Finding into death of AD

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2011 1843

REDACTED FINDING INTO DEATH WITHOUT INQUEST

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

i, PARESA ANTONIADIS SPANOS, Coroner,

having investigated the death of AD without holding an inquest: find that the identity of the deceased was AD

born on 11 November 1989

and that the death occurred on the 21 May 2011

on the eastbound lanes of Citylink, about 200m west of the entrance to the Burnley Tunnel, Southbank, Victoria 3006

from:

1 (a) MULTIPLE INJURIES SUSTAINED IN A MOTOR VEHICLE INCIDENT

(MOTORCYCLIST)

Pursuant to section 67(2) of the Coroners Act 2008, I make findings with respect to the following

circumstances:

1, AD was a 21 year old single man who resided with his family in Bundoora. He obtained his motorcycle rider licence on 22 February 2011 which was subject to a number of conditions, He was not to carry any pillion passenger, not to exceed a blood alcohol concentration of 0.00% and to comply with the Learner Approved Motorcycle Scheme (LAMS). The latter is a scheme designed to protect inexperienced motorcyclists by restricting the motorcycles they

are permitied to ride while learning by reference to engine capacity, generally less than 660cc.

2. At about 2.30pm on Saturday 21 May 2011, Mr AD met up with an acquaintance at a Sheil service station at 127 Plenty Road, Bundoora. He was riding an unregistered 2006 Yamaha YZFR1 motorcycle purchased one month earlier from an acquaintance on the understanding

that he would obtain a roadworthy certificate and arrange for its re-registration. The

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motorcycle’s engine capacity was 1000 ce and, by riding it, Mr AD was in breach of his licence conditions. After rcfuclling, they rode off on their respective motorcycles at about 2.35pm, travelling along the Metropolitan Ring Road. A number of witnesses stated that both motorcycles appeared to be travelling at excessive speeds, with one witness believing them to

be engaged in a “road rage” type incident.

They left the Metropolitan Ring Road and continued city bound on the Westgate Freeway to the Kings Way off-ramp which is a two-lane wide sweeping right-hand bend with a downward slope. The off-ramp is effectively an overpass over Citylink, with the Burnley Tunnel entrance some 500 metres further east along Citylink. While travelling in the left lane, Mr AD failed to negotiate the right-hand bend of the off-ramp, collided with the concrete barrier and rode up and over the side of the concrete barrier, landing in the centre of the three castbound lanes of Citylink. Mr AD and his motorcycle were separated at some point in the fall with the motorcycle coming to rest in the centre median strip, which separates the eastbound and westbound lanes of Citylink. Mr AD’s motorcycle helmet landed in the left castbound lane as did the motorcycle’s fuel tank.

Fortuitously, no other vehicles became involved in the collision, cither those travelling on the off-ramp, or those travelling on the eastbound lanes below, all of which managed to stop west of where Mr AD lay. A number of passers-by, including a registered nurse, came to Mr AD's assistance. She found him unconscious, bleeding profusely from his ears, nose and mouth, with no apparent signs of breathing and, initially, a thready pulse which faded when she ’ checked her watch at 3.07pm. Mr AD’s acquaintance saw Mr AD fail to negotiate the right hand bend, hit the barrier and go over the side. When he stopped, he looked over the edge and saw Mr AD lying on the ground, he rode on to the St Kilda Road Police Station to report the

matter,

Ambulance officers arrived a short time after the collision and confirmed that Mr AD was

deceased. Police arrived to secure the scene, deal with the emerging traffic problem and

commence their investigation of the collision. This finding is based on the investigation and bricf of evidence compiled by one of the attending police officers, Constable Joe Faraci from

the Melbourne Highway Patrol. The brief includes —

e A statement from Scnior Constabic Stuart Jones from the Mechanical Investigation Unit

confirming that the motorcycle was in a roadworthy condition at the time of the collision.

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e A statement from Detective Leading Senior Constable Jenelle Mehegan from the Major Collision Investigation Unit (MCIU) who made a number of calculations based on the physical evidence and configuration at the scene and concluded that when the motorcycle first commenced to yaw it was travelling at a minimum of 87.9kph and when it first left the

concrete barrier it was travelling at a minimum of 74kph.

e Several statements from eyewitnesses who described both motorcycles as driving at excessive speeds, that is well in excess of the 80kph speed limit and in a dangerous manner

immediately prior to the collision.

e A statement from the investigator, Constable Faraci, verifying that the weather was fine, the road was dry, visibility was excellent, and apart from the height of the concrete barrier which will be discussed below, there were no problems with the road surface or road infrastructure which could be said to have caused or contributed to the collision. The offramp is an 80kph zone with 50kph advisory signs clearly visible at the commencement of

the right hand bend.

6. Constable Faraci concluded that the collision resulted from Mr AD’s inexpericnce, excessive speed and dangerous manner of riding. Included in the brief was information that there had been a previous collision in the vicinity, also involving a motorcycle falling from the off-ramp

on to the roadway below.

7. There was no autopsy as Forensic Pathologist Dr Yeliena Baber from the Victorian Institute of Forensic Medicine (VIFM) performed a preliminary examination in the mortuary, reviewed the circumstances as reported by the police and post-mortem CT scamming of the whole body (PMCT) and advised that it would be reasonable to attribute death to multiple injuries sustained in a motor vehicle incident (motorcyclist) without the need for an autopsy. Dr Baber advised that her external examination showed traumatic injuries consistent with the clinical history, and that PMCT showed multiple facial fractures, fractures to the jaw, skull, cervical spine, multiple fractures to the right side of the body, bilateral

haemopneumothoraces! and pneumocephaly.’

' Blood and air within the chest cavity.

Air within the cranial cavity,

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11,

12,

Toxicological analysis of post-mortem samples undertaken at VIFM revealed no alcohol or

other commonly encountered drugs or poisons, apart from paracetamol.

Special analysis undertaken at the Australian Sports Drug Testing Laboratory, New South Wales, revealed the presence of anabolic steroid hormones in post-mortem urine, specifically testosterone/epitestosterone at a ratio of 58:1, indicative of an external source of testosterone over and above the body’s natural production; boldenone, an anabolic steroid is used in veterinary practice, with no approved use in humans, which is long lived in the body and can be detected for months after usc; and, metabolites of methandienone, a powerful androgenic/anabolic steroid, not available for human use in Australia, which is taken orally

and the metabolites of which can be detected in urine for several days after use.

Clinical Forensic Physician Dr Morris O’Dell from VIFM advised that anabolic/androgenic steroid hormones are used by body builders in an uncontrolled way to achieve an increase in muscle mass and bulk. This is not an approved or legitimate medical usc and there is no safe dose for otherwise healthy people. There arc many detrimental side effects. While they may make a person feel healthy and euphoric on first usc, androgenic steroid hormones can also cause mood swings and an increase in aggression, paranoia and depression. Effects are very

varied depending on individual factors, dose, type of hormone and duration of use.

When asked to comment on the likelihood that Mr AD’s use of these substances may have caused or contributed to risk-taking or aggressive riding behaviours, Dr O’Dell advised that he could not give an opinion regarding the effects in a particular person especially based on urine results as these are only useful qualitatively, and cannot be interpreted preciscly in terms of dose or possible effects, He did advise that, in general, the effects of steroids ave not acute, that is they build up over weeks and months, and take as long to disappear once use of the

steroid has ceased,

Based on all the evidence available to me, I find that Mr AD died from multiple injuries sustained in a single vehicle collision in which hc was a motorcycle rider, I find that his relative inexperience as a rider, the excessive power of the motorcycle he was riding, and excessive speed were all factors which arc likely to have contributed to the collision in which he suffered fatal injuries. The evidence does not support a finding that Mr AD’s use of

anabolic and/or androgenic steroids played any role in his death.

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COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected with the death:

1. Further advice was sought from the MCIU about other similar collisions in this vicinity.

Apart from the collision involving Mr AD, there has been another collision involving a motorcycle rider in virtually identical circumstances. A third collision occurred at the Power Street on-ramp to the Westgate Freeway when a motor vehicle driver failed to give way to an oncoming motorcycle rider, the rider impacted the motor vchicle windscreen, becoming airborne and passing over the concrete barrier/guardrail to land on the Domain Tunnel exit

lanes below.

2. In relation to the latter collision, VicRoads advised that they made changes to the traffic control signals so as to prevent collisions involving right turning traffic at this location. In relation to the other two collisions, including the one involving Mr AD, VicRoads advised that they are reviewing several options to increase the height of the railing at this location, before finalising the project proposal, The growth advised that proposals for improvement projects

must be considered and evaluated on a state-wide basis.

3. VicRoads also advised that the elevated section of the Kingsway off-ramp has a barrier plus a rail height of approximately 1.15m which is in accordance with the relevant standards at the time the ramp was built. The. relevant Australian Standard AS5100 is currently being reviewed. In particular, bridge barrier height is being reviewed to accommodate cyclists and motorcyclists in accordance with Austroads Guidelines. It is anticipated that the revised

AS5100 will not be finalised until 2013.

4, While I am mindful of the extent to which Mr AD’s mamner of riding contributed to the collision, the height of the barriers is problematic from a public safety perspective. While the lower height has aesthetic advantages, such collisions have the potential to imperil not only

the rider but any number of other road users, either on the off-ramp or on the roadway below.

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

The family of Mr AD Constable Joe Faraci c/o O.1.C. Diamond Creek Police/TMU

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O.LC. Major Collision Investigation Unit Ms Patricia Liew, Regional Director, Metro North West Region, VicRoads

Signature:

pao

PARESA ANTONIADIS SPANOS CORONER Date: 19 October 2012

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