Finding into death of Matthew John Stubbs

Contributing factors

• driver failure to respond to level crossing warnings
• familiarity with level crossing
• lack of expectation of train
• inadequate flashing light conspicuity for truck drivers
• incandescent lights not upgraded to LEDs
• vehicle brake inadequately maintained
• collision speed and energy transfer

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 will not notice approaching trains
4. VicRoads and Standards Australia amend standards to require warning signs and visibility of trains at least 131 metres before level crossing for heavy vehicle drivers
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 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 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 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. 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 upgrade prioritisation
13. Transport Safety Victoria cooperate with National Rail Safety Regulator in establishing root cause analysis system 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 trial root cause analysis procedures in systematic analysis of rail incidents
16. Transport Safety Director maintain and improve comprehensive reliable database of all level crossing incidents
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 events to understand role as Interim Site Controllers
20. V/Line provide same equipment, formal instruction and scenario practice events for all trained conductors 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 V/Line Rail Incident Controllers accessible to all regional level crossings
25. V/Line involve train crews and management staff in local desktop and scenario emergency service training