Welburn, Dale Robert and McPherson, Kerri Leigh

OFFICE OF THE STATE CORONER FINDINGS OF INQUEST CITATION: Inquest into the deaths of Dale Robert Welburn and Kerri Leigh McPherson TITLE OF COURT: Coroner’s Court JURISDICTION: Bundaberg FILE NO(s): 2007/82 & 83 DELIVERED ON: 21 May 2010 DELIVERED AT: Bundaberg HEARING DATE(s): 9 December 2009 FINDINGS OF: Jennifer Batts, Coroner CATCHWORDS: CORONERS: Inquest – multi vehicle road accident, Bruce Highway near Childers, driver error, poor visibility, poor road design

REPRESENTATION: Counsel Assisting Sergeant BJ Stevens

The Coroners Act 2003 provides in s45 that when an inquest is held, the coroner’s written findings must be given to the family of the person who died, each of the persons or organisations granted leave to appear at the inquest and to various specified officials with responsibility for the justice system. These are my findings in relation to the deaths of Dale Robert Welburn and Kerri Leigh McPherson. They will be distributed in accordance with the requirements of the Act and posted on the web site of the Office of State Coroner.

Between 4:00pm and 4:20pm on 27th August 2007 a traffic accident involving three vehicles occurred at the intersection of the Bruce Highway and Lucketts Road, about 2 kilometres south of Childers.

As a result of the collision Dale Robert Welburn and Kerri Leigh McPherson both aged 29 years died instantly. Three others were seriously injured. One person was uninjured.

Queensland Ambulance Service and Queensland Fire and Rescue Service attended, as did members of the Queensland Police Service. The first officer to attend the scene was Constable Alfred Allan Philipp then of Childers Police.

He noted in his report to the Coroner the following: that at the time of the accident the weather was fine and clear, the road surface, which is sealed, was dry and clean and traffic in both directions was moderate. Further at the time of the crash, "the actual crash site roadway is two lanes (one in each direction) and there is a continuous double white line dividing the two lanes. The Bruce Highway has a passing lane to the left which can be used to get around vehicles that have stopped to turn right at Lucketts Road".

Later mechanical inspections of the vehicles involved revealed that no defects of any vehicle played a part in the crash. Neither speed nor alcohol contributed to the crash.

The accident occurred as the vehicle driven by Mr Welburn, a Holden Statesman was travelling north on the Bruce Highway. Occupants of that vehicle were returning home to Rockhampton from Brisbane. Ms McPherson was the front seat passenger of that vehicle. Their vehicle came up behind a stopped Ford Laser waiting to turn right into Lucketts Road. Mr Welburn attempted to pass the Ford Laser on the right hand side but clipped it at the driver's side rear corner, veering onto the wrong side of the road and colliding with a Subaru Station Wagon travelling south.

The point of impact was the driver's side of the Holden Statesman that vehicle being "T-boned", as it is known, by the Subaru vehicle. It seems more likely than not that Mr Welburn was attempting to return to the correct lane and this caused the vehicle to veer and for him to lose control of it.

As I am required pursuant to the provision of the Coroners Act 2003 I make these formal findings: Findings of the inquest into the deaths of Dale Robert Welburn and Kerri Leigh McPherson 1

Identity of the deceased - The deceased persons were Dale Robert Welburn and Kerri Leigh McPherson.

How they died - a traffic accident involving three vehicles.

Place of death - At the intersection of the Bruce Highway and Lucketts Road, about 2 kilometres south of Childers.

Date of death - 27 August 2007.

Cause of death - Dale Robert Welburn 1(a) Haemorrhage due to 1(b) Ruptured Aorta and Severe Leg Injuries due to 1(c) Motor Vehicle Accident – Driver Kerri Leigh McPherson 1(a) Haemorrhage due to 1(b) Chest and Abdominal Injuries due to 1(c) Motor Vehicle Accident - passenger Three factors are identified to have contributed to the cause of the crash in the report of Constable Alfred Allan Philipp namely, driver error, poor visibility and poor road design.

In relation to driver error: “The deceased driver of the Holden Statesman attempted to pass the stopped Ford Laser on the incorrect side contrary to the road markings on the road at that time and the road feature given that it was at a T intersection. The road markings leading up to the stopped Ford Laser were a continuous white line left side of a broken white line leading up to the intersection and a continuous double white line after the intersection. Overtaking or crossing these lines whilst northbound is prohibited.

It may be the deceased driver came up to the Ford Laser with little time to pass safely to the left and veered right as an ”instinctive overtaking reaction”.

In relation to poor visibility: Findings of the inquest into the deaths of Dale Robert Welburn and Kerri Leigh McPherson 2

At the time of the crash, the sun is not at its lowest point on the horizon nor directly in the faces of northbound traffic. However, the sun’s rays do begin to take effect on visibility at this time of day creating shadowing, diminishing colour differentiation and glare.

Witness Michael Stanton states the sun was in his eyes when he was travelling north towards the accident scene.

Constable Philips went back at the same time the next day and concluded that the sun did very likely contribute to the crash..

In relation to poor road design: “Bruce Highway - Lucketts Road intersection is a popular “short-cut” used by Bundaberg road users travelling from Bundaberg via Goodwood Road to Hervey Bay or Brisbane and return. The intersection is more popular than ever since the recent upgrade of Goodwood Road.. Lucketts Road also houses popular tourist destinations known as ‘Mammino Icecream’ and ‘Snakes Downunder’.

The northbound passing lane on the Bruce Highway was (at time of the incident) a widened section of road enabling vehicles to pass to the left side of stopped traffic at Lucketts Road intersection. This passing lane was poorly delineated and often catches northbound traffic by surprise due to the stopped traffic being in the main northbound lane with no dedicated turn-right lane markings. In other words, northbound traffic is merrily travelling on a long flat straight section of road at 100 kilometres per hour and all of a sudden a vehicle slows or is stopped in the main lane intending to turn right into Lucketts Road.” The Inquest heard evidence from Constable Philipp and Lance Ronald Christiansen, Manager Corridor Management and Operations, a civil engineer by training employed by Queensland Transport and Main Roads whose responsibility includes considering recommendations that arise as a result of fatal crashes. Whilst several options were canvassed in relation to further improvement of the area where this crash occurred, realistically, only two options were considered by witnesses to be reasonably open and they were closing the road entirely or making it “left-in, left-out” the latter more fully discussed later in these findings.

The present arrangement, instituted very soon after the crash as a result of Police engaging with Transport and Main Roads and other stakeholders, allows a dedicated right hand turn lane for north-bound traffic. No incidents have been reported at this intersection since that alteration was made to the road.

Findings of the inquest into the deaths of Dale Robert Welburn and Kerri Leigh McPherson 3

Whilst this improvement has been made it was only ever seen as a temporary measure by the Investigating Officer and Department of Transport and Main Roads.

It is the obligation of any coroner to consider whether there is any prospect of making recommendations that would reduce the likelihood of similar deaths occurring in future or otherwise contribute to public health and safety. I consider it appropriate that I do so as it is clear on all of the evidence before me that the road design is still poor, the potential for accidents to occur due to the road design still exists and so the community is still at risk.

The Bundaberg regional Council was given notice of this Inquest. They did not seek to appear. The Inquest may have been assisted by submissions from the Council although considering the very comprehensive report of Constable Philips and the weight of the evidence from Mr Christiansen which is considerable, the following recommendation is strongly made.

It is the recommendation of this court that the relevant intersection be subject to a “left-in, left-out” arrangement. Accordingly, vehicles travelling south would be able to turn left from the Bruce Highway onto Lucketts Road or from Lucketts Road south onto the Bruce Highway. Northbound vehicles would not be able to turn right into Lucketts Road but would have the option of continuing through Childers or taking the next available right hand turn if they needed to access the two businesses referred to or Goodwood Road. This would dramatically decrease traffic turning at that intersection onto Lucketts Road (the evidence presented suggesting by half) thus decreasing risk for road users.

I thank the officer assisting me.

Finally, to the families of Dale and Kerri may I extend my sincere sympathy.

I close this inquest.

Jennifer Batts Coroner Bundaberg 21 May 2010 Findings of the inquest into the deaths of Dale Robert Welburn and Kerri Leigh McPherson 4