Bad driving decisions before long descent and faulty trailer brakes seen as contributing to fatalities
Truck and trailer maintenance and driver skills are two themes running through South Australian deputy coroner Anthony Schapel’s findings on two fatal truck crashes on the South Eastern Freeway.
While the bulk of Schapel’s recommendations related to driver responsibilities, he puts much weight on the lack of skill both drivers had in long, steep descents and the lack of proper maintenance and teeth in efforts to ensure it was undertaken.
His findings include that James Venning, a general farm hand and driver for agriculture firm Mitolo Group, failed to put his loaded semi in the appropriately low gear at the start of the descent and then was unable to as his speed increased.
He relied on brakes but while the prime mover’s brakes were sound, two of the six trailer brakes did not work at all and the effectiveness of two others was unknown.
“To my mind the inconsistency in the effectiveness of the six individual brakes of the trailer is a reflection of the variation of brake lining thickness in respect of the individual brakes and is a product of poor adjustment, lack of proper maintenance and a lack of adequate preparation having regard to the task that the trailer had to perform on the occasion in question,” the findings read.
“That any of the brakes of the trailer were in proper adjustment and were operating to a degree of effectiveness was in my view more due to happenstance than to proper maintenance.”
Evidence was that the trailer had been inherited when a farm was taken over and used rarely, and then only locally.
Though Mitolo’s B-doubles were part of the National Heavy Vehicle Accreditation Scheme (NHVAS) the inherited trailers weren’t, due to lack of use, and nor were there any maintenance records for them.
In the event, the truck rolled and Venning was killed.
Similarly in the Posnakidis case, where truck driver John Posnakidis was killed at a layby when hit by a semi carrying steel driven by In Front Transport (IFT) driver Daniel Walsh, the state of the trailer brakes was highlighted.
“No evidence of overheating of the kind observed in respect of the prime mover drive axle brakes was detected in the brake assemblies of the trailer,” the finding read.
“What was found in respect of the trailer brakes was that five of them had excessive push rod stroke lengths consistent with maladjustment.”
Despite radio pleas from other truck drivers, in neither case did the crash drivers use either of the freeway’s emergency ramps.
There was no evidence as to why, with surviving driver Walsh, who suffered serious injuries, saying he is unable to remember many details.
In neither case was the trucks’ gear boxes found to be faulty.
Along with comment on and evidence given on the state of recruitment, operations, compliance and safety at IFT, a four-truck firm that was formerly Nick Gray Transport, Walsh was found to have taken insufficient rest in the prior 24 hours, “due to the need for the delivery deadline to be met”.
“The possibility that Mr Walsh’s inability to select the appropriate gear for the descent on the South-Eastern Freeway was contributed to by fatigue has not been eliminated,” the findings read.
On maintenance, Schapel supports the inclusion of heavy vehicle maintenance within the chain of responsibility regime in the Heavy Vehicle National Law.
“The currently existing voluntary regime under the National Law has an inconsequential deterrent effect against poor maintenance.
“The Court does not know of any inspection regime or other type of auditing that existed in relation to Mr Venning’s trailer, nor of that driven by the driver in the Posnakidis matter.”
State transport and infrastructure minister Stephen Mullighan says a number of actions are underway in response to coronial recommendations.
“We will be working constructively with industry, the community and different levels of government in carefully considering the recommendations outlined in the Deputy Coroner’s findings,” Mullighan says.
“I believe any measures that we can pursue to improve safety on the South Eastern Freeway must be considered.
“I note the comments from the Deputy State Coroner that the State Government has already made changes to improve safety on the freeway.”
Actions the State Government has taken so far include:
- speed limit reduction on descent from Crafers for all heavy vehicles over 4.5 tonnes, to 60 km/h (previously restricted to heavy vehicles with five axles or more)
- speed limit reduction on descent from Crafers for other vehicles, to 90 km/h
- all trucks and buses required to use left lane only from Crafers until near the Measdays Bridge exit ramp
- increased signage and emphasis on requirement for heavy vehicles to use low gear – not brakes – on descent from Crafers
- requested interstate jurisdictions to promote the need for heavy vehicle drivers to use a low gear on the freeway descent, and not rely on brakes
- promoting the need for heavy vehicle drivers to use low gear on the freeway descent at rest stops and vehicle checking stations along the Dukes Highway
- comprehensive national information campaign using road authorities and peak industry organisations to promote the requirement to adhere to Australian Road Rule 108 – heavy vehicle drivers must use a low gear on the freeway descent, and not rely on brakes
- distributing a new brochure to all South Australian licensed heavy vehicle and bus drivers on the requirement to use low gear on the freeway descent
- renaming of arrester beds to ‘safety ramps’ to eliminate any confusion for drivers
- increased and new signage illustrating descent and location of safety ramp locations on descent
- road pavement messages at kilometre intervals alerting drivers to safety ramp locations on descent
- vegetation removal from around safety ramps for improved line of sight for drivers
- government to meet costs of heavy vehicle removal from safety ramps after emergency use
- updating the Heavy Vehicle Licence Drivers handbook to include a section on Australian Road Rule 108 and driving on very long steep descents.
- Registered Training Organisations (RTOs) to amend heavy vehicle driver training packages to include more information about Australian Road Rule 108, driving downhill, use of brakes and use of safety ramps.
The Posnadakis findings can be found here and the Venning findings can be found here.