Finding into death of Stuart Bullas

IN THE CORONERS COURT OF VICTORIA

AT MELBOURNE Court Reference: 1465/11

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

1, JOHN OLLE, Coroner having investigated the death of STUART BULLAS’

without holding an inquest:

find that the identity of the deceased was STUART THOMAS BULLAS born on 24 November 1987

and the death occurred on (between) 25 Apt il 2011

at Intersection Sydney Road and Phoenix Street, Brunswick, Victoria 3056

from:

1 (a) MULTIPLE INJURIES

Pursuant to Section 67(2) of the Coroners ‘Act 2008, Imake these findings with respect to the following circumstances;

1. Stuart Bullas was aged 23 years at the time of his death. He lived at 1/296 Hope Street,

Brunswick West.

2, The coronial brief has fully addressed the tragic circumstances of Stuart’s death.

3. Stuart and his younger sister were raised by his parents in their family home at Coburg. He.

lived independently from 2009, He achieved Year 12 qualifications and worked in hospitality

for several years after leaving school.

4, His father detailed a normal upbringing, Stuart had a keen interest in music. A passionate

drummer who played a variety of instruments,

5, Stuart played in vations bands at venues in his local area, He had retained a large circle of

friends from his’ school years and made new friends in adulthood, He socialised easily and

was well liked.

7 “Coroners Court (Amendment No, 1} Rules 2044

Stuart was a light drinker during the week, but enjoyed alcohol on the weekends, He retained a friendship with a former girlfriend who had moved to Perth, though each were committed to

living their own lives,

Cireumstances

i.

On the evening of his death, Stuart was attending a “Bucks Patty” with friends, The

celebration was into its second day and had seen heavy consumption of alcohol, At about 10.45pm the group were walking in a westerly direction along Sydney Road. They approached

the Phoenix Street intersection (the intersection).

A prime-mover/semi-trailer (the vehicle) driven by Tony Hayward was waitmg to enter Sydney Road from Phoenix Street. It was facing a “Give Way” sign, When a gap in the traffic presented Mr Hayward moved the vehicle into Sydney Road, however was unexpectedly required to stop due to heavy traffic congestion. The trailer of the vehicle was stationary across the intersection blocking the path of pedestrians. Most of the, young men

walked behind the vehicle, Stuart chose to duck under the trailer.

A witness belioves Stuart struck his head on the undercartiage before the vehicle moved. In any evont, Mr Hayward commenced to turn, driving over Stuart. The vehicle immediately stopped and emergency services called, Lay witnesses performed CPR until the ambulance

arrived, however Stuart had sustained fatal injuries.

Stuart was not encouraged by his frlends to climb under the trailer, He did so of his own volition. It was a tragic decision made whilst under the influence of alcohol, I concur with

the conclusion of the coronial investigator:

“Given Paul Hayward was in the process of turning his vehicle to the right, there was no way

he could have possibly have seen Stuart walk under the semi-trailer, even if he were of a mind to be on the lookout for such an unusual event. I can find no fault in the actions of Paul

Hayward regarding the collision.

At the time of the collision the weather was fine and clear the road surface was dry, visibility

was good due to ample street lighting and the level of traffic was moderate, a

' Summary coronial investigator Inquest Brief,

Coroners Court ( Amendment No. 1) Rules BOL)

12. Stuart was a well adjusted young man, loved by family and friends. He sustained fatal injuries,

having made a momentary error of judgement, whilst under the influence of alcohol.

13. Panl Hayward bears.no responsibility for the tragic circumstances of Stuart’s death,

Post Mortem Medical Examination

14, On 26 April 2011, Dr Michael Burke, Forensic Pathologist with the Victorian Institute of Forensic Medicine, performed an external examination only on the body of Stuart Thomas

Bullas; Dr Burke found the cause of death to be multiple injuries.

Comments:

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected

with the death: ‘

1. • The coronial investigator has recommended that protective guard or railing known as underrun protection bars could have prevented Stuart’s death, ‘The bats run along the length of the trailer on cither side, between the top of the under carriage down to approximately 200mm

above the road surface.

Leading Senior Constable Brilliant, states:

“While the primary purpose of the bar ts to prevent smaller vehicles such as motoreyctes, cars and bicycles from entering the cavity underneath the ivailer in the event of a "T-bone” or “side-swipe” style collision, the bars will also deter and/or prevent pedestrians crawling or

walking under the trailer in similar circumstances to that of the deceased.

This item is already manufactured by several companies in both steel and lighter weight aluminium, They are readily available and can be retrospectively fitted to virtually any senti-

trailer or B-double combination,”

At my sequest the Coroner’s Prevention Unit (CPU)* have researched the prevalence of similar circumstances and/or the appropriateness of the recommendation made by Leading

Senior Constable Brilliant.

2 Statement Leading Senior Constable Anthony Brilliant.

3 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 safety.

Coroners Court (Amendment No. t) Rules 2011

Heavy vehicle underrun incidents A heavy vehicle underrun crash occurs when a passenger car, motorcycle, bicycle or

pedestrian slides underneath the front, side, or rear end of a heavy commercial vehicle.

Each year in Australia, approximately 35 people are kifled in heavy vehicle underrun crashes,

with most victims being car occupants. Pedestrian deaths are difficult to quantify, a previous

estimate has been 5-7 deaths annually in Australia, Front underrun is the most common

scenario and accounts for around 75% of all underrun trawma, while side nnderrun accounts for 15%, These figures are likely to increase given an expected doubling of the freight

transport task by 2020.4

Side underrun protection for trucks

It was S/C Brillignt’s belief that Mr Bullas’ death could have been.prevented had a side guard

been installed on the semi trailer,

Crrrent situation

At present, there is no legislative requirement for heavy vehicles in Australia to be fitted with side underrun protection, From Jannary 2011 however, front underrim protection is mandatory for new rigid and articulated heavy cominercial vehicles of NC category (a Gross Vehicle Mass greater than 12 tonnes) and all existing vehicles are required to be fitted by January 2012.5 An estimated 10 lives will be saved annually in Australia due to the fitting of front

underrun protection,

A Regulation Impact Statement (RIS) for underrun protection was released by the Australian Government in July 2009, with the aim of determining whether government intervention towards new vehicle construction was necessary to reduce underran orashes.® The RIS did not recommend that side or rear underren protection be mandated on a cost-benefit basis, however

mandatory front underrun protection was deemed appropriate.

4 Information obtained from: Australian Government Department of Infrastructure, Transport, Regional Development and Local Government, Regdation Impact Statement for Underrun Protection, July 2009,

5 Vehicle Standard (Australian Design Rule $4/00 — Front Underrin Impact Protection) 2009, Also see: New Truck Safety Rule to Save Lives, Media Release 16 September 2009, Retrieved from: http:/Awww.minister infrastructure. gov.au/aa/releases/2009/September/AA398_2009.aspx

6 Australian Government Department of Infrastructere, Transport, Regional Development and Local Government.

Regulation Impact Statement for Underriut Protection, July 2009,

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The voluntary uptake of underrun protection has been described as poor, This is largely duc to the competitive nature of the industry, thé costs being borne by the vehicle manufacturer which ate then passed onto the operator and consumer, and because the safety benefits are

ultimately to other road users,

Victoria and Australia’s road safety strategies

In relation to safer heavy vehicles, Victoria’s Road Safety Strategy Arrive Alive 2008-2017

states: .

Heavy vehicles with improved scatbelt systems, improved cabin strength and better underrun protection have the potential to improve safety for all road users, These improvements could be achieved through the introduction of Australian Design Rules for heavy vehicle cabin

strength, and front, rear and side underran protection,

The National Road Safety Strategy 2011-2020 makes no specific reference to side underrun

protection.

Other industry views

The Transport Industry Safety Group of Victoria’s Buying a Safer Truck publication (2005)

includes reference to the importance of front, side and rear underrun protection,

A 2010 report by the NRMA supports the adoption of side undetrun protection for heavy

vehicles in Australia.” RACV also appear to support the uptake of side underran guards.*

The Australian Government has previously investigated options for improving the uptake of tinderran protection for heavy vehicles in Australia, While front underrun protection has since become mandatory, there are no existing requirements for side or rear underrun protection to he fitted,

TNRMA. The safety needs of heavy vehicles in Australia, A report prepared by NRMA Motoring & Services, March

2010,

® RACV, Vehicle crash compatibility. Retrieved 13 April 2012 fiom: http/www.racy, -gomaulwpshven/eonneovnferne/primaryiy+caentsaferysafety rad vice/vehite torashcompatabi

lity

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3, The value of side undetrun protection in improving the safety of road users such as car occupants, motorcyclists, cyclists and pedestrians, has been recognised for a considerable

period of time,

4, While side underrun protection is not generally designed to address the type of incident that sadly led to Mr Bullas’ death, it may nevertheless have served a role in preventing him from

entering beneath the stationary trailer.

5, Thave been made aware of the Regulation Impact Statement for Underrun Protection released by the Australian Government in July 2009, including the decision not to mandate side underrun protection for heavy vehicles on a cost-benefit basis. Despite this outcome, the uptake of side underrun guarding among heavy vehicles in Australia should continue to be

promoted,

Recommendations: _ Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendations

connected with the death:

1. That the Department of Infrastructure and ‘I'ransport (Commonwealth) further investigate and adopt appropriate measures to improve the uptake of side underrun protection among -commiercial heavy vehicles in Australia to reduce the incidence of road trauma resulting from

side underrun events,

I direct that a copy of this finding be provided to the following:

Senior next of kin; Investigating Member

Department of Infrastructure (Commonwealth);

Signature:

JOHN OLLE CORONER 30 April 2012

Coroners Court (Amendment No. 1) Rules 2014