Finding into death of Jodi Michelle Walsham

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2015 1120

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

Findings of: Paresa Antoniadis Spanos, Coroner

Deceased: Jodi Michelle Walsham

Date of birth: 23 November 1972

Date of death: 7 March 2015

Cause of death: Multiple injuries (motor vehicle impact — motorcycle passenger)

Place of death: Ensay

I, PARESA ANTONIADIS SPANOS, Coroner,

having investigated the death of JOD] MICHELLE WALSHAM without holding an inquest: find that the identity of the deceased was JODI MICHELLE WALSHAM

born on 23 November 1972

and that the death occurred on 7 March 2015

at the Great Alpine Road, Ensay, Victoria 3895

from: I(a) MULTIPLE INJURIES (MOTOR VEHICLE IMPACT —- MOTORCYCLE PASSENGER)

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

1. Jodi Michelle Walsham was a 42-year-old woman who was living in Bayswater North at the time of her death. She is survived by her two children: Dayna and Reece. Ms Walsham had

no known health issues.

2. Ms Walsham often went on motorcycle trips with her partner, Mark Rodgers. According to Justin Ezard, a friend of the couple, Ms Walsham was ‘very experienced as a pillion

[passenger]’ and ‘loved being on the bikes’.!

3. On the morning of Friday 6 March 2015, Mr Rodgers, arrived at Mr Ezard’s home riding his 2007 black Harley Davidson Softail motorcycle [Harley]. The plan was for the two men to ride to Bairnsdale, where they would meet Ms Walsham, Mr Ezard’s wife Tracey and another couple, Tony Ratcliffe and Gina Ezard. The group intended to spend the night

together in Bairnsdale before riding out to Harrietville the following day.

4, At about 11:00am, Mr Rodgers and Mr Ezard headed out, with Mr Rodgers on his own Harley and Mr Ezard riding his black 2007 Hayley Davidson Dyna Street Bob. They rode towards Warburton and turned off at Yarra Junction to head towards Noojee, stopping several times due to poor weather conditions. From Noojee, they rode through Traralgon before heading out to Bairnsdale, arriving at the Terminus Hotel at about 5:00pm.

According to Mr Ezard, it was an easy, controlled ride despite the wet weather.

5. At about 10:30pm, Ms Walsham, Mrs Ezard and Ms Ezard arrived at the Terminus Hotel, having caught a train to Bairnsdale. The group had dinner and drinks together and went to bed at around midnight.

6. On the morning of Saturday 7 March 2015, the group ate breakfast together and packed the bikes before leaving the Terminus Hotel at around 11:00am to refuel. They intended to ride

up through Bruthen, follow the Great Alpine Road [GAR] through Omeo and stop at the

' Coronial Brief of Evidence, Statement of Justin Ezard, p. 51.

Page I

Blue Duck Inn in Anglers Rest for lunch, before continuing on to Harrietville to spend the night. They left in convoy shortly afterwards, with Mr Ratcliffe in the lead, Mr Ezard behind him and Mr Rodgers bringing up the rear, and the three women riding as pillion

passengers.

7. At Bruthen, the GAR turns sharply left and continues north towards Omeo and Mount Hotham. Not long after this tum, Mr Rodgers overtook Mr Ezard and Mr Ratcliffe on a straight section of road and rode off ahead. Mr Ezard said that this was not unexpected, as Mr Rodgers was a more confident rider than himself and Mr Ratcliffe. Mr Rodgers continued north on the GAR and, about 45 kilometres from Bruthen, encountered a line of five cars. David Palmer, who was driving the centre car, saw a black Harley Davidson come up behind him, before accelerating and overtaking the entire line of traffic on a blind left-

hand corner.

8. Between Bruthen and Ensay, the GAR becomes windy and slowly rises in altitude as it follows the Tambo River, before becoming enclosed by a tree canopy. The speed limit on this section changes from 100 kilometres per hour [kph] to 80 kph as the road narrows. The GAR then climbs through a tight enclosed rock cutting whilst curving hard to the left, with no forward visibility for overtaking. At the top of the cutting the road opens out to a 300 metre straight stretch of road, known locally as the ‘Devil’s Backbone’. At this location, there is a small window of opportunity for motorcycles to overtake, due to their heavy acceleration capacity, whereas motor vehicles or larger vehicles could not do so before the

blind left hand bend ahead.

9, Upon reaching the ‘Devil’s Backbone’, Mr Rodgers encountered another line of traffic.

Neil Switzer was driving at the front of the line and saw a large black motorcycle with a rider and pillion passenger come up behind him quickly and overtake on the straight. Mr Switzer then saw the motorcycle take the tight left-hand bend up ahead, faster that the advisory speed limit of 45 kph but below the 80 kph posted speed Jimit, and disappear out of

sight.

10. As Mr Rodgers rounded the bend, a substantial bitumen mound, known as a ‘push-out’ or ‘shove’, appeared in the road surface.* The presence of the shove caused Mr Rodgers to

lose control of his Harley and swerve into the oncoming lane.

11. Meanwhile, Leading Senior Constable Gavin Murphy was travelling south on the GAR from

Omeo to Bairnsdale on a routine trip in a marked Victoria Police Nissan Patrol four wheel

2 For the sake of consistency, the road defect will be referred to as a ‘shove’ for the remainder of the finding.

drive [Patrol]. LSC Murphy entered a tight uphill left curve, and as he exited the curve, saw a black motorcycle heading straight towards him. LSC Murphy braked and moved as far left as he could but was unable to avoid a collision. The motorcycle ‘dropped’ immediately before impact, striking the Patrol at bulbar level and forcing the motorcycle and its occupants undemeath the Patrol, before bursting into flames. LSC Murphy reversed the Patrol and contacted emergency services before returning to render assistance. He attempted to extinguish the flames and dragged Mr Rodgers and Ms Walsham away from

the burning motorcycle.

12. Almost immediately thereafter, Mr Ezard reached the left-hand turn, travelling at about 40 kph and hit the shove, which he described as “a hard, sharp jolt which hit the forks and rear wheel hard. It was like a mini-ramp. It appeared about three foot long, six inches wide and six inches high. It was big and it would not have been any fun to hit it at a faster speed. I didn’t lose control when I hit the bump as I hit it ‘dead-on’. It was just the slam when you hit it’? Mr Ezard continued negotiating the turn and saw a rider on the ground, who he immediately recognised as Mr Rodgers because of his jacket. Mr Rodgers’ legs were on fire and he was unresponsive. A short distance away, he saw Ms Walsham on the ground, also

unresponsive, and stopped to render assistance.

13. Ambulance paramedics arrived a short time later. Members of the public and ambulance paramedics performed cardiopulmonary resuscitation on Ms Walsham, however she was unable to be revived and was declared deceased at the scene. Mr Rodgers was also declared

deceased at the scene.

Coronial investigation Medical investigation

14. Senior forensic pathologist, Dr Malcolm Dodd 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 Dr Dodd’s anatomical findings were bilateral rib fractures, a fracture to the jaw and a prominent fracture to the occipital region of the skull.

15. Dr Dodd also noted probable thermal injuries to Ms Walsham’s left lower leg, which

appeared to have occurred post mortem.

3 Coronial Brief of Evidence, Statement of Justin Ezard, p. 55.

16. Routine post-mortem toxicology did not detect alcohol or other commonly encountered

drugs or poisons.

17. Dr Dodd advised that it would be reasonable to attribute Ms Walsham’s death to multiple

injuries sustained in a motor vehicle impact as a motorcycle passenger, without the need for

an autopsy.

Coronial brief

18. Detective Leading Senior Constable Shane Miles of the Major Collision Investigation Unit

commenced a coronial investigation, later compiling the brief of evidence upon which this

finding is largely based. The brief demonstrates that:

a.

The collision occurred about 120 metres north of the 237 km post (which signifies the distance from Bairnsdale to Wangaratta along the GAR), about seven kilometres south of Ensay. At this location, the GAR is a bitumenised dual carriageway with a north-south orientation and provision for one lane of traffic in each direction, separated by a broken white line. Each side of the road has solid white fog lines near the bitumen edge, high mountain side cuttings on the western side of the road, and a

heavily treed, steep decline to the Tambo Valley on the eastern side.

At the time of the collision, the weather was clear and sunny and there was a

moderate level of traffic.

Mr Rodgers held a full and current Victorian car licence with motorcycle rider and

heavy combination endorsements. The Harley was validly registered.

A preliminary breath test was performed on LSC Murphy and returned a negative result.

Senior Constable Nick Brickley of the Mechanical Investigation Unit inspected the Harley. His inspection did not reveal any mechanical fault which would have caused

or contributed to the collision.

The shove was in the cornering line for the left-hand bend, about 64 metres south of the collision location. It was 60-70 millimetres in height and rectangular in shape.

D/LSC Miles spoke to VicRoads officers, who said that the cause of the shove was a pavement failure where moisture had seeped under the road surface and a heavy vehicle passing over the area caused the bitumen surface to push out and up during

weight transference through the comer.

. Beyond the shove and further into the left bend were what appeared to be postcollision marks. The Patrol was facing uphill in the opposite direction, standing off the road just prior to the gravel run off. Upon inspecting the Patrol, MCIU members noted charring and slight damage to the front black bulbar on the driver’s side, a motorcycle foot peg jammed in underneath the front of the vehicle on the passenger side and fluid spray on the undercarriage. The Harley was about five metres in front of the Patrol, and had been fully destroyed by fire. Between the motorcycle and the police vehicle there was a significant gouge in the road surface in line with the two vehicles. This appeared to be where the motorcycle struck the ground or was dropped. There was scraping damage to the left side of the motorcycle, including a damaged crank case housing which had bitumen remnants and a hole in its casing.

There was little damage to the front end of the motorcycle.

. The post-collision marks included scraping marks and a fluid trail that could not be

attributed to the collision between the Harley and the Patrol.

Subsequent enquiries revealed that Martin Taylor had been involved in a similar collision the previous day. Mr Taylor described riding his black 2000 Honda Blackbird sports tourer motorcycle [Honda] around the left hand bend when a ‘large bump’ in the road surface appeared from underneath the car in front of him, in the centre of the northbound lane. There was not enough time to avoid the bump and he struck it in the centre, causing his Honda to launch up. As it landed, the front wheel of the Honda locked up, causing Mr Taylor to drop it on its side. He skidded across the road for a short while, coming to rest shortly before the arrival of an oncoming log truck, which stopped to render assistance. Police did not attend the accident and

the ‘bump’ was not reported to VicRoads before the subject collision.

Detective Senior Constable Robert Hay of the MCIU performed a reconstruction of the collision. Based on the skid mark length, the location of the gouge pre-impact and the at-rest position of the motorcycle, DSC Hay formed the opinion that the motorcycle was travelling above the 45 kph advisory sign but less than the 80 kph posted speed limit. Based on these same markings, DSC Hay concluded that the Patrol was travelling at about 22 kph immediately before impact.

. DSC Hay found no direct evidence of the motorcycle having hit the shove, in part due to the collision involving Mr Taylor the day before and in part due to the motorcycle being so badly burnt after the collision. However, if the motorcycle hit

the shove this would have caused it to become unstable and the rider to lose control.

Alternatively, a defect of that size would cause the rider to make an evasive manoeuvre which would again unsettle the motorcycle and may have contributed to the rider losing control.

1. However, DSC Hay expressed the opinion that the location of the shove and the distance between the shove and the loss of control was consistent with the shove

causing the instability.

m. The roadway had undergone a routine inspection by a VicRoads contractor on 26

February 2015 and the inspection did not identify any hazard at the site.

n. DSC Hay was of the opinion that the shove would have taken a significant time to appear, and suspected that it was present but not noted as it was not considered

significant or large enough at the time of inspection.

19. The MCIU concluded that the presence of the shove either caused or contributed to the collision.

Further investigation

20. At my request, further information was obtained from VicRoads concerning procedures for inspecting roads, identification of road defects, and their response to identified issues. In particular, I sought to understand why the shove had not been identified and repaired prior to the collision on 7 March 2015.

21. On 21 June 2016, Henry Lam, the Manager of Operations for the Eastern Region of Victoria for VicRoads, provided a detailed statement and annexures. As the materials are voluminous, I do not purport to summarise them in this finding but will only refer to them to

the extent necessary to provide a clear narrative.

Background

22. Under the Roads Management Act 2004 [the Act], the GAR is defined as an ‘arterial road’, with VicRoads being the ‘Responsible Road Authority’.4 Section 40 of the Act places a duty on VicRoads to inspect, maintain and repair a public road to the standard specified in

the Road Management Plan.

23. VicRoads’ Road Management Plan* [RMP] and Maintenance Contract® [MC] set out the relevant standards concerning inspection, maintenance and repair of the GAR, in particular,

'

4 See ss 3(1) and 31(1(e) of the Road Management Act 2004.

5 The Road Management Plan [RMP] is a policy in accordance with s 39 of the Road Management Act 2004. It was developed in accordance with the VicRoads Code of Practice for Road Management Plans.

the identification of hazards and defects’ in the road surface and corresponding intervention response times. Response times are linked to the Road Maintenance Category [RMC] for each road. Each road is assigned an RMC from 1 to 5, with Category 1 being the highest priority.

The classification of roads is based on an assessment of risk, taking into account factors such as road type and volume and type of traffic. It enables appropriate risk management and general management together with appropriate engineering standards and planning practices to be applied to a road based on its function. It also enables allocation of limited resources to those roads in greater need due to their function. The RMC for the GAR is

Category 4.

Hazards and Defects

26,

27,

‘Hazards’ and ‘defects’ are terms VicRoads used to describe less-than-optimal conditions of its road assets. A defect is a flaw in the road asset, while a hazard is a flaw that is of such an extent that there is a risk that it could result in harm to the public. Deformities in a road surface must meet certain criteria before they are categorised as a hazard. The RMP only considers hazards and consequently does not prescribe a timeframe for responding to

defects.

Under the RMP, a deformation that measures greater than 100 millimetres under a three metre straight edge (i.e. a ‘hazard’) must be remediated within one week of inspection or notification. Alternatively, where it is not feasible to rectify the hazard within one week due to the nature of the work required, level of resources required or workload, appropriate warning of the hazard is io be provided by VicRoads or its contractor until a suitable repair

can be made.

Under the MC, a hazard must be remediated within 72 hours of inspection or notification.

Alternatively, where it is not feasible to rectify the hazard within 72 hours due to the nature of the work required, level of resources required or workload, appropriate warning of the hazard is to be provided until a suitable repair can be completed. Repair of those hazards where warning signs have been provided, and forming part of Routine Maintenance, must be

completed as soon as possible and no Jater than one week of the expiry of the response time.

6 VicRoads generally uses contractors to manage the delivery of its maintenance program. At the time of the collision the Maintenance Contract in the Eastern Region was held by Citywide Service Solutions Pty Ltd. This contract came to an end on 1 September 2015. The Maintenance Contract generally involved routine maintenance or minor works to address a defect or hazard before significant or further deterioration occurred.

? These are terms of art in this context — see paragraph 25 below.

The MC generally has a tighter standard for response times to ensure that VicRoads

complies with its RMP.

Hazard Inspections

28. According to the RMP and the MC, the maximum hazard inspection frequency for the GAR is fortnightly during the day, and annually at night. In addition to hazard inspections, the MC also required monthly defect inspections. Defects could be repaired by patrolmen while programmed works or inspections were carried out, depending on whether the patrol had the resources, tools and material available at the time to complete the repair and other factors

such as the work already programmed that day for completion.

29. When an MC is in place, the contractor is responsible for inspecting the road network and identifying and recording hazards and defects. In addition to the inspections required by the contractor under the MC, VicRoads will periodically inspect parts of the road network as part of its contract superintendence. If members of the public or other agencies contact VicRoads and report a hazard, this is recorded in its Enquiry Tracking System [ETS] and an inspection is triggered.

30. VicRoads undertook monthly inspections as part of its surveillance and audit of the contractor’s works. This involved a Surveillance Manager inspecting sections of the road network to determine if there were any defects or hazards that are present but have not been identified by the contractor from a recent inspection. There were no compliance concerns raised with respect to the GAR with the contractor during the preceding review meeting,

which was held on 6 February 2015.

pane

. Inspections are carried out on each side of the road. The contractor carries out the hazard and defect inspections from a patrol vehicle. The contractor’s road patrol staff complete programmed work (which is provided daily by their supervisor) and hazard inspections. The contractor’s road patrol Inspection Supervisor completes hazard and defect inspections

which form the basis of the programmed works delegated to the road patrol.

32. Inspections involve a visual inspection of the road while the road patrol vehicle is driven on the road being inspected at low speed with warning lights activated. The speeds are generally a minimum of 20 kph below the posted speed limit. If it is a hazard inspection, the patrol will be seeking to identify hazards only. The hazard is registered by use of a RAMM®

device and a description is then inputted identifying the hazard. If it is a defect and hazard

® Road Asset and Maintenance Management [RAMM] is an electronic maintenance management system used by Citywide. It enables logging and recording of hazards and defects by pressing a button on the machine (which has a built in GPS) and marking the location, which is then converted into a chainage position.

inspection, then both defects and hazards are sought to be identified. Road patrolmen work in the road patrol vehicle with two people in the car, and the Inspection Supervisor works with one person in the car. VicRoads carries out its monthly inspections in the same manner

as the contractor.

33. On 26 February 2015, a hazard and defect inspection was carried out on both sides of the GAR by the contractor. The inspection was undertaken by the contractor’s Road Patrol Inspection Supervisor. The records indicate no defects or hazards were identified at the

collision location during this inspection.

34. On 4 March 2015, a hazard inspection was conducted on both sides of the road by the contractor. This inspection was carried out by the Omeo Patrol (consisting of two road patrol workers). This inspection was carried out during programmed works on the GAR during which a hazard inspection was also carried out. The records indicate that no hazards

were identified at the collision location.

35. On 5 March 2015, a hazard and defect inspection was conducted by the contractor’s Road Patrol Inspection Supervisor. The records indicate that no defects or hazards were identified

at the collision location.

36. On 6 March 2015, a hazard inspection was conducted by the contractor, completed by the Omeo Patrol, ahead of the Labour Day long weekend. The records indicate that no hazards

were identified at the collision location.

Enquiry Tracking System [ETS

37. VicRoads receives reports on roads and road infrastructure from a wide variety of sources, which are then entered into the ETS. The system is web-based, and calls are placed to a call centre on the number 13 11 70 or reported online. If VicRoads is the responsible authority for the road involved, a complaint is logged on the ETS and actioned by VicRoads or a contractor. If the complainant is willing to provide their details, these details will be

recorded.

38. The location and a brief description of the issue is sought to allow VicRoads to determine the level of response that is required. A caller will be requested to respond to the question ‘do you consider this to be a hazard’, in the common usage of the term, rather than the technical definition used by VicRoads and described above. The call is then assigned to a VicRoads action officer and directed for follow-up. If the complaint is identified as a hazard under the RMP, the response category of the RMP and MC will apply. This response may

result in an immediate attendance (depending on the issue) which may involve a dispatch for

39,

the contractor to attend to inspect the reported issue. A job logged onto the ETS must be

completed before it can be closed on the system.

The ETS records relating to the month prior to the accident show that VicRoads did not receive any reports of a hazard or defect at the collision location. No report was made in relation to the accident on 6 March 2015. An ETS report was generated on 7 March 2015 as a consequence of a call placed by Victoria Police seeking collision and traffic assistance

following the accident.

The Shove

=

44,

The shove did not reach the level required for intervention under the RMP or the MC, as it was measured at only 70 millimetres (at its highest point against a 1.2 metre straight edge).

However, if it had been identified as part of a defect inspection, it would have been marked

on-site, recorded in the list of defects and programmed for completion at a future date.

. VicRoads were unable to say why the shove was not observed and therefore not recorded.

Mr Lam noted that factors that may impact on what is identified during a visual inspection from a patrol vehicle include road conditions at the time of inspection, timing of formation,

and the size and characteristics of a deformity.

The traffic volume records indicated that the traffic volume for the GAR in both directions was 809 vehicles per day with 23% comprising of heavy vehicles. This is a high volume of heavy vehicle use for an arterial road (the usual percentage of heavy vehicle use is approx.

10-12%) and was reflective of the high usage of the GAR by logging trucks. Mr Lam stated that the weight of a heavy vehicle can significantly cause or contribute to the development ofa shove and can cause deterioration in road pavement over a short period of time. The damage caused by a single loaded heavy vehicle was estimated as equivalent to 10000

standard cars.

Mr Lam stated that the RMP and the standards within it are based on an assessment of the use of the road and the risks faced by the majority of road users. As a policy it sets reasonable standards taking into account a number of different and competing factors. It does not distinguish between motor vehicles and motorcycles as users of the road. The intervention standards are based on a determination of what is a reasonable framework for hazard identification and response taking into account the road function, risk factors and

allocation of limited resources.

The hazard intervention standards identify the maximum limit; a deterioration of the road

pavement to a point where intervention is required. That is not to say that a defect which

has yet to reach the intervention level of a hazard could not be elevated io that level if it was considered to pose a risk. Or, that a defect is not recorded prior to the point of deterioration such that it becomes a hazard. Action may be to program a defect falling below intervention

levels for repait, or put signage in place.

46. In addition, defects which do not meet the definition of ‘hazard’ under the RMP or under the MC may still be addressed as part of the MC obligations for each category of road. What is prioritised will depend on available funding and competing priorities and other actions that VicRoads may be taking, such as targeted programs for motorcycles and road pavement

upgrades.

Directions hearing

47, At my request, a representative from VicRoads, in addition to members of Mr Rodgers’ and

Ms Walsham’s family, attended a directions hearing on 27 July 2017.

48. It was my preliminary view that an inquest was unlikely to elicit relevant evidence that had not already been disclosed by a competent and thorough investigation, and the investigation had identified facts leading to the deaths, sufficient to meet community expectations and to enable the findings requires by section 67(1) of the Coroners Act 2008 to be safely made without inquest. This view was supported by the families of Mr Rodgers and Ms Walsham

and by VicRoads. The transcript of the directions hearing will remain on the court file.

49, Mr Rodgers’ and Ms Walsham’s families were not legally represented at the directions hearing, however, they were given an opportunity to ask questions of the Court and of VicRoads.

50. I was also assisted during the course of the directions hearing by submissions from VicRoads concerning possible shortcomings of the current inspection regime regarding identification of road defects that are particularly hazardous to motorcycle riders, and the operation of the ETS. I foreshadowed my intention to make prevention-focused comments and recommendations, which will be outlined below.

FINDINGS

51. I find that Jodi Michelle Walsham, late of Blandford Crescent in Bayswater North, died on the Great Alpine Road in Ensay on 7 March 2015 and that the cause of her death was the

multiple injuries she sustained as a motorcycle passenger in a motor vehicle impact.

52. The available evidence also supports a finding that:

a. the shove located in the cornering line of the left-hand bend about 67 metres south of the collision location caused or contributed to Mr Rodgers’ loss of control of his

motorcycle and hence the collision;

b. that the speed at which Mr Rodgers rode was in excess of the 45 kph advisory speed for the section of road but below the 80 kph speed limit and that this likely

contributed to the collision; and

c. despite routine inspections by VicRoads and its contractor in the period leading to the collision (as detailed above), the shove had not been identified as either a hazard

or a defect, so as to warrant consideration for remediation.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment/s in connection

with the death:

we

The circumstances of this collision highlighted the particular vulnerability of motorcycle riders to irregularities in the road surface, whether hazards or defects as defined by

VicRoads, or otherwise.

It is apparent that the Great Alpine Road, Ensay, is an arterial road and that VicRoads, as the Responsible Road Authority, bears responsibility to inspect, maintain and repair the road to

the standard specified in the relevant Road Management Plan.”

Despite periodic inspections by VicRoads and its contractor pursuant to the Road Management Plan and Maintenance Contract, the shove that caused or contributed to the

collision as a result of which Ms Walsham and Mr Rodgers died, was not identified.

This state of affairs would seem to speak to inherent limitations in the current inspection regime with its reliance on a four-wheeled vehicle traversing the roadway that is illequipped to discern road conditions that may be more problematic for a two-wheeled

vehicle.

VicRoads has advised of a number of improvements along the Great Alpine Road, proximate to the collision site, as at 26 March 2018, and is to be commended for these

improvements —

a, The Motoreycle Enhanced Maintenance trial proposed for Bonang Road!°, was successful in attracting $480,000 funding to be spent on the Great Alpine Road,

9 See generally the Road Management Act 2004 and paragraphs 21 and following above.

Bonang Road and Tyers-Thomson Valley Road. This trial allowed VicRoads to increase the frequency of inspections, which allowed for earlier identification of pavement defects and in turn prioritisation for treatment within the maintenance

funding provided.

. In 2016-2017, VicRoads invested $3.69M to enhance predictable motorcycle riding

conditions along the Great Alpine Road (funded by the Transport Accident Commission — Motorcycle Safety Levy program) and included upgrading guide posts, signage improvement, sealing of gravel driveways and installation of motorcycle friendly barriers at high risk locations. At the collision site, the shoulder and pullover area on the outside of the curve was sealed with work completed in

More broadly, VicRoads is currently delivering $10m of road upgrades on the Great Alpine Road between Bruthen and Cobrunga as part of an $18M program to upgrade the full length of the Great Alpine Road. The scope of works which is to be completed in 2020 includes shoulder construction and sealing between Bruthen and

Omeo but does not include the collision site which has already been treated.

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008, | make the following recommendations

connected to the death:

That VicRoads enhances the training of its own inspectors and also requires its contractor to enhance the training of its inspectors to be more mindful of the needs of motorcycle riders and of their increased vulnerability to road imperfections when undertaking inspections.

That VicRoads further promotes the use of its hotline amongst the motorcycling community and encourages motorcycle riders to use the hotline to report any road hazards, defects or

imperfections that may endanger motorcycle riders in particular.

10 Referred to in Mr Lam’s statement dated 20 June 2016 — see paragraph 20 and following above.

I direct that a copy of this finding be provided to the following: Ms Faye Andrews Mr Frank Andrews D/LSC Shane Miles, Major Collision Investigation Unit, Victoria Police Victoria Police Civil Litigation Division VicRoads c/o Russell Kennedy Lawyers Motorcycle Expert Advisory Panel c/o VicRoads

Transport Accident Commission

Signature:

PARESA ANTONIADIS SPANOS CORONER Date: 21 May 2018