The Pettet Family

 

Ranjith Naranpanawa had picked it up at 5.20 that morning in Dandenong: a near-new 2000 model Mack prime mover pulling a triaxle tanker in Shell livery. He had filled it with diesel at Shell’s Newport refinery and delivered it to Leongatha. Now, about 10.30am, he was returning to Newport on the South Gippsland Highway.

Naranpanawa, 38, a Sri Lankan who had migrated to Australia in 1994, had been a truck driver since 1996. His employer, Cootes Holdings, regarded him as a competent, above average and experienced driver and “quiet, gentle and sober by nature”. He had no incentive to speed. Cootes paid its drivers by the hour to remove that temptation.

Michael Coleman and his wife, Carolyn, had been following the tanker since Korumburra. “He wasn’t flying away from me,” Mr Coleman recalled, estimating the truck was doing just under 100kmh.

His wife, checking the speedo from time to time, said it was closer to 90. Paul Gardiner, of Daylesford, judged it at about 95.

His fan belt would slip at anything above that speed and was not doing so that morning.

But Harold Gassman disagreed. Gassman, 71, from Phillip Island, had his cruise control on 104kmh. When the tanker overtook him, about oneanda-half kilometres from Kooweerup, he told his wife, Esther, “He’s going faster than he should go, especially in this kind of weather.” A torrent of rain had lashed across the highway about midway between the Lang Lang turnoff and the service station.

Photographer Jay Town, behind the Gassmans, recalled: “The heavens opened up and it bucketed down. It had gone from no rain to torrential rain straight away.” It lasted 10 or 15 seconds.”

“It was like one big wall of water.” Paul Gardiner said it was as if someone had suddenly thrown a bucket of water on his windscreen.

He used to work on farms in the area and short “microbursts” of “tonnes” of rain were common, he said.

Just before Sybella Avenue the highway curves and turns from divided road, separated by a median strip, into a two-kilometre, four-lane stretch of undivided tarmac. As he passed the service station, Naranpanawa was about 100 metres ahead of the Gassmans, overtaking a utility. He began to move into the left lane, correcting to pull the trailer into line behind the cab. To Gardiner the movement seemed benign and ordinary but in a heartbeat it turned to disaster.

As he watched the truck began to skate, the trailer swinging out in a wide arc as if it had hit a patch of ice. Town, 200 metres back, said: “It was in a jacknife. I saw it go around the right and screaming back that way … It was like sideways, going, swinging around … it wasn’t facing the way it was travelling.” It was like a pendulum swinging, with the arc getting longer, he recalled. It was rotating in a clockwise direction until the tanker was at a 75-degree angle to the direction it had been travelling in.

The momentum carried the truck across the double lines and into the oncoming lanes. Then the prime mover seemed to jump a couple of metres in the air. Town thought it must have hit a log on the road.

But it was a maroon Ford Fairlane taking Bill and Cherylynn Pettet and their teenage children Robert and Sharnie to a family picnic on Phillip Island.

Cesar Guajardo and his wife Rosa had driven from Hampton to buy fresh vegetables from farms around Kooweerup. They had done it often in the past, and when they were done they talked about going home but decided, for a change, to go for a drive towards Phillip Island.

Cesar was a careful motorist who drove disabled children for a living. In the line of holiday traffic, he would have been doing no more than 80kmh. He did not see the truck until the last seconds. There was nothing he could do and nowhere he could go.

Nor could Bill Pettet, driving the Fairlane ahead of Guajardo’s green Futura. The Fairlane neither swerved nor braked before the tanker ran over it. “It all happened so fast that the driver had no time to react,” Guajardo told police a month later.

Then the truck was coming at him. His only recollection was that it was across his lane. He could tell it was a tanker and remembers a flash of yellow and thinking “Shell” and that the prime mover and the trailer were at an unnatural angle to each other. Then nothing: he was unconscious for the next 11 days.

Rosa, in the seat next to him, was killed instantly.

The Pettets’ sedan was utterly destroyed. The truck had ridden over the top of the car, ripping off the roof and all the offside panels. The bonnet had been torn off and flung into the passenger compartment, the driver’s side door crushed over the driver’s seat.

The first people who ran to the wreckage saw there was nothing they could do. In the grey drizzle, they covered the family’s bodies with their bright, festive beach towels.

As he watched television that day, Alan Miller was torn between sorrow and anger – and strangely, a creeping tinge of guilt. A day or so later he again rang Andrew Wall, furious that nothing had been done following his warnings. Wall said an internal investigation was under way. Less than a month later, VicRoads began resurfacing that section of the highway.

It hadn’t been Miller’s protests that had prompted the work, nor even the deaths of five people. It was a near-miss that could have killed 19 more.

On February 12, tour driver Louise Webb had been returning a group of overseas tourists to Melbourne from Phillip Island. She had travelled that stretch of the highway probably 30 times in the previous two months. It was about 11pm and raining and she slowed her Toyota Coaster at the temporary 80kmh signs erected a fortnight before.

Then it was as if she had hit something, perhaps oil. The bus lost its grip on the road, Webb took her foot off the accelerator and the rear fishtailed. “. . . Everybody in the bus went ‘Ooooh’, everyone could feel it . . . and then within seconds it had swung.”

The Coaster slid across the road and tipped on to its side. “I don’t know how we got into the position we ended up in so I guess I blacked out,” said Webb. Incredibly, broken ribs and a broken collarbone were the worst injuries anyone suffered.

Webb borrowed a torch and went looking for the oil patch but there was nothing but water. And the police, ambulancemen and tow truck drivers on the scene all told her the same thing: “This is exactly the same spot that truck driver had the accident”.

When Harold Gassman saw the tanker overtaking him that Australia Day morning, he estimated its speed to be more than 104kmh. That made him angry. “I was so mad . . .” he told police. Understandably so: he and his wife Esther had lost two sons to road accidents.

On the morning of April 8 last year, Gassman stood in the box of the Coroner’s Court, the first witness at coroner Graeme Johnstone’s inquest into the deaths of Rosa Guajardo and the Pettet family. Expected to last three days, it would become a protracted, on-again, off-again hearing, running for nine extra days during April, June and August. And it would produce more than its share of surprises.

Gassman would provide the first. He had set his cruise control to 104 that morning, he said, because he had twice received speeding tickets and did not want any more. But he had never had his speedometer accuracy checked and agreed it might be wise to do so. “Actually I was wondering about that myself,” he said, “because sometimes I think my car is too slow because everybody overtakes me . . .”

He returned the next day with a revelation. Tests showed his speedo was over-reading by 7kmh. When he thought he was travelling at 104, he was doing 97. His estimate of the tanker’s speed was inaccurate.

But, coincidentally, the calibration was performed by mechanic Glenn Everitt, who told investigating police that he too had recently lost control on the same section. It had frightened him in a way he would never forget. Everitt was one of a procession of people, including Alan Miller and his drivers, who would tell similar stories. Investigators gathered evidence of 16 such incidents in the 30 months before the tour bus crash, all but one in the left lane of the Melbourne-bound carriageway near Sybella Avenue.

Two drivers reported losing control on two separate occasions. Tow truck operator Gregory Donoghue told how he was almost hit by an out of control car while attending to another vehicle that had slid off the highway. The spot was notorious. The problem, he said, was the surface.

Others would describe it as like glass or a billiard table when wet, even “a suicide stretch”. Donoghue called it a disaster waiting to happen and said driving on it put you “in the hands of the Gods”.

And, it seemed, into those of VicRoads.

Geoff Chettle, counsel for Ranjith Naranpanawa, is a lean, shaven-headed barrister known for his almost abrasive straight talking. But in reaching for a description of what happened after Alan Miller contacted VicRoads on his fears about the highway, Chettle found cliche. Perhaps because there were no better words, he submitted that it was a story of “bureaucratic bungle”.

After Wall had received Miller’s first phone call on November 1, he emailed a “customer action request” to Michael Potesta, VicRoads’ maintenance projects team leader. Potesta, in turn, sent engineer Henk Van Duren to inspect the area. But Van Duren apparently went to the wrong area, inspecting the Healesville-Kooweerup approach to the highway, and temporary warning signs were set up there.

The following day Wall received a note about the work and saw the mistake. He sent another e-mail, this time to Lewis Batista, who had organised the signs, asking him to “recheck”. On November 3 another e-mail crossed Wall’s screen, a copy of Batista’s note ordering signs at the highway “inbound at the beginning of the duplication at Rossiter Road”. Again the wrong location. But this time Wall didn’t pick it up.

“I don’t read everything that’s copied to me,” he told the Coroner. “In that case I probably skimmed it and didn’t look at the detail.” Nor had he made any notes of his further conversations with Miller after the tanker crash.

“It wasn’t identifying a new issue and I just treated it like most of the phone calls I might get on those sorts of issues,” he said. “Just a second,” said an incredulous Mr Johnstone. “This really wasn’t most of the phone calls you get on those sorts of issues. Five people have died . . . This isn’t just a run-of-the-mill daily phone call, surely?”

“M’mm,” replied Wall.

Then again, it should not have needed a phone call to remind VicRoads there was a problem with that shiny stretch of bitumen. In 1998, when the corridor strategy for the entire South Gippsland Highway was written, it noted that the road had an unacceptably high crash rate. Tellingly, it said a “major safety concern is the apparent lack of traction along sections of the highway, particularly in the first wet conditions following a dry spell”, adding that of 92 recorded accidents, 52 were single, one-off accident types.

The Kooweerup section had double the state average for accidents, with three people seriously injured in 10 casualty accidents between 1993 and 1998. Eight of the crashes involved loss of control and four occurred near Sybella Avenue.

That section had last been surfaced in January 1996 and was inspected each October.

In 2000, just weeks before Alan Miller lost control, the report showed a texture loss of five – maximum loss, indicating a real danger of skidding – placing it in category one for priority attention. Yet the same figures had been seen in 1998 and 1999.

On Australia Day, Sergeant Christopher Carnie, of the Major Collision Investigation Unit, inspected the road. The right-hand lanes in each direction were in good condition, he noted, but the left lanes, particularly westbound, were another matter. There was significant bitumen bleeding – in which the smooth bitumen rises to the surface, covering the stone aggregate material – “resulting in a polished and smooth surface for several hundred metres”.

“This lane was below standard,” he concluded.

His MCIU colleague, Sergeant Peter Bellion, an expert in reconstructing collisions, conducted skid testing on both Melbourne-bound lanes. He found that the left lane was “slippery and defective”.

Further, the marked difference in texture of the two lanes led to a “split friction phenonemon” in which the capacity of the left lane to decelerate a vehicle was only 55 per cent of that in lane two. In fact, he testified: “the friction value on that left lane is probably less than you’d get on, say, a gravel shoulder”.

If a vehicle decelerated while it had wheels in each lane, the left wheels could skid while the right wheels slowed, causing the vehicle to rotate on its axis. That, in turn, could lead to jackknifing.

Computer simulations later showed that appeared to be what happened to the Shell tanker. After overtaking at about 97 kmh, Naranpanawa began to move into the left lane. Decelerating, he corrected his steering to bring the trailer in behind him, at which point he lost control. Scuff marks showed his nearside drive wheels were about a metre or a third of the way into the left lane when it lost traction.

Bellion said Naranpanawa may have oversteered but speed was not a factor.

“In terms of the outcome of the collision, if it (the prime mover) was doing 90kmh, you backed off the throttle, did a lane change manoeuvre with a little bit too much steering input – see you later, you’re going to be out of control.”

Traffic consultant David Axup said once Naranpanawa lost traction, there was nothing he could do. The time between losing control and hitting the Pettet’s car was 1.5 to two seconds.

VicRoads would later submit that the Coroner should find that Naranpanawa’s actions were “a cause” of the accident. Sergeant Bellion recommended criminal proceedings but was overruled by his superiors. “We would be conveniently ignoring the existence of overwhelming evidence that indicates the road surface on the left-hand lane . . . was in need of urgent repair at the time of the collision,” said Inspector Geoff Alway. “There is also evidence that the road surface has been the primary cause of a number of other collisions both prior to and after this fatal collision.”

Alan Miller, it turned out, had not been the only driver to warn of the perils of that road, though his was the only complaint on VicRoads records. Three others passed on concerns. One, a driver named Farrell, twice lost control but when he phoned VicRoads was told to “put it in writing”.

The day after the deaths, maintenance team leader Michael Potesta inspected the site. Like Wall, he had not made written notes after acting – unsuccessfully – on Miller’s initial complaint and on this visit also made none. “There was no need to make an assessment as such,” he explained.

In fact, as Potesta let slip on the sixth day of the inquest, there appeared to be a VicRoads directive to do quite the opposite. And this was put in writing.

The instruction to VicRoads’ staff was explicit: when investigating “serious incidents” involving fatality or serious injury; where potential liability was above $20,000; or where there was a prospect of court proceedings involving censure of VicRoads or its officers, “No written assessment of the site or accident by VicRoads should be documented.”

The edict was contained in a work instruction issued in March 2001, but which had existed in draft form before the crash. It arose from a report to VicRoads’ Corporate Management Group in June 1999 aimed at managing incidents that might expose the corporation to liability for damages, prosecution or adverse findings by tribunals – such as coroner’s inquests.

Each year VicRoads incurred more than $1 million in damages, costs and expenses.

“It is becoming fashionable to blame the road rather than the driver,” it said. The number and cost of successful claims could be kept in check by “managing the nature and volume of reports and information generated in the aftermath of a liability accident”. Staff should provide oral reports to their managers rather than unnecessary documents “which may be subject to compulsory disclosure to persons with opposing interests”. Any such documents should be labelled as being solely for the purposes of obtaining legal advice. It was almost the exact template, Geoff Chettle would later submit, that VicRoads would use to respond to the five deaths that Australia Day.

Coroner Johnstone was bemused by the instructions. “This document doesn’t sit comfortably,” he said. “I need some answers and I’m not going to stop until I receive some answers.”

VicRoads chief executive officer David Anderson attempted to provide those answers. The work instruction, he testified, was an effort to provide “guidance” to staff unsure of what the corporation’s response should be to road incidents. VicRoads wanted to ensure that it gathered only “proper facts” not an individual’s “surmising or subjective opinion . . . And I understand that there are feelings that this is some way of limiting information, and I can assure you that it was produced for exactly the opposite reason.”

The coroner was unconvinced. “I am not left with the impression . . . that (it) is anything other than a document that is designed to protect anything that is created from an agency such as mine, or police.

“The imperative to your officers is not to make notes, not to make written assessments, to make oral assessments,” said Mr Johnstone. “. . . In blunt terms, that’s exactly what happened here. VicRoads conducted no proper investigation of what occurred on 26 January in terms of a safety audit or other proper investigation, but went straight to your lawyers.”

Those procedures were “legally wrong”, had the potential to mislead employees and he would need to refer them to the Attorney-General and the relevant minister. They left him, he said three times, with “a very uncomfortable feeling”.

Alan Miller had been left with something worse than an uncomfortable feeling. It was irrational and unnecessary, he knew, but what remained was a strange sense of personal guilt.

Miller was in the witness box telling of how he tried to warn VicRoads that someone was going to die on that slippery stretch of road. He told how twice he had gone to his MP, Ken Smith, and also to independent MLA Susan Davies. “They said they would look into it. I didn’t hear any further.

“In hindsight I should have done more by being on their back a bit harder, getting something done . . . I thought I had tried by going to my local member and doing those things, but when you look back at the cost that has been paid, I probably should have gone at it a bit harder. Because of the accident, I had a guilt that I hadn’t done everything when I should have . . .”

“Mr Miller,” interrupted the Coroner, “you have made a complaint to VicRoads, you have gone to see your member of Parliament, what are you saying you should have done further? From where I sit at the moment . . . you have done a considerable amount more than many other citizens would have done by actually taking the next step . . .”

“I understand exactly where you are coming from,” said Miller. “But it’s . . .”

“You are saying you can’t help feeling this way?”

“I can’t help it, yes,” he replied.

The coroner has finished taking evidence on the Kooweerup crash, and is presently considering his finding.