Deceased
Sabrina Michelle Brady; Madison Lee Dobie; Justin Ross Pomery
Demographics
19y, female
Coroner
Coroner Heather Spooner
Date of death
2009-04-16
Finding date
2011-03-30
Cause of death
Mechanical asphyxia due to crush injuries sustained under coach rollover; pregnancy contributed to restriction of breathing
AI-generated summary
On 16 April 2009, a V-Line coach rolled over on the Princes Highway near Heathmere, Victoria, killing three occupants: Sabrina Brady (19 years, 7 months pregnant), her daughter Madison Dobie, and Justin Pomery. The coach lost control while navigating a right-hand bend in wet conditions. The coroner found the primary cause was the poor road surface condition—marked by severe bleeding, polishing, and deep rutting with water pooling—which reduced friction well below recommended levels. While road surface was the dominant factor, none of the three fatalities were wearing seatbelts despite them being available. The coroner found that seatbelts could potentially have prevented deaths or reduced injuries. Key preventable factors included: VicRoads' inadequate road maintenance and hazard management systems; failure to implement water blasting recommended years earlier despite prior fatalities at the same location; and poor seatbelt compliance culture on buses, with drivers inconsistently promoting use and passengers perceiving buses as inherently safe. The coroner noted the bus was mechanically sound, the driver was not at fault, and the defect notice system had communication gaps but was not primary to this incident.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Error types
Court Reference: 2038/09
FORM 37 Rule 60(1)
FINDING INTO DEATH WITH IN QUEST Section 67 of the Coroners Act 2008 Inquest into the Death of SABRINA MICHELLE BRADY Delivered On: 30 March 2011
Delivered At: Coroners Court, Level 11,
222 Exhibition Street, Melbourne
Hearing Dates: 2 August 2010 — Directions Hearing 6, 7 and 8 October 2010 and 6, 7, 8, 9 and 10 December 2010
Findings of: : Coroner Heather Spooner
Place of death/Suspected Princess Highway, Heathmere, Victoria 3305 death: : .8
PCSU: Leading Senior Constable Remo Antolini Representation: Ms 8 Hinchley for VicRoads and
The Department of Transport
Mr T Keely for Warrnambool Bus Lines Mr J Atkins for Mr Maxwell Shayler Mr Rattray for Iveco
1 of 35
Court Reference: 2038/09
FORM 37 Rule 60(1)
FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 In the Coroners Court of Victoria at Melbourne
| Heather Spooner Coroner having investigated the death of:
Details of deceased:
Surname: BRADY First name: SABRINA Address: 1 [awong Diive, Mount Gambier, South Australia 5291
AND haying held an inquest in relation to this death on 6, 7 and 8 October
2010, 6, 7, 8, 9 and 10 December 2010 and 30 March 2011 at Melbourne
Find: that the identity of the deceased was Sabrina Michelle Brady And: that the death occurred on 16" April, 2009 At: Princess Highway, Heathmere, Victoria 3305
From: la, MECHANICAL ASPHYXIA
lb. MOTOR VEHICLE ACCIDENT (BUS)
In the following circumstances:
Date and Place of Death
2 of 35
Circumstances Surrounding Death
The road surface was in poor condition, The posted speed was 100kph and a VicRoads advisory sign located approximately 700 metres south warned of slippery
conditions when wet.
departed Portland.
4, On this fateful evening, the coach entered a sweeping right hand bend and Mr Shayler lost tiaction/control as it travelled in a straight line onto the opposite south bound lane. Mr Donald Marshall who was driving his Toyota Hilux in a southerly direction on the Princes Highway, saw lights and a large mass coming toward him.
Mr Shayler also saw Mr Marshaill’s vehicle and in an attempt to regain control and avoid the oncoming traffic, he oversteered the coach to the left. Mr Marshall also moved to his far left and heard a ‘whoosh’ as the coach “passed close by. Mrs Marshall who was travelling behind her husband saw it pass within centimetres of his vehicle. The coach rotated and rolled over, leaving the bitumen road surface and landing on the driver’s (off) side. It eventually came to rest on a grassy culvert on the
left western side of the highway.
to the left of her mother. Mr Pomery sat a few rows forward in a window seat on the
drivers (off) side of the coach. During the rollover, five passengers were ejected or
3 of 35
partially ejected from the coach. Ms Brady who was seven months pregnant, her
young daughter Madison and Mr Pomery, all sustained fatal injuries.
wore lap sash seatbelts as required.
Portland Hospital with minor injuries.
restriction signs were erected soon after the coach incident.
Issues at Inquest
failure of passengers to comply with seatbelt legislation and measures to improve this
low compliance rate.
Investigations
Carnie. He prepared an extensive coronial brief and organised two site visits on 28
July and 8 October 2010, with the support of local Portland police members.
4 of 35
Investigator (OCI report)! also became available.
12, This finding does not summarise all the extremely detailed investigations and
reports but is based on the material and the evidence at inquest.
The Roadway and Incident Inspection
contributing factor to the incident.
14, Sergeant Carnie in his summary described the roadway and rural setting of the
Princes Highway at Heathmere where the incident occurred:
“Ht is defined as a road related area under the Road Safety Act and has a restricted speed limit of 100 km/h. The Princes Highway lies in a general north/south direction, At the location of the collision there is provision for one lane of traffic in each direction. These lanes are divided by a double solid white centre lines with tactile strips. For vehicles travelling in a northerly direction
on approach to the collision scene they enter a sweeping right hand curve.
The south bound lane is defined to the east by a single white fog line with tactile strips. There is a bitumen shoulder to the east of this fog line which abuts onto a grass reservation with small shrubs growing on it. To the east of this grass reservation is farming land. The south bound lane is approximately 3.5 metres
in width,
' www. transport. vic.gov.au... http://www. transport. vic.gov.au/chiefinvestigator Since the Coroners Act 2008 became operational, access-to the coronial file may be sought pursuant to section 115 of the Act ‘
5 of 35
The northbound lane is defined to the west hy a single white fog line with tactile strips. There is a bitumen shoulder to the west of this fog line. At the bitumen edge is a “W" steel barrier, which follows the full length of the right hand curve. There are a number of large shrubs and trees growing to west of this barrier, This barrier commences to the north of a turn out road which allows access to farming properties and a bus stop, This turn out road is located to the south of the right curve and to the west of the bitumen surface. “It is approximately 400 metres in length and runs parallel to the highway before reJoining the highway to the north of the collision scene, Af the collision scene there is a large grassed area and culvert between the north bound lane and the
turnout lane, The northbound lane is approximately 3.8 metres in width.
the Princes Highway is constructed of a bituminous substance. When police investigators examined the road surface they formed the opinion that it was in
poor condition.
There were three different surfaces with a high variation in skid resistance within a small area near the collision scene. Approximately 28 metres south of where the coach left the road, the read surface in the north bound lane changed significantly. The section most northerly in the north bound lane was in relatively good condition and appeared to have been recently resurfaced, The south end section of the north bound lane had suffered extensive bleeding with large and plentiful areas of polished road surface. The south bound lanes displayed a different road surface. Although it did not appear to have been recently resurfaced the south bound lane was in better condition than the north bound lane, Within the right curve prior to the collision scene and in the straight approaching the scene in the north bound lane, deep ruts were evident in a number of areas, The maximum rut depth was measured at 36.0mm. These
ruts displayed large areas of water pooling.
An examination of the scene located a number of tyre scuff marks. The marks commenced on the bitumen in the south bound lane and continued back across the north bound lane and onto the bitumen shoulder of the west side of the road.
‘these tyre scuff marks were in the form of yaw marks and curved to the left.
6 of 35
These yaw marks led to the continuation of a series of tyre marks leading into the grassed culvert. The yaw marks are consistent with the coach being over steered to the left. The marks then cease but lead to the point of impact between the coach and the embankment on the west side of the culvert, It was evident from the cessation of these marks that the bus became airborne across the culvert, North of the yaw mark in the north bound lane and west bitumen Shoulder are three significant gouges. Measurements of these gouges are consistent with the pillars at the roofline of the coach. The gouges are consistent with having been caused by the impact between the coach and the road during roll over. The three marks were the result of impact with the road and the rear corner at the roofline, the pillar dividing the sixth and sevenths windows of the coach at the roofline and the pillar dividing the fifth and sixth windows of the bus at the roafline all on the driver side. These gouges led to Jurther gouges and scrapes leading from the north bound lane, across the west bitumen and gravel shoulder and into the grassed culvert to the resi position of the coach, These scrapes and gouges are consistent with the coach having rolled onto the driver side and then continuing to slide on the driver side whilst rotating in an anti clockwise direction. On the west side of the grass culvert were two areas of significant gouging in the dirt. These gouges are consistent with having been caused by the initial impact of the front driver side corner of the coach after being airborne and then the secondary impact with the front
driver side corner roofline during roll over.
A reconstruction of the collision revealed the coach would have been travelling between a minimum speed of 55 km/h and a maximum speed of 73 km/h when it
was oversteered to the left.”
1S. Senior Constable Mehegan agreed in evidence at the inquest that it was difficult to know whether or not the first loss of control by Mr Shayler was due to road surface conditions or bus handling or a combination of both. . In her statement
she indicated:
7 of 35
“The driver of the vehicle negotiated a right curve before the vehicle has crossed onto the incorrect side of the road for an unknown reason. The driver of the coach has then responded by inputting a severe left steering manoeuvre causing the vehicle to commence to yaw. The coach has rotated in an anticlockwise direction about its vertical axis while sliding back onto the correct side of the road. The coach had rotated about 90° and was being led by the driver side of the vehicle when the front of the vehicle left the bitumen road surface to the west. The front of the coach became airborne for about 7.0 metres across a deep culvert. As the front driver side of the coach impacted with the embankment on the west side of the culvert the coach rolled onto the driver side and commenced to slide. The front of the coach dug into the culvert whilst the rear of the bus continued to rotate around in an anti clockwise direction. The coach remained on its driver side as it continued across the grassed culvert. The vehicle came to rest on the driver side on the west side of
the culvert after having rotated 180°.
Al the time of the collision the road was in poor condition with severe bleeding, polishing and rutting. Both the bleeding and polishing can result in reduced friction. The severe rutting and water pooling can lead to aquaplaning. While it is not possible to determine ‘whether the loss of control was caused by a reduced friction or aquaplaning it is highly likely that it was one of these
factors.”
The skid resistance level was calculated at well below the recommended level
of VicRoads.
Post Crash Incidents
On the morning of 20 April 2009, a few days after the crash, Acting Sergeant
Hetherington attended the scene. He saw that the speed limit for the location had
reverted to 80kp/h, noted the poor road surface and ‘.observed traffic travelling north
around the bend and noted that heavy vehicles tended to move about as they drove
down around the bend. Watching the top of the trailers, on B doubles, they would
8 of 35
move up and down and pitch to the left. As the A trailer pitched to the left the B
trailer would remain straight then also pitch and roll to the left.’
tipping over past the right hand side of the roadway.
19, Constable Apps and Senior Constable Handley, attended the scene and
observed other trucks also having difficulty driving on the roadway surface.
The Coach Driver
20, Mr Shayler was aged 57 years. He was an experienced driver and had been
employed by South Western Roadways trading as Warrnambool Bus Lines (WBL), for approximately two years. [He routinely drove the coach and route where the
incident occurred.
may have caused or contributed to the collision.
oncoming traffic.
9 of 35
23, A passenger described Mr Shayler as a top class driver however, others
thought he may have been going a bit fast for the conditions.
73kp/h.
25, Leading Senior Constable Finnegan told the inquest that during a conversation with Mr Shayler at the scene, he asked what happened and Mr Shayler replied with
words to the effect of:
“I was coming from Portland to Heywood, coming around the corner, I was doing 100, the rain was easing when the back of the bus started sliding. I was heading towards oncoming traffic and then I think I overcorrected. The bus
overturned and slid over the road.”
stated:
“Just to clarify.
Alright, Pretty well I w-, I went straight out of ~ out of town, I didn’t make any announcements because the people that were on had already been on, so I didn’t see any need to make any announcements. I headed through Bolwarra.
It was dark and I was using my high beam on and off. The roads were still a little bit wet, but besides using my — my wipers, I think just before Portland I ~T don't remember using them on that road, Maybe — if it — they just gol a bit damp, [ might've just flicked them on intermittent, but they weren’t on, going all
the time.
Continuously, yeah,
10 of 35
through Bolwarra. No— no problems. Slowed down there, and then pickéd up the speed again, until I came to the — the ~ the truck stop — what 1 call the truck stop, and that’s a — a — a curve to the — it curves to the — to the right, and then curves to the - to the lefi. It’s a slow curve. Idon'!- I don’t know what speed I was doing, but I would have thought that I probably would’ve backed it off a little bit. So — because I wasn’t looking, I was concentrating on the road, . I wou-, I would’ve maybe backed it off to 90, but I- I can’t ~ because I wasn't looking at it I don’t know. I got to —I did the — the — the right-hand curve fine.
When I went to take it back to the — to the left, it didn’t — it didn’t go. It just wouldn't, lt went straight ahead, the — the bus physically just went — slid or whatever straight ahead. There was oncoming traffic. ‘There was two cars
coming. I know the first one was a four wheel drive,”
27, Sergeant Carnie told the Inquest he had no reason to dispute Mr Shayler’s evidence to the effect that he may have taken his foot off the pedal as he entered the
sweeping bend and slowed to 90kp/h.
28, When Sergeant Carnie was asked whether Mr Shayler may have entered the bend too fast, he noted that with the benefit of hindsight it could be suggested, although the average driver would not agree. According to Sergeant Carnie, Mr Shayler was familiar with the area and would be expected to tate some caution going into the road curvature, however, dropping his speed to 60kph, 70kph or 90kph as was the case here, may be sufficient. He added that any driver who had concerns about the performance of the coach and the road and wet weather conditions would have
taken added caution as to the way the coach was driven.
traffic coming from the opposite direction.
11 of 35
Coach Drivers Concerns
conditions with bus 38.
improve stability,
32, Mr Balmer recalled an incident earlier in 2007, whilst driving bus 38 in poor weather and ‘bleeding’ road conditions: ‘J was about three quarters through the go around the corner, the way I was steering it. The bus was sliding straight whilst I was steering right...’ He reported the incident to the company and he had ‘no
criticism whatsoever’ about their response.
Another driver, Mr Bruce, also told of his experience with bus 38 in May
The wind was apparently ‘gusting’ and -the road surface poor: ‘...J was travelling south-west, there is a sweeping right hand bend. About half way through the bend, round about the apex of the corner, the bus started into a slide off to the left side of the road.’ -Although he had another incident of ‘split second’ loss of control he had not reported this to the company as he ‘. believed investigations were ongoing
within the company lo rectify the problem...’.
He recounted that after participating in a test drive with the foreman he arranged for
12 of 35
Koni shock absorbers to be fitted to the front of the bus and then after further concerns were raised about wind buffeting they were also fitted to the rear. Mr Twigg indicated that this could have a very good effect on steering and handling. He agreed that if there had been further concerns he would have retumed to investigate and that
if there were any other issues they were not identified by him,
distribution and overall design.
or factor in the incident that occurred,
involved wind and low speed, neither of which were really a factor on 16 April 2009,
38, Mr Yelland was the other regular bus 38 driver and he handed the bus over to Mr Shayler on 16 April 2009. He told the inquest that five weeks prior to the incident he felt the front end of bus 38 move to the left whilst travelling from Heywood to Portland. It involved a small smooth area of bitumen on a slight curve on a wet raining day. He had not mentioned it to anyone nor had he filed a defect notice and
portrayed it as a ‘very minor incident that didn't cause any concerns.’
39, Another driver told the inquest of an incident, which involved such a severe loss of control that his failure to stop the bus, file a defect notice or deal with it in the | very serious manner it would have deserved, cast his evidence in some considerable
doubt.
13 of 35
40, About a month prior to the incident another driver, Mr Palfreyman, whilst driving the same bus on the same roadway in dry conditions; ‘Jost all grip on the Jront tyres....it was like within a split second this all happened before I felt the front tyres grip and I regained control of the bus.’ He went on to tell the Inquest that he
had rung a company mechanic and told im that he thought it was the road.
The Bus Inspection and Mechanical Condition
ihe numerous and intensive post incident inspections failed to reveal it.
42, The Euro-3 bus chassis was purchased from Iveco by WBL in 2006. The body of the bus had been constructed by ‘Coach Design’ and it entered service in November 2006. The bus was licensed to carry 53 passengers. It was intended for distance passenger travel on the V-Line run between Warrnambool and Mount
Gambier and was known within the fleet as bus 38.
of all the windows on the right hand side,
mechanically well maintained,’
cross winds, poor road surface conditions, i.e. wet surfaces and sinooth bitumen surfaces e.g. bitumen bleed. It appears that a combination of these conditions need to be present together with a degree of steering input i.e. negotiating a bend or curve
before a serious loss of control is experienced..’.
14 of 35
46, There was somewhat contradictory evidence from another police member who told the Inquest that the coach would have been strictly classified as ‘wnroadworthy’ due to some frayed seatbelts on board. It was apparent from his evidence however, that this was due to a very limited and fine technical interpretation of the legislation governing roadworthiness and he was somewhat conflicted about categorising the
coach in this way, 47, Sergeant Carnie told the Inquest: ‘From my investigation, I couldn't identify any fault either mechanically or design wise that would indicate a component of the
vehicle contributed to the collision,’
WBL and the Defect Notice System
subject to audit by the Public Transport Safety Board of Victoria.
The evidence from the drivers revealed irregular and inconsistent compliance with the Defect Notice System. Some drivers apparently preferred to express their concerns ‘orally despite an awareness of the requirements of the system, One driver told the inquest ‘.../’m a person who likes to speak direct I know it’s a breach of protocolprefer to tell problems by word of mouth...get better response...’. He later conceded
that ifhe were being honest it came down to laziness on the part of the driver.
breakdown in communication.
15 of 35
51: By contrast, Mr Bruce told the inquest about an incident at Crossley Corner prior to the Iveco intervention, when he lost control of bus 38 on another right hand bend. He reported this incident and together with representatives from the company, VicRoads and the Moyne Shire Council, they attended the scene and decided on a
rerouting of the coach given the condition of the road. He had no criticism of the
company and their genuine desire to rectify any problems with the bus. He told the
Inquest that ‘...when the bus went back on the road it was in good faith,’ VicRoads
concession:
“.. Your Honour, it’s my instruction from VicRoads that we acknowledge that there is sufficient evidence in the coronial brief for Your Honour to draw a connection between the road surface and the loss of control, and I wonder, Your Honour, if that might in fact shorten proceedings both in terms of the questions my friends might need to ask but also whether or not those witnesses need to be brought along. Obviously their statements still go in and it is accepted that the evidence is there, and Your Honour we wish to make it clear that VicRoads does not say that this the only factor, but we certainly do concede that there is — together with the additional evidence that has been put forward by my friend, sufficient evidence (indistinct) for Your Honour to draw a connection between
the road surface and the loss of function as well.”
53, Mr Robyn Miles, Regional Director, South Western Region, VicRoads gave evidence at the inquest. He produced a lengthy statement and was subject to extensive cross examination. In his statement and in his evidence he conceded that
the road surface texture was poor and proposed some improvements.
which VicRoads has responsibility. He explained the VicRoads maintenance regime
and the involvement of Contractors, VicRoads Surveillance Officers and local
16 of 35
Glenelg Shire staff in the roads inspection and repair process and pursuant to the
Roads Maintenance Standards.
55, There was evidence about the crash history going back to 2004, including another fatality in Jane of that year’, a semi trailer crash in April 2006, this bus
rollover in April 2009 and Mr Beaugelhole’s paper delivery truck crash in May 2009.
56, It was also apparent that this section of the Princes Highway was seeing increasing mining, logging and interstate truck traffic at a significant level and that
this location was part of the Green Triangle Freight Action Plan.
e In August 2004, following a fatality, a VicRoads inspection of the site was performed and ‘Slippery when wet’ signs were installed and sideways force co-efficient routine investigations machine (SCRIM) testing requested.
e In September 2004, the SCRIM testing revealed skid resistance or surface texture values below the VicRoads investigatory level necessitating sitc inspection. .
e In October 2004, an inspection revealed significant texture loss.
e In December 2004, a funding bid to reseal a section of the road was launched,
¢ In March 2005, Surface Inspection Rating (SRI) assessment of the crash site
noted it as a candidate for water blasting, however, VicRoads decided to await he further reseal in March 2006 following the success of the earlier funding bid,
e In March 2006, a reseal was performed however, due to an error in the bidding
process the work performed was 130 metres short of that previously identified as required for the site,
® In Spring 2006, another funding bid for the extra 130m reseal failed to attract funding.
the roughness of the road and wheel rutting were moderate,
Coroners case no 3381/04
17 of 35
In Spring 2007, an inspection noted that the 130m unsealed roadway was in
poor condition and the balance of the crash site needed water blasting. The
successful funding bid that followed was limited to the 130m reseal and did
not include any waterblasting.
Tn January 2008, a further SIR survey noted texture loss and again recorded it as a candidate for waterblasting.
In Spring 2008, an inspection’of the crash site only noted low skid resistance on the 130m unsealed section.
In February 2009, the 130m reseal was completed,
On 17 April 2009, a day after the bus rollover, the speed limit was reduced to 80kph
On 6 May 2009, VicRoads received the results of a March 2009 pavement survey revealing wheel rutting, but not at a depth that.would usually require rem edi al treatment.
On 17 May a paper delivery truck lost control upon entering the samme right hand bend.
On 26 May 2009, a different SCRIM testing vehicle from NSW performed testing which revealed varicd surface friction results at the crash site,
On 26 May 2009, the road was waterblasted.
On 27 May 2009, further SCRIM test results revealed si gnificantly increased
surface friction values for the crash site after waterblasting was performed. -
Mr Miles suggested to the inquest that as there was no further note in Spring
2008 of the need for waterblasting, the accelerated deterioration of the road likely
occurred during the prolonged and extreme heatwave conditions between then and
April 2009. He also considered it unfortunate that in February 2009, the Contractor
who performed the extra 130m reseal did not alert VicRoads to the poor condition of
the roadway, nor had the VicRoads Surveillance officers or Glenelg shire officers
noted it during their routine inspections,
59,
Mr Miles agreed however that despite any over arching obligations, there was
. ho specific provision or process for the contractor or inspectors to alert VicRoads to
the adjacent poor road condition and that previous suggestions for waterblasting had
18 of 35
gone unheeded, He interpreted the Spring 2007 ‘note about the need for water blasting, as merely a need. to keep an eye on the area because there was no urgency flag or note attached to it. He also agreed that the VicRoads ‘description of intervention criteria’ for ‘safety inspections and response’ was deficient in that there was really no provision for reporting hazards such as the severe bleeding, polishing and rutting that. were so apparent at this crash site. Mr Miles acknowledged that the road had alsa been incorrectly categorised for ‘safety inspection frequency’ explaining
that it was due to some confusion over a dual roadway number.
additional funding or change prionties which could have occurred.
6l. Mr Miles agreed that the reporting back to VicRoads had not been as good as it could have been and that improvements were required. During the course of his evidence he referred to those improvements set out in his statement and mentioned several proposals:
e To improve the reporting and feedback about how a road surface was actually deteriorating over a period of time.
e To improve the pavement diary to clarify the extent of a work site and whether
a seal needs to be extended. He suggested that when a surveillance officer goes to mark out a work site with a contractor, that would be placed in the pavement diary for checking off during the Spring maintenance check.
To identify any funding bid errors by arranging for the surveillance manager to inspect the site before any work commences and alert VicRoads to any errors and the need for more funding.
To develop and provide a particular training module for VicRoads
Surveillance Officers.
19 of 35
The Pettet/Guajardo Findings & Recommendations
condilion with bitumen bleeding and polished smooth appearance.
recommendations that were raised,
Passenger Evidence at Inquest
seat belt safety messages or wore their scat belts.
65, Mr Hoggan was seated in the second seat from the back and over the back wheel on the near side. He was aware of Madison lying down behind him. Just prior to the incident he felt the coach slide to the left, close to the guard rail on the left hand side and felt stones flicking off the back wheels, .Mr Hoggan could not be 100% sure that he was wearing a scat belt as he did not always wear one. He told the Inquest that the need to wear seatbelts was not generally verbalised by the drivers and he could not
recall seeing a flashing sign at the front of the bus.
3 Coroners cases Nos: 269, 270, 271, 272 & 273/01.
20 of 35
the flashing seat belt sign but did not recall the driver mentioning seatbelts.
overall she was not concerned about the driver’s management of the bus.
68, Mr Verma was seated next to the window in the third row of seats from the front nearside of the bus. He wore his seatbelt because of the flashing sign ahead. Mr Verma had heard the driver advise of the need to wear seatbelts but was unclear as to when it was said on this occasion. He thought that the flashing seat belt sign operated
if you were not wearing a seatbelt.
bullet’) but he also stated that it would have been travelling under the speed limit.
When he got on at Warrnambool ‘the driver made some brief statement that the bus was fitled with seatbelts and required to, but usually not worn and most passengers didn’t have one on.’ He had not seen the flashing seatbelt sign. When questioned he
stated that ‘this is a pretty ineffective way of getting people to wear them.." and
21 of 35
suggested that something more like an airline warning with the driver going down the aisle as being more effective. There was a need for ‘a bit of encouragement’ according to Mr Stipanov. When it was put to him that people did not need to be told he disagreed, staling ‘people become complacent.’ He had looked around the bus on this day and ‘no-one was even listening, which was not an effective way of getting
people to wear seatbelts.’
New Bus safety Legislation
The purpose of this new legislation is to “provide for the safe operation of bus’
services in Victoria.” The objects of this Act are to promote:-
(@ the safety of bus services;
(b) the effective management of safety risks in bus services;
(c) continuous improvement in bus safety management;
(d) public confidence in the safety of the transport of passengers by bus;
(e) the involvement of relevant stakeholders in bus safety;
ip a safety culture among persons who participate in the provision of bus
services,
responsible for administering the Act.
Expert Evidence
Dr Richardson was apparently unable to identify any mechanical and/or design defects with the bus prior to the collision and it was his opinion that the roadway
surface caused the incident.
74, A report was requested from Mr John Lambert, Safety Consultant and he gave evidence at the inquest. Mr Lambert highlighted a number of bus safety issues
including the role of seatbelts in a crash event, the use of child restraints and the
22 of 35
potential survivability of this particular incident. His report also provided background
information on bus crash and fatality rates:
ie]
Buses are generally considered to be the safest mode of road transport and fatal crash rates and fatalities have been decreasing steadily since 1990.
Most people who are injured in bus crashes are not bus occupants. In fatal bus-involved crashes, bus occupants typically represent 30% of those who
die and 40% of those hospitalised.
Seatbelts may have an impact in reducing or eliminating occupant deaths in up to 75 to 80 per cent of fatal crashes. Circumstances where seatbelts may provide limited protection to an occupant, include severe collisions resulting in massive intrusion into the bus occupant space. Occupants may die through direct contact with other occupants, the vehicle. Seats may
sheer off the floor in very severe head on crashes.
Adult lap-sash belts are entirely unsuitable for restraining children under 7
years old.
There may be situations where passengers wearing seatbelts are still injured in a bus rollover, through impact with the interior of the bus.
However, because most bus rollovers are slow, these injuries would
normally not be expected to be severe or fatal.
Seatbelt Requirements
75,
It was apparent that this Iveco coach was defined as a ‘heavy omnibus’ and
thus categorised as a ‘ME’ for the purposes of the Vehicle Standard (Australian
Design Rule 68/00-Occupant Protection in Buses) 2006 (ADR68/00).
76,
Bus 38 complied with the ADR68/00 requirement, in that all seats were
equipped with a lap sash seatbelt and six seats had child restraint anchor fittings.
Whilst it is a requirement that child restraint anchorages be fitted in ME buses, there
is no requirement for child restraint devices to be provided.
23 of 35
77, The applicable legal framework governing the fitting and wearing of seatbelts and child restraints is attached and marked with the letter ‘B’ (Attachment B). There appears to be no statutory obligation on parents or guardians travelling with children under the age of sixteen to ensure that the child is restrained, when on a bus fitted
with seat belts.
78, Ina broader context, it was apparent that there may be buses operating in Victoria on high-speed roads (including school buses), that are not subject to ADR68/00 requiring seat belts to be fitted. There may also be buses in operation that were manufactured prior to the commencement of ADR68/00, Although this inquest did not involve a ‘school’ bus the Australian Government’s “Seatbelts for Kids” funding programme’, does demonstrate the importance of the safety of children on buses as does an NRMA policy paper which calls ‘for the fitting of seatbelts complying with ADR68/00 in all buses used at any time to transport school children* The Country Mayors Association of NSW recently called for the mandatory
installation of seat belts in school buses.°
Improving Seatbelt Compliance
79, The Iveco bus had seat belt signs installed although several witnesses indicated that they paid little attention to these signs. Some passengers recalled looking around to see if others had chosen to wear their seat belt before deciding
whether or not they would.
only issued it at the start of the journey. One acknowledged that they should do it
http://www. infrastructure. gov. au/roads/safety/seatbeltsforkids/index aspxtsubsidy
§ http://www.coffscoastadvocale,com.au/story/2011/03/25/country-mayors-support-belt-up-campaign/
24 of 35
more often than they did. Another did not commence the waming until he had driven
further out of town.
and a seat belt is available, they are required to wear them — just as they do ina car.
bus, as they do ina car.
training.
84, ‘fhe appropriateness and practicalities of attaching stickers to buses to inform passengers of the requirement to wear their scat belt was raised at the inquest. Mr Apps agreed that this would be a simple, practical and inexpensive initiative that industry operators could undertake.? Mr Lambert noted that a verbal reminder by bus
drivers was important as not all occupants may be able to read.
Seatbelts for Expectant Mothers
necessary.
"Transcript 9 December 2010, page 591, § Transcript 9 December 2010, page 601,
25 of 35
docs not put pressure on the foetus.
Child Restraints
87, The death of Madison Dobie brought into sharp focus a significant gap in the seat belt regulatory framework. there were no child restraints available on the bus, nor were they required to be fitted. This is despite all buses subject to ADR68/00 being required to have adult lap/sash seat belts on all seats and a minimum of six child
restraint anchor fittings.
distance road coaches,
89, Mr Apps told the inquest that the BIC docs not have a national policy position on this issue, nor has the issue ever been raised in the eight years he has been Executive Director. The complexities of introducing child restraints onto the bus fleet
became apparent during the course of the inquest. Some issues included:
o Under six months -- baby restraint/capsule with in-built hamess.
oO Six months to’ under four years — child restraint with in-built harness.
26 of 35
o Four to seven years — booster seat with seat belt or harness; or a child restraint with in-built harness.”
e Who would be responsible for providing such devices — the parents or the bus operators? Parents and guardians who do not own a car would not possess a child restraint and therefore would not be able to supply their own device. One could not reasonably expect a parent or carer to carry a child seat along with their child.
It was noted that child numbers may increase during particular times such as school holidays.
e¢ Who would be required to fit the child restraint to the seat — parents or bus drivers? If bus drivers were required to fit the devices, they would need to receive the appropriate training to appropriately install the devices. Some bus drivers who gave evidence at the inquest indicated disapproval of the onus being placed on drivers.
e« Hygienic issues associated with using a communal seat were raised.
¢ Possible avenues to advise parents and guardians on the need for children to be restrained and the potential to bring along their own restraint was discussed. Mr Apps noted that most people nowadays booked tickets online or over the phone. If this werc the case, bus companies could ensure the required number of restraints were made ‘available at the commencement of the route trip.
Clearly, there are a range of operational challenges to address.
27 of 35
Post Mortem Medical Examination
90 An Autopsy was performed by Dr Paul Bedford, General Pathologist at the Victorian Institute of Forensic Medicine. Dr Bedford formulated the cause of death
and made the following comments:
“Death appears to have occurred from crush injuries sustained under a bus and leading to decreased movement of the chest. This movement is essential for breathing. This restriction of breathing is termed mechanical asphyxia.
Restriction of breathing is also affected by the pregnancy.
Fractures to the pelvis and lower spine are noted.
A female foetus was present.”
‘Lhe Families
belt compliance,
Acknowledgements
I wish to particularly thank and acknowledge the role of the police investigating member, the police assistant, coronial staff and members of the Coroners Prevention
Unit'® for their co-ordination, support and assistance.
0 The Coroners Prevention Unit is a specialist service for coroners created to strengthen their prevention role and provide them with professional assistance on issues pertaining to public heath and safely.
28 of 35
Comments and Findings
Pursuant to section 67 of the Coroners Act 2008, I make the following comments and findings connected with this death:
It was impossible to determine exactly why the coach initially crossed over onto the
wrong side of the road but I find that it was related to the poor road surface.
VicRoads made a sensible concession about the condition of the roadway and proposed some partly implemented improvements however, it is a pity that it took an
incident such as this for that to occur.
Whilst acknowledging the vast road network responsibilities of VicRoads and the limited road maintenance budget, this particular section of road had been in a very bad way for several years with bleeding, polishing, rutting and loss of road surface texture. There was a fatality in 2004, a crash in 2006 and at least one other close by, together with increasing heavy vehicular traffic flow however the reporting regime, prioritisation and resources surrounding inspection, monitoring, identification,
signage, funding, maintenance and repair went awry.
It was extraordinary that one section of roadway could be repaired whilst another adjacent section was left in bad condition. In the years prior to this incident VicRoads inspections had identified the site as needing water blasting but that -was not performed until after this incident occurred and the excuses swrounding the intervening delay were unsatisfactory. Although relevant, it was not good enough to
blame recent extreme weather or suggest that responsibility lay with others.
The system was flawed and protracted and failed to adequately identify hazards and manage risk as it should have done under the Road Management Plan. Whilst that Plan was intended to manage risk, it was found wanting and unable to effectively gather or use information on this occasion. An expanded checklist and internal system to encourage and support the reporting of risks and maintenance. and signage
requirements was needed.
29 of 35
It is apparent that VicRoads did consider and at least partially act on the recommendations of the Pettet/Guajardo findings, however those recommendations still have such general application for the management of risk that they remain
relevant today and apply equally to the site of this incident.
The former State Coroner wrote in a Summary :
“As with most large and small government agencies there is always a need to learn from events and continually work on improving processes. The. deaths examined in this inquest have tested VicRoads own systems and identified significant areas for improvement. In summary VicRoads systems jor identifying and dealing with significant maintenance problems that had
potential to adversely effect safety have failed.”
So too in this incident, VicRoads systems for identifying and fixing a similar " maintenance problem to the Pettet/Guajardo incident failed despite it having responsibility for ensuring that road maintenance problems do not adversely effect
safety.
T find:
The poor road surface and low friction values were responsible for this
incident occurring.
The 100km/h speed designation was probably excessive and the slippery when wet warning sign was inadequate to warn traffic of the poor road surface
conditions.
VicRoads system for management of risk, hazard identification, road
maintenance, funding and repair were inadequate.
30 of 35
‘The coach was well maintained and no mechanical or design defects were detected.
The evidence that
bus 38 had particular handling problems was not sufficiently made
out to support a finding that this may, of itself or in combination, caused this incident
to occur, I conclud
more likely due to
Although it did no
in the communica
ed that the handling problems some drivers complained about were
prevailing weather, wind or road conditions.
necessarily impact on this incident, shortcomings were identified
ion of driver concerns and the operation of the Defect Notice
System, It is apparent that the bus operators will need to be increasingly active and
vigilant with their
systems surrounding these issues particularly given the provisions
of the new Bus Safety Act.
I find:
The bus wa
s well maintained and there was no apparent mechanical or design .
defect in the bus that caused the loss of control in this incident .
The WBL system for communication of driver concerns and the completing of
Defect Noti
ces failed to operate as it should,
Although there was a suggestion that Mr Shayler may have entered the road curvature
too fast for the prevailing conditions, neither his speed nor his driving of the bus in
general could be co
I find:
Mr Shayler
nsidered inappropriate.
was not responsible for this incident.
31 of 35
The bus industry has a good safety record to date. Bus travel is considered the safest mode of road transport in Australia however that does not diminish the importance of continuous improvement. The demand for bus services together with bus passenger numbers will inevitably increase ‘as the population grows and people are encouraged
to make better use of public transport.
While buses are considered fo have a low probability of experiencing a crash, the consequences, including the potential loss of life are substantial given the high
number of occupants on board at any one time.
Seatbelt compliance was poor and there was a prevailing culture of not buckling up.
A real shift in public perception about bus safety is necessary as is the importance of wearing the available seatbelt, as required by current law. The importance of seatbelts for school children travelling on high speed coaches, whilst an ancillary issue, has
also been highlighted in this inquest.
The absence of any form of child restraint being available on buses is unsatisfactory.
While there may be operational and practical difficulties associated with fitting child restraints, I am confident that they could be overcome through sensible collaboration
and co-operation between all interested parties.
In a recent coronial finding into an Egyptian bus crash in which five Victorians died, Coroner Spanos commented that “the wearing of seatbelts could potentially have prevented ejection from the bus and saved some lives and ameliorated some injuries"!
It is also apparent from the evidence of Mr Lambert that scat belts are not an isolated measure to protect bus occupants in the event of a crash and a different approach to bus window design may be possible whereby they flex and contain occupants rather
than break as was the case here.
" Coronial findings nos.219-223/2006
32 af 35
This new Bus Safety Act appears to be a significant reform in transport safety in Victoria and offers a proactive approach to risk identification and management in the bus industry. The concept of “shared responsibility’ between bus operators, regulators and patrons emphasises the move towards a bus safety culture, which
should address many of the safety issues identified by this investigation.
I find:
Ms Sabrina Brady, Madison Dobie and Mr Justin Pomery may have survived
and their unfortunate deaths prevented had they all been properly restrained.
33 of 35
Recommendations
Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendations connected with this death.
1, T recommend that VicRoads review their road maintenance system in light of this finding, and the Comments and Recommendations from Pettet/ Guajardo and implement a “best practice” system for inspecting, monitoring, auditing, funding and repairing road surfaces to minimise the risk of crashes. This system should also incorporate specific considerations relating to the incidence of extreme climate events
and road surface management.
Recommendations relating to road maintenance and risk,
Such messages would need to emphasise the importance of seat belts in the event of a
crash, and the applicable penalties for failing to comply.
with ‘Transport Safety Victoria, introduce a policy for stickers to be provided on all.
seats of huses fitted with seat belts in order to improve compliance, Such stickers should cmphasise the importance of seat belts in reducing the risk of injury, and
monetary penaltics associated with non-compliance.
restraints to be made available on all buses operating in Victoria that are subject to
34 of 35
6, I recommend that in the event child restraints are made mandatory for buses subject to ADR68/00 in Victoria, the Department of Transport review the Road Rules 2009 to define the responsibilities for ensuring that a child is suitably restrained in a
bus,
awareness of the importance of seat belts,
recommended above) to improve compliance.
measures in addition to seat belts, including retentive window glazing.
Signature:
TN we
a iy oO (rm oe
Acather Spooner Coroner 30 March 2011
Distribution List:
2, Michael Apps, Executive Director - Bus Industry Confederation of Australia
4, Alan Osborne, Director - Transport Safety Victoria
The Ilon. Mr Terry Mulder MP, Minister for Public Transport and Minister for Roads
Jim Betts, Secretary — Department of Transport
Simon Overland, Chief Commissioner - Victoria Police
Gary Liddle, Chief Executive - VicRoads
Nick Dimopoulos, Chief Executive - National Transport Commission
35 of 35
VicRoads Letter
In the Inquest of:
Sabrina Michelle Brady 2038/09 Madison Lee Dobie 2039/09
Justin Ross Pomery 2040/09
140 William Street Melbourne Vic 3000 PO Box 4307 Malbourne Vic 3001 Australia DX 147 Melbourne * Tel +614 3.9274 6000 Fax +84 39274 S111
” weandlaphillipsfox.com
Our ref! RAW:0471253
23 December 2010
Remo Antolini
Coroner's Assistants Unit Coroners Gourt
Level 14
222 Exhibition Strect MELBOURNE ViC 3000
Deer Remo Re: Inquest into the deaths of Brady and others
The Coroner has asked VicRoads to descrlbe how it responded to Recommendations 2 and 3 In the Inquest into the Deaths of Pettet and others on the South Cippstend Hwy at Koo Wee Rup in January 2001. c,
Recommendation 2 was:
That improvements need to be made to the data collectian and computer software systems at VicRoads io ensure that aif data collected whether from the public, internal reports on problems with maintenance or the stale of the road, accident information, ete, be able to be automatically cross referenced to ensure thal, as a minimum, the extent of the problem is recognised dnd the risk evaluated and managed (within the bounds of practicalily and resources),
It fs essential that the data systems ‘actually work to proactively identify and manage the information in a timely way,
VicRoads jesponded to this recommendation by Introducing the Enquiry Tracking’ System (ETS). The ETS is used to record and track enquirles and complaints from the public received via VicRoads’ call centres and customer service centres and its website, including complaints and enquiries about road hazard management. Enquiries and complaints about the state of the road are tracked and monitored. The risk is evaluated and actions required to mitigate the problem are identified. Tha ETS also captures Information about crashes and other incidents that are notified to VicRoads.
Each enquiry or complaint is allocated to a VicRoads officer for action, and the system sends reminders of the action items until the matter Is dealt with and closed off.
DLA Phillips Fox fs a member of
Please notify us if this communication has been sent'ta you by mistake, ifithas been, any client legal DLA Piper Group, an alllance of Pet : aE independent legal practices. Ikls a privilege Is nat walved or lost and You aye not entitled to use it in any way, separate and distinct legal entily.
GLA Phillips Fax offices are located in Adelaide Auckland Brisbane
4119901808 \ 0471263 | RXGO2 Senerta hopourne Perth Sydnay
Recommendation 3 was:
That VicRoads examine the issue of éstablishing a well resourced special rapid response team(s) in each region supporting road mainteriance teams and surveillance officers and helping to identify and dealing with managing Identified areas of increased tisk as a result of road surface maintenance prodleins.
The feams would be managed by a centrallsad unit answerable to the Chief Executive Officer.
The teams in each region would need to be multi-disciplinary (engineers, risk managers, analysts, ofc), have special skills and expertise in identifying areas of risk (with the abllity to have on-site access fo relevant VicRoads data systems relating to road safely planning and maintenance) countermeasures, signally or in combination In a fimely manner (fle temporary road signage, speed
limit reduction, ete)
Such a unit could also assist with in the training of maintenance teams and surveéiilance officers to help them Identify other potential areas of risk potentially encountered In the daily routine of maintenance work and thereby further assisting in better targeting areas of increased risk.
Subcontractors also need to be trained in any néw procedures to help In the risk management pracess..
Finally, safety needs fo be the focus of the unit’s work and any problems also need fo ba considered from the motorist’s perspective.
VicRoads considered this recommendation along with all the recommendations directed at It in the Pettet Inquest, It has not implemented the system descrlbed by the Coroner in the Peitet Inquest.
However, VicRoads aimed for similar outcomes by developing Its skid resistance policy. This policy - provides for VicRoads to respond te a member ofthe public, municipality, or VicRoads whe expresses a concern that a road surface is contributing to crashes or the potential for crashes. Aspart of the process under this policy, VicRoads analyses the crash history of the location, carries
‘out site inspections, and if tls determined that road safety could be enhanced by improving skid
rasistanoe, then skid resistance is measured to enable a business case to be prepared for funding the Improvement. Independently of this policy, VicRoads also carries out Inspections of locations on arierial roads where fatal crashes have occurred, as well as carrying out regular malntenance
‘inspection under the Road Management Plan. You will recall that Mr Miles gave evidence touching _ upon these Issues at the inquest hearing, .
Yours sincerely:
Rant.
Rachel Walsh - Elana Oreilly .
Pariner , Solicitor
Direct +61 3 9274 5223 Direct +61 292745219 | rachel. walsh @dlaphtllipsfox.com elana.orellly@diaphitipsfox.com
Fitting and Wearing of Seatbelts
In the Inquest of: Sabrina Michelle Brady 2038/09 Madison Lee Dobie 2039/09
Justin Ross Pomery 2040/09
Requirement to wear seatbelts in Victorian Buses
Rule 265 of both the Road Safety (Road Rules) Regulations 1999 (‘former Rules”)
' and its successo
r, the Road: Safety Road Rules 2009 (“current Rules”) require that a
passenger in a motor vehicle of 16 years or older is to “occupy a seating position that py &p 4
is fitted with as
eatbelt; and...must wear the seatbelt properly adjusted and fastened,”
. when the vehicle is either moving or stationary (but not parked). Moreover, both the
former and curr
ent Rules do not spécify the categories of motor vehicles to which
Rule 265 applies, and thus would extend to passengers on a ME bus.
Driver’s Obligations
Both the former’
and current Rules place an onus on the driver of the motor vehicle” —
but not being a bus or taxi— to ensure that each passenger who is 16 years old or older complies with Rule 266 which details the requirement for persons aged under 16
years old to be s (which is age de;
Another piece o
eatbelt restrained in motor vehicles, and specifies the type of restraint pendent).
f legislation worth considering is the Bus Safety Act (Vic) 2009, which
came into operation on 31 December 2010. Section 15 of that Act provides that an
‘operator’ (see reasonably prac
footnote 3 for the definition)’ of a bus service must so far as is icable ensure the safety of the bus service. This concept of ensuring
safety is detailed further in section 14, whereby a bus service operator must eliminate all risks to safety so far.as is reasonably practicable; and where it is not reasonably
practicable to ¢!
practicable, In di
etermining what is reasonably practicable, section 14(2) sets out a list
of matters that must be considered in determining what is reasonably practicable in relation to ensuring safety’,
The following pages contain extracts from relevant legislation.
' Which came into operation on, 9 November 2009
2 The definition of ‘
vehicle..
‘operator” includ
=
degree of harm
‘motor vehicle” in the Road Safety Act I 986, means “a vehicle that is used or
intended to be used on a highway and that is built to be propelled by a motor that forms pant of the
7 An‘ operator’ is defined as “the person who is responsible for controlling or directing the operations of a bus service in connection with a business or activity for, or involving, the transport of passengers by road by that bus scrvice, but does not include a person who merely— (a) arranges for the registration of a bus; or (b) maintains or arranges for the maintenance of a bus”. Given this definition (and the reference to “driver” in other parts of the Act), it does not appear that the definition of
es the bus driver.
hese matters include: (a) the likelihood of the hazard or tisk concerned eventuating; (b) the
that would result if the hazard or risk eventuated; (c) what the person
concerned knows, or ought reasonably to know, about the hazard or risk‘and any ways of eliminating or reducing the hazard or risk; (d) the availability and suitability of ways to
risk.
eliminate or reduce the hazard or risk; (¢) the cost of eliminating or reducing the hazard or
iminate risks to safety, to reduce those risks so far as is reasonably "
Extract of relevant legislation
Vehicle Standard (Australian Design Rule 68/00 — Occupant Protection in Buses) 2006
Li. The function of this ADR is to specify, for certam omnibuses, requirements for seatbelts, the strength of ‘Secfs’, seat-anchorages, seatbelt ‘dnchorages’ and ‘Child Restraint dnchorages’, and provisions for protecting occupants from impact with ‘Sear’ backs and accessories on Seats’ and armrests,
21.0) Subject to the following clause, this ADR applies to the design and
construction of vehicles as set out in the table below.
2.2. This ADR does not apply to ‘Route Service Ommibuses’, or omnibuses with less than 17 ‘Seats’ including the driver and crew, or vehicles in which all passenger ‘Seats’ have a ‘Reference Height’ of less than 1.0 Inetre.
ROUTE SERVICE OMNIBUS - an omnibus specially designed with spaces for standing passengers.
2.3. Vehicles certified to the requirements of an acceptable prior rule, as shown below in the Applicability Table for a particular category, are deemed to comply with this rule.
APPLICABILITY TABLE ADR UNECE Category Category | Manufactured Acceptable Vehicle Category Code Code on ov After Prior Rules rm Heavy omnibus ME | M3 | I Inty 1994 nil
: DEFINITIONS Al, Refer to Vehicle Standard (Australian Design Rule Definitions and
Vehicle Categories) 2005.
All ‘Seats’ with a ‘Reference Height’ greater than 1.0 metre, other than driver's ‘Seat’, must meet the requirements set out in this rule.
Seatbelt Assemblies
Each ‘Seat’ must be equipped with a ‘Seatbelt Assembh’.
The ‘Seatbelt Assembly’ of front-facing ‘Seats’ must be a ‘Lap-Sash Belt’
equipped with an ‘Emergency Locking Retractor’ as specified in ADR
Seatbelt Anchorages
‘Sects’ must be equipped with seatbelt ‘drchorages’ which for:
all front-facing ‘Seats’ must have anchorages for pelvic and upper torso restraint, as specified in clause Li, and Provision for Child Restraints At least six ‘Seats’ in the vehicle must be provided with ‘Child Restraint Anchor Fillings’ or at the ‘Manufacturer's’ option, ‘Child Restraint
Anchorages’ and ‘Child Restraint Anchor Fittings’ meeting the requirements specified in ADR 34/...,
Road Safety Act 1986: bus means a motor vehicle which (together with any trailer attached to if) seats nore than 12 adults (including the driver);
motor vehicle means a vehicle that is used or intended to be used on a highway and that is built to be propelled by a motor that forms part of the vehicle but does not include—
(a) a vehicle intended to be used on a4 ’ railway or trantway; or
(b} a motorised wheel-chair capable of a speed of not more than 10 kilometres per hour which is used solely for the conveyance of an injured or disabled person; or
(c) a vehicle that is not a motor vehicle by virtue of a declaration under subsection (2)(b);
inserted by - No. 891997
Road Safety (Road Rules) Regulations 1999 (note these Regulations have been superseded by the Road Safety Road Rules 2009 on 9 Novémber 2009)
Wearing of seatbelts by passengers 16 years old, or older
(1)
A passenger in or on a motor vehicle that is moving, or is stationary but not parked, must comply with this rule if the passenger is 16 years old, or older.
Penalty: 5 penalty units.
Note Motor vehicle is defined in the Road Safety Act 1986, and park is defined in the dictionary.
Wearing. of seatbelts by passengers under 16 years old
(1)
(3)
The driver of a motor vehicle (except a bus or motor bike) that is moving, or is stationary but not parked, must ensure that this rule is complied with for each passenger in or on the vehicle who is uncer 16 years old.
Penalty: 5 penalty units.
Note Bus and motor vehicle are defined in the Road Safety Act 1986, and motor bike and park are defined in the dictionary.
f the passenger is under 1 year old, and not exempt from wearing a seatbelt under rule 267, the passenger must be restrained in a suitable approved child estraint that is properly fastened and adjusted, unless the driver is exempt rom this subrule under subrule (5).
Note Approved child restraint is defined in subrule ().
f the passenger is atleast 1 year old but under 16 years ald, and not exempt from wearing a seatbelt under rule 267, the passenger must be restrained in a suitable approved child restraint that is properly fastened and adjusted, or occupy a seating position fitted with a suitable seatbelt and wear the seatbelt properly adjusted and fastened, if a suitable approved child restraint, or a seating position fitted with a suitable seatbelt, is available in the motor vehicle for the passenger.
=
If the motor vehicle has 2 or more rows of seats, the passenger must not be in the front row of seats unless the passenger is restrained in a suitable approved child restraint or occupying a seating position fitted with a seatbelt.
The driver of a public minibus or taxi is exempt from subrule (2) in relation to a passenger if—
(a there is no suitable approved child restraint available in the minibus or taxi for the passenger; and
(b ifthe minibus or taxi has 2 or more rows of seats—the Passenger is not in the front row of seats.
Note — Publie minibus and tax! are defined in the dictionary,
267." Exemptions from wearing seatbelts
(1)
(2)
(4)
A person is exempt from wearing a seatbelt if the Corporation has certified
that it would be wear a seatbelt.
impracticable, undesirable or inexpedient for the person to
A person in or on a motor vehicle is exempt from wearing a seatbelt if—
(a) the person is engaged in the door-to-door delivery or collection of
goods, or in or out o
in the collection of waste or garbage, and is required to get the vehicle, or on er off the vehicle, at frequent intervals; and
(b) the vehicle is not travelling over 25 kilometres per hour.
Note Motor vehicle is defined in the Road Safety Act 1986.
Aperson is exempt from wearing a seatbelt ift—
(a) the person (or, for a passenger, the driver of the vehicle in which the
person is a passenger) is carrying a certificate signed by a registered medical practitioner certifying that because of—
(i) medical unfitness; or
(ii) physical disability—
it is impracticable, undesirable or inexpecient that the person wear a seatbelt; and
(9) the person is complying with the conditions (if any) stated in the
certificate;
and
(c) _ the certificate shows the date on which the exemption expires.
However, a person is not exempt under subrule (3) from wearing a seatbelt if the person (or, for a passenger, the driver of the vehicle in which the person is a passenger) does not immediately produce the certificate mentioned in the subrule for inspection when a police officer or authorised person asks the person (or the driver) whether the person is exempt from wearing a seatbelt,
Note Authorised person and police officer are defined in the dictionary,
A passenger in seatbelt.
a police or emergency vehicle is exempt from wearing 4
Note Emergency vehicle and police vehiele are defined in the dictionary.
Road Safety Road Rules 2009 (came into operation on 9 November 2009):
265 Wearing of seatbelts by passengers 16 years old, or oldex
(1) A passenger in or on a motor vehicle that is moving, or that is stationary but not parked, must comply with subrule (2) if he or she-—
(a) is 16 years old or older; and
(b) is not exempt from wearing a seatbelt under ‘rule 267.
Penalty: 10 penalty units. | (2) The passenger—
(a) must occupy a seating position that is fitted with a seatbelt: and
(c) must wear the seatbelt properly adjusted and fastened,
(3) The driver of a motor vehicle (except a bus or taxi) that is moving, or that is stationary but not parked, nuist ensure that each passenger in or on the vehicle who is 16 years old or older complies with subrule (2), unless the passenger is exempt from wearing a seatbelt under rule 267.
Penalty: 10 penalty units.
266 Wenring of seatbelts by passengers under 16 years old
(1) The driver of a motor vehicle (except a bus or
motor bike) that is moving, or is stationary but not parked, must ensure that this rule is complied with for each passenger in or on the vehicle who is under 16 years old,
Penalty: 10 penalty units.
(2A) If the passenger is 6 months old or older, but is less than 4 years old, he or she must be restrained in a suitable and properly fastened and adjusted—
(a) rearward facing approved child
(b) forward facing approved child has an inbuilt harness,
restramt: or
restraint that
(3) A passenger who is under 4 years old must not be
in the front row of a motor vehicle t more rows of seats.
hat has 2 or
(3A) A passenger who is 4 years old or older, but is less
than 7 years old, must not be in the
front row of a
totor vehicle that has 2 or more rows of seats unless all of the other seats in the row or rows
behind the front row are oceupied b who are also under 7 years old.
¥ passengers
(5) Subject to subrule (5A), the driver of a public minibus or taxi is exempt from subrules (2), (2A) and (2B) in relation to'a passenger if—
(a) there is no suitable approved child restraint available in the minibus or taxi for the
passenger: and
(b) if the minibus or taxi has 2 or more rows of seats—the passenger is not in the front row
of seats.
Nate
Puotic minibus and foxé are defined in the
dictionary.
267 Exemptions from wenring seatbelts
(1A) A person in or on a motor vehicle is exenipt from
weating a seatbelt if —
(a) the seating position that he or she occupies is
not fitted with a seatbelt: and
(b) there is no requirement for that seating
position to be fitted with a seatbelt: and
(ce) all passengers in the vehicle who are exempt
subrule (8),
re
( oe
under ? years old.
Toll Wearing a seatbelt are complying with
B) Subrule (1A) does not apply to a person who is
(1C) To aveid doubt, subrule (1A) does not authorise a passenger to whom subrule 266(3) or GA) applies to occupy a seat in the front row of seats in a vehicle that has 2 or more rows of seats,
(8) Ifa vehicle does not have seatbelts or approved child restraints fitted to all its passenger sea positions, a passenger who is xenipt from wearing a seatbelt under this rule must not occupy
a seating position that is fitted with as an approved child restraint if the resul that a passenger who is not exempt fro
eathbe WoO mlwe
a seatbelt under this rule would be tequired
occhpy a seating position that is not fi seatbelt or an approved child restraint.
ted w.
ing
tor
d be aring a
ith a
Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…
A 9-year-old boy died from cranio-cervical dislocation sustained in a head-on motor vehicle collision. He was seated in the rear seat wearing only an adult seatbelt without a booster seat. Current best practice guideline…
A 57-year-old man with schizophrenia and schizoaffective disorder died by hanging in prison on 4 August 2024. He had been receiving antipsychotic treatment via injection (paliperidone) but ceased antipsychotic medication…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries are for educational purposes only and must not be treated as legal documents. Report an inaccuracy.