Finding into death of Mr ST

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2014 006579

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: Paresa Antoniadis Spanos, Coroner Deceased: MrsT Date of birth: 2 January 1980 Date of death: 29 December 2014 Cause of death: Multiple injuries

Place of death: West Melbourne

I, PARESA ANTONIADIS SPANOS, Coroner,

having investigated the death of Mr ST without holding an inquest:

find that the identity of the deceased was Mr ST born on 2 January 1980 and that the death occurred on 29 December 2014

at Appleton Dock Road, West Melbourne, Victoria 3003

from:

I(a)

MULTPLE INJURIES

Pursuant to section 67(1) of the Coroners Act 2008, I make findings with respect to the following circumstances:

Mr ST was a 34-year old forklift driver who lived with his father in Lakes Entrance. He was the third of the four children born to his parents. He was a ‘happy-go-lucky kid’ growing up in the Gippsland area, a good student and keen sportsman who developed an interest in

motorcycles and classic cars in adolescence.

Mr ST started to ride motorcycles in the bush at the age of twelve. He owned his first motorcycle at 13 years of age and started rebuilding engines and restoring cars with his father around the same time. According to his father, once licenced to drive/ride, Mr ST was a competent and sensible motorcyclist, though he did receive a few speeding tickets, Mr ST had also been found guilty of offences involving driving in breach of driver’s licence/permit conditions, driving without a licence and using an unregistered vehicle, though none after

After completing tertiary studies, Mr ST returned to work as a trawler fisherman. He met his fature wife, Ms DA, while at university and was devastated when she was killed in a motor

vehicle collision three years after their marriage in 2009.

in November 2013, Mr ST commenced work as a forklift driver with a company in Melbourne, dividing his time between his father’s home in Lakes Entrance and the home of a friend, Mr JR, in Altona Meadows. He apparently loved the job but disliked ‘fast-paced’

Melbourne, remaining a ‘country boy’ at heart.

Between about 7.45am and 8.30am on 29 December 2014, Scott Spence, an employee of Murray Goulburn Global Distribution Centre situated on Appleton Dock Road between Coode Road and Anderson Road in West Melbourne, saw an orange and black Honda motorcycle [Honda] being ridden down Appleton Dock Road several times at a spced estimated to be well

in excess of 100 kilometres per hour [km/p/h].

Around 8.45am, Chris Devon was working in the Patrick’s Port Logistics yard near cyclone

fencing adjacent to the westbound carriageway of Appleton Dock Road, near its intersection

with Anderson Road. He observed an Iveco prime mover with skeleton trailer [Iveco] parked

with its engine off in the “Truck Queue Lane’, the lane closest to him on Appleton Dock Road.

Mr Devon saw the Iveco slowly drive out of the Truck Queue Lane and into and across the

westbound lanes of Appleton Dock Road as though positioning itself to perform a U-turn or to

turn right into Anderson Road. Simultancously, he first heard and then saw a motorcycle approaching from Coode Road, accelerating and shifting through the gears quickly as it travelled on Appleton Dock Road towards Anderson Road. Mr Devon lost sight of the Honda

behind the Iveco’s trailer before hearing a collision.

Mr Devon and other witnesses attended to render assistance and found the motorcyclist, later identified as Mr ST,! lying on the road, unresponsive and with obvious injuries, not far from the Honda and the Iveco which was stopped in the middle of the road wholly blocking the westbound lanes of Appleton Dock Road. The Iveco’s driver-side cabin and stairs were

damaged in the impact.

Emergency services were called. Attending paramedics found Mr ST not breathing, without a pulse and with injuries incompatible with life. A short time later, he was pronounced.

deceased at the scene.

Police attended to secure the scene, co-ordinate traffic movement and commence the investigation of the collision and Mr ST’s death. This finding is based on the brief of evidence compiled by one of the attending police officers, Senior Constable Phillip La Peyre of Melbourne Highway Patrol. The brief includes documents showing that:

a. Appleton Dock Road has a posted speed limit of 50 km/p/h and is a bitumised.

surface that is in good repair. The road runs roughly north-east to south-west through a predominantly industrial area. Appleton Dock Road consists of four lanes for traffic, the two eastbound and the two westbound lanes divided by broken white lines and the eastbound and westbound carriageways separated by a single solid white line until the cast of the Appleton Dock-Anderson Road intersection where there is a traffic island with a ‘Keep Left’ sign. The solid white dividing line

resumes west of the intersection.

b. There are truck queue lanes, used as a truck parking areas, on the edge of the westbound carriageway and on the edge of the castbound carriageway south-west of

the intersection of Appleton Dock and Anderson Roads.

‘Mr ST was presumptively identified at the scene from identification documents found in a wallet in his possession and by the visual identification provided Mr JR. Mr ST was formally identified by his father on 31 December 2014.

The Appleton Dock-Anderson Road intersection is a Y-shaped junction. There are two entry points to Anderson Road from Appleton Dock Road, one via the two lanes for right-turning westbound traffic and, relevantly, a second for eastbound traffic via a slip lane.

Following the collision, the Iveco stopped west of the Appleton Dock-Anderson Road intersection with its nose over the continuous white line centre line, facing north, with the prime mover and trailer blocking both westbound lanes, the trailer still facing west. Impact damage was evident on the driver’s side of truck, on the

cabin wall just behind the driver’s door and to the steps leading to driver’s door.

The motorcycle, with significant damage consistent with a front end collision, came to rest on its side in the outside westbound lane while Mr ST was found prone in the

eastbound carriageway, both about two metres from the prime mover.

Askid mark from a single tyre was apparent on the road in the left-hand westbound

lane, ceasing in line with the stairs to the Iveco’s cabin.

Scuff marks were evident on the road from the rear of the Iveco’s trailer to the parking bay further behind it. According to Andrew Stroud, a VicRoads’ Automotive Technician, these marks were suggestive of the Iveco moving off without sufficient running time to pressurise the trailer’s braking system, causing the

trailer’s tyres to skid and leave the marks on the road.

. The Honda was in good condition prior to the collision. It had been in third gear at the time of the collision. A full mechanical inspection performed by Leading Senior Constable Ian Ellis of the Mechanical Investigation Unit identified no mechanical

fault that may have caused or contributed to the collision.

Mr Stroud inspected the Iveco prime mover and trailer identifying a number of faults including worn tires, a major oil leak, cracked rear indicator lights and an insecure front axle suspension I-beam that pre-dated the collision. He formed the view that the Iveco had been poorly maintained and was not roadworthy. Mr Stroud did not

comment on whether these faults may have caused or contributed to the collision.

Mr ST was licenced to drive cars and to ride motorcycles. He had been wearing motorcycling leathers and a helmet at the time of the collision, but police were unable to determine whether the helmet had been securely fastened as the chin strap

was tucked up near the cheek pads when they arrived.

Ll.

k. A number of witnesses observed the Honda travelling at estimated speeds of up to

130 km/p/h prior to and around the time of the collision.

1. Mr Basam Saloom, the 49-year old male driver of the Iveco, was licenced to drive cars and heavy combination vehicles at the time of the collision. Preliminary breath

and oral fluid tests conducted after the collision detected no alcohol or drugs.

m. At the time of the collision, traffic conditions were moderate, and the weather was

fine and dry.

On the basis of his investigation of the collision, SC La Peyre opined that Mr Saloom had parked the Iveco in the west-facing Truck Queue Lane on Appleton Dock Road. Upon receiving a text message notifying him to collect his load, he started the engine, moving off before the trailer’s braking system had pressurised, causing the tyres to skid. Mr Saloom commenced an illegal U-turn and apparently misjudged the speed of Mr ST’s Honda which was travelling at a speed in excess of the posted speed limit westbound on Appleton Dock Road. He considered Mr Saloom’s unsafe U-turn and Mr ST’s excessive speed to have

contributed to the collision.

Mr Saloom was charged with the offences of failing to give way when making a U-turn, performing an unsafe U-turn and driving across a single dividing line to perform a U-turn.

The offences were found proven when heard at Melbourne Magistrates’ Court in 2016, and an

aggregate fine was imposed.

Senior forensic pathologist, Associate Professor David Ranson of the Victorian Institute of Forensic Medicine, reviewed the circumstances of the death as reported by police to the coroner, post-mortem computer assisted tomography [PMCT] scans of the whole body and performed an external examination. Among A/Prof Ranson’s anatomical findings were bruising, abrasions and lacerations scattered over much of Mr ST’s body together with

visceral injuries and extensive fracturing to the skull, spine, ribs and limbs.

Routine toxicological analysis of post-mortem specimens detected delta-9tetrahydrocamnabinol at a level of ~13ng/mL, indicative of recent use of cannabis, but no other

commonly encountered drugs, poisons or alcohol.

A/Prof attributed Mr ST’s death to multiple injuries.

On 7 June 2016, I attended the scene for a “view” in the company of SC La Peyre and a member of the Police Coronial Support Unit. En route to the collision site, we travelled by car along the route Mr ST was likely to have taken given the road layout and the observations of

witnesses along Coode and Appleton Dock Roads in West Melbourne.

We also parked for a period in the Truck Queue Lane adjacent to the westbound carriageway of Appleton Dock Road near its intersection with Anderson Road. Here, we observed several prime movers perform illegal U-turns from parking positions in the Truck Queue Lane in order to enter Anderson Road via the slip road intended for left-turning eastbound vehicles

traveling along Appleton Dock Road, thus entering the dock via the shortest route.

{am advised that the Port of Melbourne Authority and VicRoads are jointly responsible for

the roads around the dock.

I find that Mr ST, late of Lakes Entrance, died on 29 December 2014 of the multiple injuries he sustained as a motorcyclist involved in a collision with a prime mover and skeleton trailer performing an unsafe and illegal U-turn across the westbound lanes of Appleton Dock Road,

West Melbourne.

I further find it likely that the speed at which Mr ST was travelling, a speed well in excess of the 50 km/p/h posted limit, contributed to the collision.

RECOMMENDATION

Pursuant to section 72(2) of the Corners Act 2008, I make the following recommendation in

connection with the death, including matters relating to public safety or the administration of

justice:

While | find that a combination of factors contributed to the collision in which Mr ST died, my observations at the scene amply demonstrated the ease and frequency with which heavy vehicles performed illegal U-turns from the westbound carriageway of Appleton Dock Road and into Anderson Road in order to enter the dock by the shortest route. This situation is

unsatisfactory and, as Mr ST’s death highlights, unsafe.

I therefore recommend that the Port of Melbourne Corporation and VicRoads review the

area and consider remediation of the road layout at the Appleton Dock-Anderson Road intersection, West Melbourne, either by construction of a physical barricr to prevent illegal U-turns at the collision site, a viable roundabout or U-turn facility further down Appleton

Dock Road or otherwise.

I direct that a copy of this finding be provided to the following: Mr ST’s family Port of Melbourne Corporation VicRoads Transport Accident Commission

Senior Constable Phillip La Peyre (#37240) c/o O.LC. Melbourne Highway Patrol

Signature:

PARESA ANTONIADIS SPANOS CORONER Date: 23 June 2017