Attachment a

Contributing factors

• Drivers familiar with level crossings did not expect trains despite active warning systems
• Flashing light warning systems ineffective for experienced drivers on routine journeys
• Train visibility obscured by roadside vegetation at critical approach distance
• Insufficient stopping distance (131 metres required but not always available)
• Heavy vehicle approach speeds (100 kph) exceeding safe braking capability
• Semi-trailer brake maintenance deficiencies (worn linings, excessive push rod extensions)
• Light sources designed for car driver eye height ineffective for truck driver sightlines
• Failure to escalate patient triage to appropriate regional trauma centre
• Air ambulance transfer without Mobile Intensive Care paramedic support despite high-risk condition
• Emergency response communication fragmentation across multiple agencies

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 drivers unresponsive to current warning signs
3. Transport Safety Victoria and VicRoads conduct 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 train visibility at least 131 metres before level crossing, more on 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 requires mechanics have access to and comply with manufacturers' maintenance instructions
8. Transport Safety Victoria investigate factors influencing drivers' capacity to hear train horns and develop improved horn design
9. Transport Safety Victoria and VicRoads extend development and evaluation of new level crossing countermeasures with reference to capacity to alert drivers
10. Standards Australia review Australian Standard AS1742.7-2007 regarding left turn slip lanes and LED specifications
11. Standards Australia implement schedule of more frequent routine reviews of Australian Standard AS1742.7-2007
12. Transport Safety Victoria and VicRoads establish formal cooperative arrangements for sharing information on predictive risk assessment and innovative warning systems
13. Transport Safety Victoria cooperate with National Rail Safety Regulator in establishing system for undertaking and analysing root cause analyses for fatal 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 continue applying systematic analysis procedures in analysis of fatal rail incidents
16. Transport Safety Victoria maintain and improve comprehensive reliable database of all level crossing incidents in Victoria
17. Transport Safety Victoria and VicRoads commit to joint human factors research and innovative technology to alert drivers unresponsive to existing warnings
18. VicTrack, VicRoads, Transport Safety Victoria and rail operators cooperate to implement innovative in-vehicle warning systems
19. Ambulance Victoria and Air Ambulance Victoria carefully consider risks of tension pneumothorax when triaging trauma patients for fixed-wing aircraft transfer without Mobile Intensive Care support
20. V/Line provide train drivers and conductors with formal instruction and scenario practice in their role as Interim Site Controllers
21. V/Line provide equipment, formal instruction and scenario practice events for all trained conductors to assist in Interim Site Control duties
22. V/Line provide first aid supplies on all regional trains including blankets and bandages appropriate for major emergencies
23. V/Line provide tools and gloves on all regional trains for removing seats and freeing passengers trapped in debris
24. Victoria Police ensure Incident Commanders include representatives of all support organisations in Emergency Management Team
25. V/Line review management arrangements to ensure trained V/Line Rail Incident Controllers available at all regional level crossings
26. V/Line involve train crews and management in local desktop and scenario emergency service training to identify communication deficiencies