A 30-year-old male motorcyclist died from head and neck injuries sustained in a motorcycle incident on the Western Ring Road on-ramp on 26 July 2018. The coroner found that a water leak from a fire hydrant on VicRoads-owned infrastructure created a wet patch on the road surface. This wet patch, combined with poorly prepared road markings (black-painted lines without adequate abrasive material) that eliminated macro and micro texture, resulted in loss of traction when the motorcycle crossed the painted line. The coroner identified significant system failures: a water leak was reported to Greater Western Water in May 2018 but remained unrepaired for approximately 2.5 months due to delays in identifying the correct VicRoads contact person, poor inter-agency communication, and lack of documented asset ownership protocols. While not entirely preventable, the death may have been mitigated if the water leak had been addressed promptly and road markings properly prepared.
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Specialties
forensic medicine
Error types
systemcommunicationdelay
Contributing factors
Water leak from fire hydrant on road surface
Poor road surface conditions at collision location
Road markings prepared inadequately - black paint without abrasive material reducing surface friction
Delay in identifying asset ownership (fire hydrant owned by VicRoads)
Lack of documented contact procedures between Greater Western Water and VicRoads
Inter-agency communication failures
Water leak reported in May 2018 but not repaired until 26 July 2018
Section of road surface without macro and micro texture due to black paint application
Coroner's recommendations
That the Department of Transport and Planning consider working with all water authorities in Victoria to establish a shared asset register to expedite communication in relation to asset management and maintenance
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