Finding into death of Danielle Louise Meredith

Contributing factors

• Level crossing warning lights not visible to/noticed by heavy vehicle driver despite activation
• Flashing red incandescent lights focused at car driver eye height, not elevated truck driver perspective
• Driver familiarity with crossing reducing expectation of train
• Unroadworthy trailer brakes with worn linings not replaced prior to incident
• Inadequate brake inspection and maintenance procedures at transport company
• Driver unable to stop in time (90 metres away when train became visible, requiring 131 metres minimum stopping distance)
• Speed limit of 100 kph on approach to crossing insufficient reaction time
• Curve 165 metres before crossing obscuring view, allowing only 0.5 seconds to respond
• Train horn ineffective at alerting driver due to inadequate sound characteristics
• Lack of boom gates at level crossing

Coroner's recommendations

1. Adopt systematic approach to collecting routine detailed human factors information about level crossing collisions to better understand driver behaviour and awareness failures
2. Investigate and implement new level crossing infrastructure designed to alert drivers unfamiliar with current warnings to approaching trains
3. Commit to joint sophisticated human factors research and innovative technology with specific focus on alerting drivers unable to respond to current level crossing infrastructure
4. Amend standards to require warning signs and train visibility at least 131 metres before level crossing for heavy vehicle drivers, accounting for their elevated eye position and stopping distances
5. Require National Heavy Vehicle Regulator to amend Code of Practice for weekly or fortnightly inspection of brake pads and push rod extensions on trailers
6. Expand National Heavy Vehicle Accreditation Scheme to include all Victorian heavy vehicle operators performing in-house maintenance
7. Ensure Code of Practice requires mechanics performing heavy vehicle maintenance have access to and comply with manufacturers' maintenance instructions
8. Investigate directed sounds from horns and sirens to increase conspicuity of locomotives and likelihood of road vehicle driver awareness
9. Extend development and evaluation of level crossing countermeasures with specific reference to alerting drivers to presence of approaching trains
10. Standards Australia to review AS1742.7-2007 regarding left-turn slip lanes at side road crossings and LED specifications in flashing red light infrastructure
11. Standards Australia implement more frequent routine reviews of AS1742.7-2007 for currency and compatibility with new infrastructure and technology
12. Transport Safety Victoria and VicRoads establish formal cooperative arrangements for sharing information on predictive risk assessment, prioritisation of upgrades and innovative warning systems
13. Transport Safety Victoria cooperate with National Rail Safety Regulator in establishing system for root cause analyses of fatal level crossing collisions
14. Improve accuracy, content and relevance of traffic count data used in predictive risk analysis for level crossing upgrade decisions
15. Australian Transport Safety Bureau continue systematic analysis procedures with multi-factorial understanding of contributing factors in rail incidents
16. Transport Safety Director 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 as next stage for warning drivers failing to respond to existing infrastructure
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 to understand their role as Interim Site Controllers
20. V/Line provide trained conductors with equipment, formal instruction and scenario practice to assist in Interim Site Control duties
21. V/Line provide first aid supplies on all regional trains including blankets and bandages appropriate for major emergencies
22. V/Line provide tools and gloves on all regional trains adequate for removing seats and freeing passengers trapped in debris
23. Victoria Police ensure Incident Commanders and Emergency Management Coordinators include representatives of all support organisations in Emergency Management Team
24. V/Line review management arrangements to ensure trained Rail Incident Controllers are within accessible distance to all level crossings in regional Victoria
25. V/Line involve train crews and management staff in local desktop and scenario emergency service training to identify communication and management inadequacies