Finding into death of Rosanne Eve McMonnies

Contributing factors

• Driver failed to see flashing red warning lights at level crossing
• Driver not expecting a train despite being familiar with crossing
• Red-filtered incandescent lights had poor conspicuity for truck drivers (focused on car driver eye height)
• Train horn ineffective at alerting driver
• Heavy vehicle driver's familiarity with crossing led to inattention
• Inadequate stopping distance available (only 0.5 seconds to respond after seeing train)
• Unroadworthy heavy vehicle brakes (excessive push rod travel)
• Inadequate brake inspection frequency (3-monthly vs manufacturer recommendation of 4-weekly)
• Right-hand curve obscured driver's view of approaching train until too late
• Maintenance of level crossing lights deficient during transition of rail operator responsibilities (Pacific National to V/Line)
• Inadequate emergency response coordination and communication
• Inappropriate transfer of trauma patient by fixed-wing aircraft without paramedic support

Coroner's recommendations

1. Transport Safety Victoria, Public Transport Victoria and VicRoads adopt systematic approach to collecting detailed human factors information about level crossing collisions
2. Transport Safety Victoria and VicRoads investigate and implement new level crossing infrastructure designed to alert drivers unresponsive to current warning signs
3. Transport Safety Victoria and VicRoads undertake sophisticated human factors research and innovative technology development for driver alerting systems
4. VicRoads and Standards Australia amend standards to require warning signs and train visibility at least 131 metres before level crossing, more for B-double and B-triple routes
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 ensures mechanics have access to and comply with manufacturer 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 new level crossing countermeasures with specific reference to alerting drivers to approaching trains
10. Standards Australia review AS1742.7-2007 regarding left turn slip lanes at side road crossings and LED specifications
11. Standards Australia implement more frequent routine reviews of AS1742.7-2007
12. Transport Safety Victoria and VicRoads establish formal cooperative arrangements for predictive risk assessment and innovative train warning systems
13. Transport Safety Victoria cooperate with National Rail Safety Regulator establishing root cause analysis system for fatal level crossing collisions
14. Transport Safety Victoria improve accuracy, content and relevance of data 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
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 for their role as Interim Site Controllers
20. V/Line provide equipment, formal instruction and scenario practice 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 for major emergencies
22. V/Line provide tools and gloves on all 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 to ensure trained Rail Incident Controllers available at level crossings in timely manner
25. V/Line involve train crews and management staff in local desktop and scenario emergency service training