer of an older trauma patient.

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

Specialties

emergency medicinetrauma surgeryanaesthesiaparamedicine

Error types

systemdelay

Clinical conditions

multiple traumatic injuriesblunt force traumapenetrating trauma

Contributing factors

  • Level crossing driver unaware of approaching train despite flashing lights
  • Driver familiar with crossing, not expecting to see train
  • Flashing red incandescent lights poorly visible to truck drivers
  • Train horn not heard by driver
  • Vehicle maintenance issues—trailer brakes unroadworthy with excessive push rod travel
  • Inadequate early level crossing infrastructure
  • Failure to upgrade to LED lights pre-collision despite recommendations
  • Over-triage and inappropriate air transfer of major trauma patient (Harold Long) with risk of tension pneumothorax

Coroner's recommendations

  1. Transport Safety Victoria, Public Transport Victoria, and VicRoads adopt 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 approaching trains who are unresponsive to current warnings
  3. Transport Safety Victoria and VicRoads commit to joint sophisticated human factors research and innovative technology to alert drivers who otherwise will not notice approaching trains
  4. 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
  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 performing in-house maintenance
  7. National Heavy Vehicle Regulator ensure Code of Practice requires mechanics have access to and comply with manufacturers' maintenance instructions
  8. Transport Safety Victoria investigate directed sounds from horns and sirens to increase locomotive conspicuity
  9. Transport Safety Victoria, Public Transport Victoria and VicRoads extend development and evaluation of level crossing countermeasures with specific reference to capacity to alert drivers to approaching trains
  10. Standards Australia review AS1742.7-2007 to include advice on left turn slip lanes at side road crossings 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 and level crossing upgrades
  13. Transport Safety Victoria cooperate with National Rail Safety Regulator in establishing system for root cause analyses of fatal level crossing collisions
  14. Transport Safety Victoria improve accuracy and relevance of data used in predictive risk analysis for level crossing upgrades
  15. Australian Transport Safety Bureau through Transport Safety Victoria continue systematic analysis procedures for fatal rail incidents
  16. Transport Safety Director maintain and improve comprehensive reliable database of level crossing incidents in Victoria
  17. VicTrack, VicRoads, Transport Safety Victoria and rail operators implement innovative in-vehicle warning systems for road vehicle drivers
  18. Ambulance Victoria and Air Ambulance Victoria carefully consider tension pneumothorax risks when triaging trauma patients for fixed wing air transfer without Mobile Intensive Care support
  19. V/Line provide train drivers and conductors with formal instruction and scenario practice for Interim Site Controller role
  20. V/Line provide equipment, formal instruction and scenario practice for 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 injuries
  22. V/Line provide tools and gloves on regional trains for removing seats and freeing trapped passengers
  23. Victoria Police ensure Incident Commanders aware of importance of including all support organisations in Emergency Management Team
  24. V/Line review management arrangements to ensure trained Rail Incident Controllers accessible to all regional level crossings
  25. V/Line involve train crews and management in local desktop and scenario emergency service training
Full text
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