Finding into death of Geoffrey Ian McMonnies

Contributing factors

• driver failure to perceive flashing red lights at level crossing
• driver not expecting train despite familiarity with crossing
• inadequate maintenance of truck brakes
• insufficient sighting distance for heavy vehicle drivers
• level crossing infrastructure focused on car drivers not truck drivers
• driver familiarity with level crossing contributing to inattention
• delayed recognition of collision severity by emergency services
• over-triage and over-deployment of air ambulance resources

Coroner's recommendations

1. That Transport Safety Victoria, Public Transport Victoria, and VicRoads adopt a systematic approach to collecting routine detailed human factors information about level crossing collisions.
2. That 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 the current suite of level crossing warning signs.
3. That 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 otherwise not notice an approaching train in the context of current level crossing warnings.
4. That VicRoads and Standards Australia amend their standards to require warning signs and visibility of the train to heavy vehicle combination drivers when they are at least 131 metres before the level crossing, more on B double and B-triple combination routes.
5. That the National Heavy Vehicle Regulator amend their Code of Practice to require inspection of brake pads and push rod extensions weekly or fortnightly.
6. That the National Heavy Vehicle Regulator ensure that the National Heavy Vehicle Accreditation Scheme is expanded to include all Victorian heavy vehicle operators who perform their own maintenance in-house.
7. That the National Heavy Vehicle Regulator ensure that the Code of Practice adopted by the National Heavy Vehicle Accreditation Scheme also ensures that mechanics performing maintenance work on heavy vehicles have access to and comply with manufacturers' maintenance instructions.
8. That Transport Safety Victoria and Public Transport Victoria investigate the way in which directed sounds from horns and sirens can be used to increase the conspicuity of locomotives in regional areas and increase the likelihood of road vehicle drivers' awareness of an approaching train.
9. That Transport Safety Victoria, Public Transport Victoria and VicRoads extend their development and evaluation of new level crossing countermeasures with specific reference to the countermeasure's capacity to alert road vehicle drivers to the presence of an approaching train.
10. That Standards Australia review Australian Standard AS1742.7-2007 to include advice in relation to left turn slip lanes where level crossings are on side roads and specifications for light emitting diodes (LEDs) in flashing red light infrastructure.
11. That Standards Australia implement a schedule of more frequent routine reviews of Australian Standard AS1742.7-2007 for currency and compatibility with new infrastructure and technology.
12. That Transport Safety Victoria, Public Transport Victoria and VicRoads establish formal cooperative arrangements in relation to sharing of information required for predictive risk assessment of level crossings, prioritisation of level crossing upgrades and development of innovative train warning systems.
13. That Transport Safety Victoria cooperate with the National Rail Safety Regulator in establishing a system for undertaking and analysing the results of root cause analyses for fatal level crossing collisions to better inform improvements in level crossing infrastructure and level crossing safety.
14. That Transport Safety Victoria and Public Transport Victoria improve the accuracy, content and relevance of data used in predictive risk analysis used to inform decisions about upgrading of level crossings in Victoria.
15. That the Australian Transport Safety Bureau, through the Transport Safety Victoria, continue to apply the systematic analysis procedures in their analysis of fatal rail incidents.
16. That the Transport Safety Director continue to maintain and improve a comprehensive reliable data base of all level crossing incidents that occur in Victoria.
17. That VicTrack, VicRoads, Transport Safety Victoria and rail operators cooperate with each other to implement innovative in-vehicle warning systems as the next stage of warning road vehicle drivers who fail to respond to existing level crossing paraphernalia that a train is approaching.
18. That Ambulance Victoria and Air Ambulance Victoria carefully consider the risks of tension pneumothorax when triaging trauma patients for transfer by fixed wing aircraft without Mobile Intensive Care Ambulance support.
19. That V/Line provide train drivers and conductors with formal instruction and scenario practice events to ensure they understand their role as Interim Site Controllers.
20. That V/Line provide the same with equipment, formal instruction and scenario practice events for all trained conductors to enable them to assist the train driver and the conductor in their Interim Site Control duties.
21. That V/Line provide first aid supplies on all regional trains including blankets and bandages appropriate for use in major emergencies.
22. That V/Line provide tools and gloves on all regional trains adequate for removing seats and freeing of passengers trapped in the debris in a major collision involving a heavy vehicle combination.
23. That Victoria Police ensure that Incident Commanders and Emergency Management Coordinators are aware of the importance of including representatives of all the support organisations involved in the emergency response in the Emergency Management Team.
24. That V/Line review their management arrangements to ensure that trained V/Line Rail Incident Controllers are within access to all level crossings in regional Victoria in a timely manner to support train crews and Victoria Police in the case of an emergency.
25. That V/Line involve their train crews and management staff in local desk top and scenario emergency service training so that inadequacies in communication and management can be identified and corrected.