Finding into death of Robyn Anthea Rodd

Court Reference: 1985/2010

FORM 38 Rule 60(2)

FINDING INTO DEATH WITHOUT INQUEST Section 67 of the Coroners Act 2008

In the Coroners Court of Victoria at Wangaralta

I, Gerard Bryant, Coroner having investigated the death oft

Details of deceased:

Surmame: _ RODD First name: ROBYN ANTHEA Address 485 Dights Forest Road JinderaNSW

without holding an inquest: find that the identity of the deceased was Robyn Rodd and the death occurred on 26 May 2010 on the Great Alpine Road. between Harrietville and Mt Hotham

from HEAD AND CHEST INJURIES SUSTAINED IN A MOTOR VEHICLE INCIDENT

(CYCLIST)

Pursuant to Section 67(2) of the Coroners Act 2008, an inquest into the death was not held and the deceased was not immediately before the person died, a person placed in custody or cave; but there is a public interest to be served in making findings regarding the following circumstances:

CIRCUMSTANCES SURROUNDING THE DEATH OF ROBYN RODD

1. Robyn Rodd (“Rodd”) was 55 yeats of age when she died. She was an experienced recreational cyclist who had considerable experience ascending and descending Mt Hotham.

According to her training partner Dr Gordon Taylor (‘Taylor’) who was with her on the day she died, she had cycled to the top of Mt Hotham and descended on 11 occasions previously.

2. On the day she met Taylor in Bright and they travelled by bicycle via Harrietville to the summit of Mt Hotham reaching the Mt Hotham village around 1-1.15pm. The conditions were described as cold and windy and both cyclists changed into appropriate warmer clothing. Rodd was wearing fluorescent green jacket for the descent.

. 3, Both cyclists descended below the snowline and it appears that Rodd was travelling 50 metres in front of Taylor and at about 40 kmh prior to the incident. As they descended to a point between the 109 and 110 kilometre posts, they approached a sharp left hand bend that was govemed by an advisory speed sign of 30 kmh.

4, At the same time and unbeknown to the descending cyclists, a large prime mover truck was ascending the road in the opposite direction, The truck driven by Bradley Skahill (‘‘Skahill”) was a 2004 Model T-650 Kenworth truck towing a drake low loader en route to Dinner Plain, Skahill was an experienced truck driver that had travelled that road on a number of occasions previously.

5, Police measured the truck as having a width of 2.5 metres, a total length of 19.5 metres with ‘oversize signs fiited, and 19.3 with the signs removed. The truck was travelling on the correct side of the road at all times.

6. Witness accounts to the collision are generally consistent, in that it appears that Rodd approached the sharp left hand bend at which point the truck driven by Skahill came into view on the corner of the road. Rodd has then applied her brakes, which resulted in a fishtailing motion with the rear wheel of the bike moving from side to side before Rodd was ejected from the bike and into the path of the slow moving truck. Rodd died instantly,

ISSUES ARISING FROM THE DEATH

7, Tn accordance with the powers conferred by section 67(3) and 72 (2) of the Coroners Act (2008),(“The Act”), a Coroner has the power to comment or make recommendations’on any matter connected with the death, including matters relating to public health and safety or the administration of justice.

8. A number of matters arose from the circumstances surrounding the death which were identified as follows: ;

A) Safety considerations arising from the use of the Great Alpine Road by large heavy vehicles

B) Safety considerations arising from any changes to road design or signage to increase awareness among the diverse users of the Great Alpine Road

9, A number of stakeholders were invited to make detailed submissions to the coroner addressing the above issues. Submissions were received from the following parties

@ Mt Hotham resort management e Falls Creek resort management e Mt Buller resort management « Audax Australia Cycling Club e Amy Gillett Foundation e Bicycle Victoria

• @ Wangaratta Rural City cycling tourism officer

e Vic Roads

10. Recent crash history conducted by Vic Roads for the Great Alpine Road indicated that in a 5 year period prior to the this incident that there had been no other crashes within 200 metres of the crash site. Within 5 kilometres of the site, there had been 12 crashes within the same period, two of which involved cyclists. In both cases, the cyclists received serious injuries.

In the 5-year period from 1 July 2004 to 30 June 2009 there have been 35 casualty crashes involving motorcycles on the Great Alpine Road.

11. The road services important industries including timber logging and milling, agriculture, viticulture and grazing. It also has high tourism value for motorcyclists and cyclists alike, due to the mountainous terrain and high environmental value of the area, Unlike other alpine toads, it is a thoroughfare to East Gippsland, and not merely an access road for the resort at the sununit.

12. The competing uses of the road and the number of death and serious injuries occurring on the road have led to a number of calls from stakeholders to investigate ways in which the road may be made safer for the benefit of all users.

THE USE OF OVER DIMENSIONAL VEHICLES ON THE GREAT ALPINE ROAD

13, A preliminary issue had arisen concerning the size of the truck and whether it complied with road safety regulations and requirements, and, in particular whether the truck required an escort vehicle.

14, The vehicle in question was measured with a width of 2.5 metres and a length of 19.5 metres, As such, the vehicle is classified as a “class 1” vehicle under regulation 177(1) of the Road Safety regulations. :

15. Clause 7 of the schedule to the Road Safety(Vehicles) Regulations 2009 states: Class 1 vehicles only permitted on specified highways and at specified times A class 1 vehicle may only be used on a highway—

(a) that is in an area, or on a route; and ,

(b) at the times— _ specified by the Corporation by notice published in the Government Gazette or by a Class 1 permit.

16. The relevant gazette applicable to the road where the collision took place id 8,235 dated 21 September 2007

A Class 1 load carrying vehicle and a Class 1 vehicle that is specially designed to carry a large indivisible item are permitted to operate on all roads within the meaning of the Road Management Act 2004, except for:

(a) in the Mountainous Area and the Otway Area, where the vehicle must not exceed 2.5 rmetres in width and/or 19.0 metres in length; .

(b) in the Gippsland Ranges Area and Colac—Surf Coast Area, where the vehicle must not exceed 3.0 metres in width and/or 22.0 metres in length or

(c) on Restricted Routes; or

(d) on Prohibited Bridges.

17. The “mountainous area” identified in the gazette does cover some stretches of the Great Alpine Road but not apparently the section between Harrietville and Mt Hotham

18, According to Vic Roads in order for a class] vehicle ( a vehicle exceeding 19m ) to travel on the Great Alpine Road a class I permit must be obtained pursuant to regulation 180

180 Exemption from Schedule 7 by class 1 permit

(1) The Corporation may issue a permit that exempts one or more class 1 vehicles from any of the following requirements sct out in Schedule 7—

(a) amass or dimension limit other than a limit that relates to a GVM, a GCM or a manufacturer's limit;

(b) any other requirement, ;

(2) A class | permit may be issued under sub regulation (1) for more than one motor

vehicle that is a class 1 vehicle only ifthe motor vehicles are registered in the name | of the same registered operator. :

(3) A class | permit may exempt a combination consisting of more than one prime mover or hauling unit from compliance with the individtial GCM of a prime mover or hauling unit on the condition that thé sum of the individual GCMs is not exceeded.

(4) Aclass 1 permit may contain any conditions the Corporation thinks fit.

(5) Conditions imposed under sub regulation (4) may include conditions designed to secure payment for—

(a) any damage or road wear caused by the vehicle when being used pursuant to the permit; and

(b) any roadwork or other work required to allow the vehicle to use the roads specified in the permit.

(6) An application for a permit must be in the form approved by the Corporation under regulation 11, and be accompanied by the relevant fee set out in Schedule 5,

(7) The Corporation may require that an application for a permit is submitted with— (a). aréport and survey of the route;

(b) an inspection and report on structures and other obstructions on the proposed route; :

(c) areport on proposed safety measures and traffic management measures;

(d) details of the proposed escort of the oversize or over mass vehicle, complying with the relevant provisions of Part 5 of Schedule 7.

19. Police investigations reveal that the truck in question did not hold a valid class! permit.

Correspondence from Vic Roads suggests that whilst Vic Roads have the power to impose conditions on permits, Vic Roads would have issued such a permit for travel to Mt Hotham.

The regional director of Vic Roads stated, “there would not have been any requirement for a pilot or escort car to precede the vehicle combination on it’s journey”.

20. Vic Roads did state that the driver of the vehicle had committed an offence under regulation 182 (2) by driving the vehicle in that area without a valid permit. The relevant penalty is 10 penalty units. It is not the purpose of this inquest to find blame or liability, and the absence of a permit does not have any bearing on the issues under consideration.

2i.

Dr Gordon Taylor had stated in correspondence received by the Coroners office, that in his view, had a pilot vehicle on this tortuous mountain road been present then it was his belief that Rodd would not have braked in a manner that led to her death.

A consideration of the safety issues arising from the use of the Great Alpine Road by large heavy vehicles are detailed in the submissions received from a variety of stakeholders below.

SUMMARY OF SUBMISSIONS RECEIVED

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The Coroner is grateful to the informant, and to the various interest groups that were approached and asked to make submissions on the issues raised in this inquest. The submissions were clearly given a great deal of thought and effort by the parties, and the .

detail contained in many of the submissions was very helpful.

The various stakeholders approached by the inquest can be categorised into three principal groups, alpine management resorts, cycling organisations and Vic Roads who have authority

-over alpine roads.

The parties were given an opportunity to reply to the submissions received from the other patties so as to provide for as broad as possible discourse on the issues identified in the inquest. The submissions can be usefully summarised as follows;

Mt Hotham resort management

Escort vehicles

It was the view of the Board that any benefit derived from the use of ‘escort vehicles for smaller classes of vehicle would be far outweighed by cost and complexity. The Board argued that the provision of an escort vehicle may simply become thé first hazard encountered rather than.the vehiclé behind. The Board did not believe that a requirement to escort larger class 1 vehicles would be an effective safety measure outcome.

Other safety initiatives

27. The Board welcomed a review of the advisory signage needs and standards if it could be established as an effective road safety improvement measure.

Falls creck resort management Escort vehicles

28. The Board recommended mandatory use of pilot vehicles for all articulated trucks travelling on the Bogong High Plains Road. The Board was ofthe view that the use of pilot vehicles would prepare oncoming users for the potential of large vehicles crossing lanes. The Board observed that the use of pilot vehicles was ad hoc at present. ‘

Other safety initiatives

29. Many of the initiatives suggested by the Board were unique to the Bogong High Plains Road, and arguably do not touch directly on factors, which may have contributed to the death under investigation: There are however, a number of matters raised which have generic application to the use of alpine roads and the safety implications of such use. ,

30. The recommendations included the following:

1. A signage program that educates various user groups on appropriate behaviour, road conditions, safely and hazards.

2. Improve vegetation management around comers

3. Removal of unbroken lines around blind corners

4. Enforce Road Closures during major cycling events

5. Consideration of cyclists riding in single file at all times

6. Review use of mirrors on corners

Mt Buller Resort management

31. Resort management provided a number of recommendations to the inquest, noting however that the Mt Buller Tourist Road is an end destination and so does not experience a large amount of through traffic or heavy vehicles.

32. The recommendations included:

1. The installation of signage warning vehicles to be aware of vehicles on the road.

2. Mirrors on blind corners

3. Promotional campaign by Vic Roads to improve general understanding of multiple road users.

4. The development of a communications tool by Vic Roads that can be circulated to known commercial suppliers who require heavy vehicle access to the Victorian resort, warning them to be aware of cyclists using the road

5. The creation of dedicated (asphalted) bike lanes along major resort access roads :

Bicycle Victoria

33. The inquest received an extensive submission from Bicycle Victoria which provided a great deal of background information on the increase in cycling numbers, the increasing incidence of cycling deaths, and serious injury and the dangers faced b cyclists in rural areas. . :

34, Bicycle Victoria outlined a number of risks to rural cyclists and proposed measures to ameliorate those risks, Some of them would only have limited application to cycling safety on alpine roads. Many of the recommendations nevertheless contain sensible observations and measures that require.consideration. .

35. Among the matters identified by Bicycle Victoria were ;

1. the sealing of toad shoulders in high risk areas

2. improved signage on known bike routes

3. better maintenance of road surfaces and removal of debris from the surface

4. improve sight lines by the removal of vegetation

Amy Gillett Foundation

36. The inquest received detailed and targeted submissions from the foundation on the question of cycling safety in alpine areas. :

37, The submissions included, but were not limited to;

1. Improved signage indicating gradients, sharp or blind bends or intersections and signage warning cyclists that to avoid setious injury in the event of a collision/ accident, that the trauma threshold is 35kmh.

2. Placement of “a metre matters” signage to gether with advice to wait until safe before passing riders

3. That cyclists should wear bright coloured clothing and use front and rear flashing lights particularly in poor conditions

4. Bicycle education and awareness and in particular, distribution of an alpine roads code of conduct and bicycle education and awareness programs to be distributed on alpine tourism websites.

Audax Australia Cycling Club

38. The club has been involved in organising cycling events in the alpine areas of Victoria for 26 years and holds a well-patronised cycling event in January of every year called the “Audax Alpine Classic”.

39. The club recommended the following to make alpine roads safer for cyclists and motorists; .

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Sealing of shoulders on valley roads. It was pointed out that on many natrow roads found in alpine valleys that the roads are narrow and that oncoming vehicles can create a sudden convergence leaving insufficient room on the road for two motor vehicles and a cyclist. The priority roads identified by the club were the Great Alpine way from Bright to Harrietville and the Kiewa Valley highway north of Tawonga South.

Monitoring of road conditions and pro-active maintenance to pr event debris and reduce the number of corrugations and potholes.

Mirrors on dangerous corners - the club noted the use of such mirrors in © alpine regions in Europe, and called for more research into their effectiveness in alpine areas particularly on hairpin or tight corners.

Driver education - the club recommended increasing. driver awareness of the vulnerability of cyclists in alpine areas as a result of travel in the areas often being on narrow winding roads with limited visibility due to weather conditions or road layout. The club also suggested a number of messages that could be contemplated by authorities.

Rider education - the club recommended the dissemination of rider safety information through cafes, hotels and visitor information centres in regard to weather, clothing and safe riding.

Distance markers on climbs - the club recommended distance markers to inform cyclists of distances so that they can better judge the distance and effort required to negotiate their journey without putting themselves at risk of _ fatigue at levels that may endanger their safety when high levels of concentration are required such as steep ascents or descents.

Cycle Tourism North East Vietoria

40, The cycling tourism officer representing the Rural City of Wangaratta, Alpine and Indigo Shires made a number of recommendations.

41. Those recommendations included; °

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The sealing of road shoulders on a number of roads identified by bike user groups as having high patronage from cyclists, including the Great Alpine Hwy between Bright and Harrietville,

Road signage, including comering rating on descents, reduced speed limits on blind spots and “share the road” signage on both the great Alpine Road between Wangaratta and Omeo and the Bogong High Plains Road

Cyclist education including funding for local area initiatives to promote cyclist awareness and driver behavioural change

Cyclist visibility, including mandatory fixture of lighting to bikes at point of sale.

Vie Roads

42, The inquest is grateful for the extensive and carefully considered submissions made by Vic Roads.

43, Vic Roads had determined that there were no road related factors that contributed to the collision, however since the incident Vic Roads has taken a number of steps to improve cyclist safety within the region generally.

44, Vic Roads also responded to the three safety issues arising from the terms of tefererice and a summary of their response is detailed below.

45. The submissions made were as follows; Use of great Alpine Road by large heavy vehicles

1. The nature of the terrain and high environmental value of the area the road passes through, leaves little scope for major engineering works to improve: the alignment of the road and to reduce the potential for crashes generally.

2. Vic Roads has obtained funding to seal a shoulder section of the great alpine road between chainage 78.38km to.81.35km

3. Vic Roads raised no specific objection to the mandating of pilot vehicles for oversize vehicles'on alpine roads.

Use of mirrors on blind bends

1. Vic Roads only use mirrors where sight distances are severely restricted and in accordance with guidelines. and management notes. The road does not meet their criteria for the use of mirrors. There are no plans to install them.

2. There is no evidence that mirrors would have prevented the collision, as the cause of the collision was cyclist error.

Use of signs to improve awareness of other road users

1. Vic Roads is currently in the process of evaluating whether further research is

required in relation to the effectiveness of bicycle warming signs aimed at drivers.

2. Vic Roads has installed an additional 33 sets of signs in the North East region alerting drivers to the presence of cyclists on the road, and to remind road users to share the road,

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COMMENTS AND RECOMMENDATIONS

Use of great Alpine Road by large heavy vehicles

[he driver of the heavy vehicle involved in the fatality under investigation did not contribute to the death of Rodd. The vehicle was being driven slowly and-on the correct side of the dividing line.

[he issue that arises from the circumstances surrounding the death is whether anything can be done to prevent fatalities or serious injury in similar circumstances in the future.

In considering the facts in this case, it is important to note that the vehicle in question was a long and heavy vehicle. Photographs of the scene depicting the truck would strongly suggest that given the length and width of the truck that it would have great difficulty negotiating a sharp or tight bend without crossing the median line.

Where a vehicle is required to frequently cross over the median line to negotiate a bend or turn, or where its sheer mass means it takes up a substantial portion of a lane, there atises a threshold issue. That issue is whether a pilot vehicle ought to be used to warn on coming traffic of the presence of a vehicle of that magnitude, and the manoeuvres necessary for it to ascend or descend such a road.

It would be trite to suggest that because the circumstances of this particular fatality did not involve a truck undertaking such manoeuvrers, that the inquest should not look at the safety considerations arising from the practice of driving oversized vehicles on such a road.

The powers conferred-by secs 67 and 72 of the Act require a Coroner to look at any means by which a collision between competing road users may be avoided in the future. ;

The Great Alpine Road is not unique in that it contains a number of hairpin and blind corners common to many alpine and coastal roads. Where it is unique, is the steep gradients found on the road, and the frequent adverse weather conditions it experiences. Its topography draws an ever-increasing number of recreational motor cyclists and cyclists.

The potential for collisions resulting in serious injury or a fatality are ever present given this mix of road users, conditions and topography. In considering the submissions made by the various parties, there is a sufficient basis for Vic Roads to consider the utility of requiring a pilot vehicle for over size vehicles (class 1) on the Great Alpine Road. Steep roads that contain multiple hairpin or blind bends which necessitate the vehicle crossing the centre median strip or where the vehicle’s mass means it takes up a substantial portion of the lane should only be navigated by class!

vehicles with the use of a pilot vehicle.

54, The existence of a pilot vehicle would serve not only to alert descending road users to the presence of such a vehicle, but also to the possibility that they may be required to stop entirely or slow down considerably on such a narrow road .

55, The cost and inconvenience to the transport industry would not outweigh the increase in safety to other road users brought about by a mandatory requirement to have a pilot vehicle escort over sized vehicles on roads such as the Great Alpine Road,

Recommendation

That heavy vehicles in excess of 19mctres (class 1 vehicles) be mandated to use a pilot vehicle whilst using the Great Alpine Road between Harrietville and Dinner Plain

Vic Roads should also consider such mandatory requirements for vehicles travelling on roads experiencing similar terrain such as the Bogong High Plains Road and Mt Buller Road.

Safety initiatives Comment

56, Any further research linking driver behaviour and cyclist safety through appropriate targeted signage is to be encouraged. The recent deployment of cycling safety signs ~ alerting motorists to the presence of cyclists and the need to share the road in alpine areas is commendable.

57, Signage that alerts road users to the dangers and risk associated with the use of alpine roads is also to be encouraged. The placement and format of such signs is beyond the expertise of this inquest, but focusing the minds of potential users of the alpine roads on the dangers associated with such use, has the potential of reducing exposure to harm through better-informed decision making, and potentially more conservative driving/riding behaviour.

58. Identifying through signage the incidence of serious injury and death on a road, is but one example that may be useful in bringing about the requisite behaviour change.

‘59, Many of the submissions received identified a strong need for asphalt shoulders on roads, which attract high levels of motor vehicle traffic and cyclists. Typically, cyclists will avoid high traffic roads with no shoulder unless there is no other route possible, The Great Alpine Road between Bright and Harrietville is the only road that provides access to Mt Hotham and consideration ought to be given, subject to a detailed cost/ benefit analysis to creating a shoulder on this stretch of road.

60. The fact that the use of mirrors on roads such as the Great Alpine Road, do not fit within Vic Roads guidelines should not be a bar to considering whether they may be

auseful safety tool in certain areas of the road. The practice, as noted by some of the.

submissions received, is not an uncommon one in Europe, and a trial of such mirrors ought not to be so cost prohibitive to justify dismissing consideration, of their use on the road. . ‘

pues

. Subject to a detailed cost/benefit analysis any organised cycling event on this road or other similar alpine roads, which involve cyclists descending at speed, be closed to motor vehicle traffic for the duration of the event.

Signature: