RECORD OF INVESTIGATION INTO DEATH

Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

I, Peter Henric Wilson, Coroner, having investigated the deaths of

Bianca Maree THORP, Sherilea Anne KEATING, Larissa Anne HERON,

Claire Helen TAPSON & Bianca GOURLEY

WITHOUT HOLDING AN INQUEST

FIND THAT :

Bianca Maree THORP died on or about the 25th day of February 2006 on the Bass Highway, Round Hill, Burnie.

Bianca Maree THORP was born at Burnie on the 4th of October 1991 and at the time of her death was aged 14 year(s).

Bianca Maree THORP was a single person whose occupation at the time of her death was a Student.

I find that the deceased died as a result of Head, Chest & Abdominal Injuries due to a Motor Vehicle Collision.

At the time of the deceased person’s death she was not being treated by a medical practitioner.

Sherilea Anne KEATING died on or about the 25th day of February 2006 on the Bass Highway, Round Hill, Burnie.

Sherilea Anne KEATING was born at Smithton on the 9th of January 1970 and at the time of her death was aged 36 year(s).

Sherilea Anne KEATING was in a de facto relationship whose occupation at the time of her death was Home duties.

I find that the deceased died as a result of Head & Chest Injuries due to a Motor Vehicle Collision.

At the time of the deceased person’s death she was not being treated by a medical practitioner.

Larissa Maree HERON died on or about the 25th day of February 2006 at Bass Highway, Round Hill, Burnie.

Larissa Maree HERON was born at Smithton on the 12th of October 1992 and at the time of her death was aged 13 year(s).

Larissa Maree HERON was a single person whose occupation at the time of her death was a Student.

I find that the deceased died as a result of Head, Chest & Abdominal Injuires due to a Motor Vehicle Collision.

At the time of the deceased person’s death she was not being treated by a medical practitioner.

Claire Helen TAPSON died on or about the 25th day of February 2006 on the Bass Highway, Round Hill, Burnie.

Claire Helen TAPSON was born at Smithton on the 10th of June 1991 and at the time of her death was aged 14 year(s).

Claire Helen TAPSON was a single person whose occupation at the time of her death was a Student.

I find that the deceased died as a result of Multiple Injuries due to a Motor Vehicle Collision.

At the time of the deceased person’s death she was not being treated by a medical practitioner.

Bianca GOURLEY died on or about the 2th day of February 2006 on the Bass Highway, Round Hill, Burnie.

Bianca GOURLEY was born at Hobart on the 15th of May 1980 and at the time of her death was aged 25 year(s).

Bianca GOURLEY was a married person whose occupation at the time of her death was a Business Owner.

I find that the deceased died as a result of Head Injuies due to a Motor Vehicle Collision.

At the time of the deceased person’s death she was not being treated by a medical practitioner.

CIRCUMSTANCES SURROUNDING THE DEATH : -

At approximately 8.35am on Saturday 25 February 2006, a fatal three-vehicle accident occurred in the westbound lanes, of the Bass Highway, Round Hill, Burnie. The accident occurred approximately 1.6km east of Stowport Road.

Initial scene observations were that the road surface was wet and there was light rain falling.

The accident was investigated by 1/c Constable C T Willcox of the Tasmania Police Accident Investigation Section and his detailed review and analysis which is here in substance largely reproduced as my findings.

Unit 1: The deceased, Bianca Gourley was the coach of the Smithton Saints Under 16 basketball team. She left her residence at Smithton, at approximately 7.20am and was in “good spirits”. Gourley was to travel to the East Devonport Stadium where the basketball team was to participate in a tournament. The start time of their first game was 9.20am. She picked up the deceased, Sherilea Keating and her daughter, Larissa Anne Heron from 29 Hellyer Street, Smithton. The deceased, Claire Helen Tapson was picked up from 6 Tatlow Street, Smithton. (Tapson had stayed at this address due to the fact that they were leaving so early. Tapson’s normal residence at Marrawah is approximately 45 minutes from Smithton.) They travelled on the Bass Highway to the Forest/Stanley intersection where they picked up the deceased Bianca Thorp. Thorp was waiting at this intersection with her mother, Roseanne Thorp. Mrs Thorp states that they left this intersection at approximately 7.45am. They were travelling in Gourley’s white Commodore sedan. (The distance from this location to the East Devonport Stadium is approximately 100km. This would allow them about 1 hour and 20 minutes to travel to East Devonport, and allow about 15 minutes for the girls to get ready for their first game.)

Unit 2: Peter Anthony John George and his wife, Helen Maree George, left their residence at approximately 8.10am. When they first left home it was overcast, but not raining. They were travelling to Burnie in a blue Mitsubishi Pajero 4x4, with the intention of looking to purchase a motor vehicle. They travelled along the Bass Highway at the posted speed limit or just under for most of the journey. Around the Sulphur Creek area rain started to fall heavily. The speed limit in this area is 110km/h. Once they passed through the Heybridge roundabout they travelled at a speed of between 90 and 100km/h. The rain had eased off in this area. The speed limit at this location is 100km/h.

Unit 3: Peter John Smith left his residence abetween 8.00am and 8.10am, to travel to Burnie. The purpose of his journey was to travel to his place of employment. Smith is a car salesman Cooee. Smith travelled along the Bass Highway towards Burnie. He was overtaken by a “dark coloured Pajero” between Ulverstone and Penguin. (This Pajero was being driven by George). Smith followed the Pajero from this point, through to Round Hill, Burnie, where the accident occurred. Smith states that throughout the journey both himself and George’s vehicle travelled at the posted speed limit or just under and states that, “……As we went past Blinking Billy (the lighthouse at Roundhill) both myself and the Pajero were in the left lane. We travelled around a sweeping left hand bend. At this stage we would have been travelling at about 90 to 100km/h……”

Events at the scene:

George was travelling in a westerly direction on the Bass Highway at approximately 90 to 100km/. He has driven past Blinking Billy (the lighthouse at Roundhill) in the left hand lane. He has negotiated a sweeping left hand bend before travelling along a short straight. At this stage Smith was travelling a short distance behind George and was also in the left lane. Light rain was falling at this time.

Gourley was driving her white Commodore sedan in an easterly direction on the Bass Highway. She has driven past the industrial businesses at Roundhill and negotiated several left and right hand curves. As she has approached a sweeping left hand bend, she has lost control of the vehicle. The Commodore has started to spin in an anti-clockwise rotation, before crossing the concrete median strip that divides the east and westbound lanes.

George has attempted to take evasive action by braking heavily and turning to the left. The Commodore has continued to travel directly into the path of George, who was unable to avoid the collision. The primary impact occurred between the front of George’s Pajero and the driver’s side of the Commodore. Upon separation the Commodore has rotated approximately 180 degrees in a clockwise direction before coming to final rest in the middle of the westbound lanes, facing in a general south-easterly direction.

Smith also attempted to take evasive action by turning to the right and braking heavily. Smith was unable to avoid the collision and has made light contact with the passenger side rear guard, before coming to rest in the right lane.

Evidence at the scene:

The Bass Highway is the main arterial road into and out of the City of Burnie, and generally travels in an east/west direction. The posted speed limit is 100km/h. The land use in this area could best be described as commercial / light industrial. The highways curvilinear nature is due to the significant geographical constraints in the general area. The coastline is on the northern side and steep rising hillsides on the Southern side of the roadway.

The accident had occurred in the westbound lanes near the Burnie Ten foot-race turning point. This is approximately 1.6km east of Stowport Road.

The roadway consists of two eastbound and two westbound lanes which comprise a bitumen aggregate with hotmix shoulders. The road surface was in reasonable condition and devoid of any major defects.

The travelled portion of each of the four lanes measured approximately 3.5 metres in width. All lanes are divided by single broken white painted centre lines. The east and westbound lanes are divided by a concrete median strip, bound by shallow water drains on both sides, measuring a total of 3 metres in width. The median strip is angled upwards with the low side bordering the eastbound lanes.

The shoulder on the left of the westbound lanes measured 3.5 metres in width and also comprised a slip lane which was delineated by broken white edge lines. This shoulder is then bound by a gravel/grass verge. There is a 1.75 metre shoulder on the right side of the westbound lane which is then bound by Armco railing. This Armco railing concludes 9.5 metres east of the point where the Commodore crossed the median strip. There is no form of railing, fencing or protective barrier on the median strip throughout this area. (This Armco railing ends 9.5 metres east of the point where the Commodore crossed the median strip. There is no form of railing, fencing or protective barrier on the median strip throughout this area).

The shoulder on the left of the eastbound lane measured 3 metres in width and the shoulder on the right measured 1.5 metres in width. There is Armco railing present on the left at this location. As stated above, there is no barrier of any kind, present on the right hand side.

An inspection of the eastbound lanes on the approach to the accident scene, where the Commodore was alleged to have lost control did not reveal any tyre or skid marks on the actual travel portion of the roadway, due to the road surface being wet, nor were any foreign objects located on the roadway. Two tyre marks were present between the right edge line and the median strip that divides the east and westbound lanes. It is at this point that four distinct tyre marks appear on the median strip. These marks came from the Commodore. These marks indicated that the Commodore was side slipping and rotating in an anti-clockwise direction and travelling from the eastbound lanes towards the westbound lanes.

The first and longest of the tyre marks measured 17 metres in length. This was attributed to the right rear tyre of the Commodore. The second tyre mark measured 12 metres in length and is attributed to the left rear tyre of the vehicle. The third tyre mark which is attributed to the front right tyre and measured 14 metres in length. The fourth tyre mark which is attributed to the front left tyre and measured 13 metres in length. A scratch mark measuring 3 metres was located on the concrete median strip. This scratch was inside the longest tyre mark and was consistent with being caused by the right rear rim.

At the conclusion of the marks made by the right rear tyre, there was a break or gap of approximately 2.5 metres, before the appearance of a gouge mark which extended across the right lane of the westbound lanes. This gouge mark measured 12.5 metres and concluded basically at the centre line of the westbound lanes.

1/c Constable Willcox believed the Commodore became airborne as it left the median strip, before landing on the right rear rim. The rim has dug into the road surface as the vehicle has continued to slide eastward. The gouge stopped approximately 9.5 metres west from the area of impact (or maximum engagement).

Using a drag tyre (a part tyre filled with concrete), 1/c Constable Willcox and Constable Mason established that the co-efficient of friction of the road surface in the eastbound lanes was 0.606, which is about average for a wet road. The concrete median strip was determined to be 0.696. This was slightly higher than the road surface, due to the coarse nature of the concrete and the fact that the tyre was dragged upwards in the same direction of travel as the Commodore.

The Commodore had come to final rest basically in the middle of both westbound lanes facing in a general south easterly direction. This vehicle suffered a massive impact to the driver’s side of the vehicle, with the main point of impact extending from just in front of the ‘B’ pillar to the rear driver’s side wheel.

The Pajero had come to final rest also facing in a general south easterly direction on the grass/gravel verge on the south eastern side of the roadway. This vehicle has suffered extensive damage to the entire front section of the vehicle.

The Camry sedan came to final rest in the right hand lane, slightly diagonal to the centre line. This vehicle sustained very minor damage to the front of the vehicle, indicating a very low speed impact. The damage consisted of minor dents to the front registration plate and bonnet, as well as a small amount of paint scraping.

Evidence of the vehicles:

1/c Constable Willcox conducted a detailed inspection of the vehicles involved with the following observations:

1998 white Holden Commodore VT sedan, Registered Number DZ 5238.

Inside this vehicle he observed the bodies of five females, being the deceased. The two front seat occupants appeared to be adult females, whilst the three rear seat passengers appeared to be young teenagers. All occupants were wearing seatbelts.

The Commodore had suffered extensive damage to the entire driver’s side of the vehicle. The main damage commenced basically at the centre of the driver’s door and concluded at the back of the rear wheel. The driver’s side B-pillar had been pushed in approximately 944mm towards the centre of the vehicle. The distance between the B-pillars measured approximately 980mm. The standard width dimensions of this particular vehicle pre-collision is 1824mm.

The driver’s side doors, pillars and both front and rear mudguards were buckled, with the boot, roof and bonnet also buckled. The front bumper bar was dislodged and all driver’s side window glass, front windscreen and rear window glass was shattered. The driver’s seat had been pushed inwards and twisted towards the centre of the vehicle. The dash was dislodged from its mountings.

The Commodore’s odometer indicated the vehicle had travelled 140,945km prior to the accident. The vehicle was fitted with an automatic transmission and was in the drive position. The heater was on medium with air recirculating. The fan was off. The windscreen wipers were in the on position.

The vehicle was fitted with Pos-A-Traction P205/65 R15 brand tyres on all four wheels, and the tyres were fitted to AMG alloy rims. All tyres were deflated with the exception of the front right tyre. It appears that the remaining three tyres were deflated due to rim damage sustained in the accident. All tyres displayed good tread pattern. The Commodore appeared to be in a good roadworthy condition prior to the accident.

Unit 2: 2003 blue Mitsubishi Pajero 4x4 wagon, Registered Number ER 0099.

The Pajero had suffered extensive damage to the entire front section of the vehicle. The front bumper, both front mudguards, and the bonnet had all been pushed rearwards approximately 530mm. The vehicle measured approximately 4300mm in length. The standard length dimensions of this particular vehicle pre-collision is 4830mm.

The driver’s door was buckled and the windscreen was cracked. The inside of the vehicle was relatively intact. Both the driver and passenger airbags had deployed.

He was unable to determine the mileage of the vehicle as it had an electric odometer fitted. (According to Peter George the vehicle had travelled approximately 179,500km.) The vehicle was fitted with a 5 speed manual transmission which was in the neutral position. The heater was positioned on cold and directed at the face. The fan was on (2). The windscreen wiper lever was broken off, so he was unable to determine if the wipers were activated.

The vehicle was fitted with alloy rims and Dunlop Grandtrek 265/70 R16 brand tyres on all four wheels. All tyres were inflated and displayed good tread pattern. The Pajero appeared to be in a good roadworthy condition prior to the accident.

Unit 3: 2000 green Toyota Camry Sedan, Registered Number EJ 1149.

The Camry had sustained very minor damage to the front of the vehicle, indicating a very low speed impact. The damage consisted of minor dents to the front registration plate and bonnet, as well as a small amount of paint scraping.

The Camry’s odometer indicated the vehicle had travelled 52 473km prior to the accident. The vehicle was fitted with an automatic transmission and was in the park position. The heater was positioned on cold directed at the face. The fan was off. The windscreen wipers were in the off position.

The vehicle was fitted with Michelin Certis 205/65 R15 brand tyres on all four wheels, which were inflated and displayed good tread pattern. The Camry appeared to be in a good roadworthy condition prior to the accident.

Post accident investigation:

On Sunday the 26th of February 2006 1/c Constable Willcox returned to the scene with Constable Mason. Together they completed a survey of the scene using the Geodimeter 500 Infra-red Total Survey Station. All items of relevance were surveyed. Those computations were later downloaded to computer and Constable Mason produced several scale plans of the scene.

On Tuesday the 28th of February 2006 1/c Constable Willcox made arrangements for a “Virtual Reality” of the scene to be conducted. “Virtual Reality” is a number of digital images that are electronically “stitched” together to give a 360 degree panoramic view of the scene. It basically allows for a “walk through” view of the scene. This procedure was conducted by personnel from Burnie Forensic Services.

He requested a report from the Bureau of Meteorology in relation to rain fall over the preceding days. It was found that “there was little rain in the seven weeks leading up to the incident, and very few especially wet days. There were light showers or drizzle in the area at the time of the incident.” The report states, “……Of significance is the generally light rainfall in the weeks prior to the incident. There were several moderate falls during December, but after 1 January (when 24-hour totals of around 10 to 15mm were common), most falls were less than 2mm; many were less than 1mm. The main rain events in February were around the 1st, 9th and 13th. There were falls (mostly of less than 2mm) in the 24 hours to 9am on the 23rd, with Round Hill registering 1mm.” The report for 9am on the 25th “shows slight intermittent drizzle, as there had been in the previous 3 hours. The total amount recorded was 0.2mm, since 3pm the previous day……”

Witnesses (drivers):

Peter John Smith of Ulverstone.

A summary of his evidence discloses:-

• He was the driver of green Camry sedan involved in this accident;

• States he left his residence at “about 8am to 8.10am” to travel to Cooee for work;

• Recalls being overtaken by a blue Pajero between Ulverstone and Penguin, which he followed all the way to Burnie;

• States that he “followed this vehicle at a distance of between 50 and 80 metres for most of the way”;

• States that throughout the journey both the Pajero and his vehicle travelled at, or just under the posted speed limit;

• Was following the Pajero when he observed the Commodore cross the median strip and become “airborne for a short distance before landing on the driver’s side wheels”;

• States that the Pajero braked and veered to the left before it collided “heavily with the driver’s side of the sedan”;

• States that he braked and turned to the right to avoid the accident, but was unable to avoid lightly colliding with the left rear of the Commodore;

• States “at the time of the accident I believe it was lightly raining. The road surface was wet, but water was not sitting on the road”; and

• States “there was nothing the driver of the Pajero could have done to avoid the accident”.

Peter Anthony John George of Turners Beach.

A summary of his evidence discloses:-

• He was the river of the blue Pajero 4x4 involved in this accident;

• States he left his residence at approximately 8.10am to travel to Burnie to look for a new car for his wife;

• States “it was raining quite heavily around Sulphur Creek. It rained heavily through until around the old Tioxide site. The rain eased off around here. The road surface was very wet, but it wasn’t forming pools. I drove at the speed limit or just under all the way”;

• Recalls travelling in the left lane as he went past Blinking Billy and driving around a sweeping left hand bend. He then observed “a white sedan in the eastbound lanes,” lose control;

• He then observed the vehicle cross the median strip and directly into his path. He braked heavily and swerved to the left in an attempt to avoid the accident. “The front of my Pajero collided heavily with the driver’s side of the vehicle”;

• States “I recall seeing the Commodore lose control, but I don’t know what caused it. I would not say that the vehicle was speeding. The speed limit is 100km/h and I don’t think it would have been in excess of 100”; and

• Has had the Pajero for about three years and “would average about 60,000km per year.”

Consultation with D.I.E.R. engineers and their recommendations:

On Monday the 27th of February 2006 1/c Constable Willcox met with D.I.E.R. engineers at the scene. He informed them of the circumstances surrounding the accident and made several recommendations to them. He indicated that his main concern at this location was the lack of protective barriers, railing, or fencing between the east and westbound lanes. The engineers indicated that given the current road environment (the presence of a U-turn facility west of the accident site) a protective barrier was not an immediate option, as there were visibility issues for vehicles performing a U-turn. He requested that as an interim measure could consideration be given to lowering the speed limit to 80km/h. This was due to the fact that with winter approaching and the likelihood of more wet weather and hazardous road conditions, a lowering of the speed limit may reduce the likelihood of a similar accident.

Subsequently he was forwarded a preliminary report dated 29 March 2006, written by Peter Hubble (D.I.E.R), which contained a Accident History/Analysis in relation to the number of reported accidents for the 1.5km section of roadway from Clarke Street to the Chasm Creek Lighthouse, which incorporates the accident site. These statistics were for the period 1 January 2001 to 25 February 2006. The report states that the westbound carriageway had 9 reported accidents with 5 occurring during wet road and weather conditions. There were 4 accidents reported for the eastbound carriageway all of which occurred during wet road and weather conditions. Younger drivers are almost exclusively represented in these accidents.

The report details the inspection and observations of the engineers at the accident site. Of interest is the last three points listed for the eastbound carriageway:-

· All four bends have been checked using a vehicle mounted ball bank indicator with a good conditions ‘advisory speed’ finding of approximately 85km/h for

each. (The weather and road conditions at the time of this accident were poor.);

· Asset data indicates that the pavement was last resurfaced in 1999 with a sprayed seal. (Seven years since last reseal.); and

· A desktop review of skid resistance survey data, collected using the Sideway-force Coefficient Routine Investigation Machine (SCRIM), indicates that further investigation, as per Austroads guidelines, is advised. (Indicates that road surface friction is close to the minimum required by Austroads guidelines)

The following recommendations were listed in this preliminary report:-

· As an interim measure lower speed limit from 100km/h to 80km/h by extending existing 80km/h limit near Stowport Road to a point east of bend D. Following implementation of any physical roadworks consultation with the community to take place in terms of any reversion of the limit back to 100km/h;

· As an interim measure install guideposts in the central median around bend C;

· Design and construct a u-turn facility at the existing median opening located at Link 52 CH 5.22km;

· Close the central median opening at Link 52 CH 5.98km;

· Install wire rope safety barrier in the central median between Link 52 CH 6.18km and CH 5.86km;

· Consider options for the development and design of slippery when wet flashing light warning sign arrangements that automatically activate during periods of wet weather including an investigation of any possible sign locations; and

· Asset Management Group to undertake a detailed investigation of road surface condition in the general area and identify any warranted treatments such as pavement resurfacing and drainage of any road surface standing water.

On Wednesday the 5th of April 2006 a second accident occurred at the same location and in similar weather conditions. The circumstances surrounding the second accident are basically identical to this accident. Mr Damien Wilton was travelling in an easterly direction on the Bass Highway, when he lost control of his vehicle on the same left hand bend. He was unable to regain control and as a result crossed the median strip and continued across the westbound lanes before colliding with the embankment on the south-eastern side of the roadway. On this occasion there was no westbound traffic, thus, there was not a side impact collision. Wilton states that at the time of the accident he was travelling at approximately 100km/h. 1/c Constable Willcox informed the Department of Infrastructure Energy and Resources (D.I.E.R.) of this accident and as a result the speed limit was reduced to 80km/h the following week.

On Thursday the 27th of April 2006 1/c Constable Willcox met with the Secretary of D.I.E.R. Mr Mark Addis and several of his engineers. Together issues were raised concerning changes to the section of the Bass Highway where this accident occurred, resulting in the following:

Median Strip Barrier:

1/c Constable Willcox’s opinion is that a protective barrier must be erected between the east and westbound lanes at this accident site. D.I.E.R. indicated that Brifon fencing would be installed in the future, but could not elaborate when this would occur.

He requested the installation of guideposts as an interim measure and they indicated that this would occur as soon as practicable.

This particular section of road becomes very slippery in wet conditions and without some form of protective barrier, there is nothing to stop eastbound vehicles encroaching into the westbound lanes if the driver loses control. The reasons provided by D.I.E.R. engineers for the absence of protective barriers, concern visibility issues for vehicles performing U-turns west of the accident site. This U-turn facility is approximately 80 metres west of the accident site. D.I.E.R. did however indicate that closure of the current U-turn facility, and the construction of a new U-turn facility was no longer a preferred option. They have since conducted further enquiries and believe a realignment of the highway would be a better option.

He believes that had some form of protective barrier been present, this accident would not have had the same tragic outcome. A barrier should prevent a vehicle from encroaching into the oncoming lanes. The impact with a protective barrier would not have been anywhere near as severe, as colliding with a vehicle travelling in the opposite direction. It is almost certain all five occupants would not have died had a protective barrier been present. The fact that the vehicles were travelling in opposite directions gives an approximate impact speed of 180 to 200km/h. As the accident involved a side impact, at this combined speed, the occupants of the Commodore had very little chance of survival, even though all were wearing seatbelts.

Resealing the road surface:

Skid resistance tests conducted by the D.I.E.R. engineers “indicates that further investigation, as per Austroads guidelines, is advised.” Pavement resurfacing is going to occur in the future when final arrangements are made in relation to the road alignment.

There is no indication as to when the road resurfacing would occur, and as we are now approaching the winter months, it is unlikely to be completed soon. This is a concern given the slippery conditions when the road surface is wet.

The road and weather conditions at the time of this accident were certainly contributing factors. The lack of rain over the previous weeks would have allowed oil, diesel, and other forms of sediment to settle on the road surface. This area is used by a large number of heavy vehicles and due to the slight incline would cause these vehicles to omit a large amount of fumes and smoke. The minimal amount of rain in the days prior to the accident, would not have been sufficient to wash away sediment that had built up over the preceding weeks. Although not a factor in this accident, this area also has issues with water settling on the road surface during periods of heavy rain. These issues give weight to the importance of the resurfacing work to be carried out as a matter of priority.

Warning lights and speed limit:

The erection of automatically activated flashing warning lights (that come on automatically in wet conditions) is still being considered. D.I.E.R. consider warning lights or a flashing speed limit sign (80km/h) may be an option, however further investigation by D.I.E.R. is required.

The reduction in speed limit from 100km/h to 80km/h as an interim measure, has occurred, thus, reducing the risk of driver’s losing control, however this does not prevent vehicles encroaching into the westbound lanes. There have been no incidents of reported accidents since the speed reduction has been implemented. Police have noted the high level of public compliance to the revised speed limit.

Conclusion:

Bianca Gourley was travelling in an easterly direction on the Bass Highway, Round Hill, Burnie, when she has lost control of the Commodore sedan, in wet conditions, on a sweeping left hand bend. The vehicle has broke traction and started to rotate in an anti-clockwise direction. She has been unable to regain control of the vehicle and has subsequently crossed the concrete median strip that divides the east and westbound lanes. The Commodore has continued to travel into the westbound lanes, directly into the path of the Pajero driven by Peter George. The point of maximum engagement occurred between the driver’s side of the Commodore and the front of the Pajero. The impact could best be described as massive. Upon separation, the Commodore has rotated 180 degrees in a clock-wise direction before coming to final rest in the middle of the westbound lanes. (The forces on the occupants would have been extreme). At this stage the green Camry, driven by Peter Smith, has collided lightly with the rear passenger side guard of the Commodore. This secondary impact was of little significance.

As a result of 1/c Constable Willcox’s investigation into this accident it is obvious that no blame can be attributed to drivers George and Smith. Both have endeavoured to avoid the collision, however, have been unable to do so. George and Smith have been travelling at approximately 95 to 100km/h which is within the speed limit of 100km/h for the area.

He was unable to complete a speed analysis for this accident, but due to the damage to the vehicles involved and witness accounts (Leon Rayner and Peter George), he believed the Commodore would have been travelling around 100km/h. Witnesses state that the Commodore did not appear to be in excess of the 100km/h speed limit.

In his opinion a protective barrier must be erected between the east and westbound lanes at this accident site as soon as practicable. This would hopefully prevent vehicles from encroaching into the opposite lanes if a driver was to lose control, and should prevent a similar tragedy occurring again.

Once a protective barrier has been erected, resurfacing would not be seen as urgent. The main issue at this location is preventing encroachment of eastbound vehicles into the westbound lanes.

The erection of flashing warning lights which will automatically activate in wet conditions, would be another option if the resealing process was to take longer than expected.

Again I wish to thank 1/c Constable Willcox for his detailed review of this accident and his attention to detail, which has assisted me greatly in handing down my findings into this tragic event.

COMMENTS & RECOMMENDATIONS :-

I find that the deceased Bianca MareeTHORP died as a result of Head, Chest & Abdominal Injuries due to a Motor Vehicle Collision.

I find that the deceased Sherilea Anne KEATING died as a result of Head & Chest Injuries due to a Motor Vehicle Collision.

I find that the deceased Larissa Maree HERON died as a result of Head, Chest & Abdominal Injuires due to a Motor Vehicle Collision.

I find that the deceased Claire Helen TAPSON died as a result of Multiple Injuries due to a Motor Vehicle Collision.

I find that the deceased Bianca GOURLEY died as a result of Head Injuies due to a Motor Vehicle Collision.

Having regard to the evidence before me, I recommend that the Department of Infrastructure, Energy and Resources implement the following recommendations as a matter of priority:-

· The erection of Brifon fencing between the east and westbound lanes at the accident site;

· The resealing of the road surface; and

· The erection of automatically activated warning lights.

I further find that road and weather conditions were major contributing factors in this accident. Bianca Gourley has lost control of the vehicle in wet and slippery conditions. This indicates that although not in excess of the speed limit, she may have been travelling at an excessive speed for the circumstances existing (wet road, raining).

In this connection, had the vehicle been fitted with The Electronic Stability Program (ESP) which uses intelligent sensors to detect skidding, then reduces engine torque and selectively applies brakes to individual wheels to bring the vehicle back on track, then this tragic event may have been avoided.

It is particularly effective during sudden evasive manoeuvres. Many cars manufactured in Europe now have ESP as standard, although many of the European makes which are imported to Australia do not..

I am aware that the Victorian State Coroner and Monash University Accident Research Centre have already recommended its standard fitment to all new cars and I would encourage the motor vehicle industry to consider the fitting of this life saving technology to all cars, both local and imported.

Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased for their loss.

This matter is now concluded

DATED : Thursday, 1st of June 2006 at Launceston in the state of Tasmania

Peter Henric Wilson

CORONER