A Letter to the NSW Coroner

In 2016, I wrote to the NSW Coroner requesting a coronial inquest into the death of my husband, Karl Langheinrich. I was gratified that at least he considered my request, although he ultimately decided  not to hold an inquest.

He was satisfied with the information that Tweed Shire Council provided and that they had done a good job.

An inquest would have brought to light many of the issues and factors (including deeply relevant official crash data) that I have unearthed since Karl died in February 2016.

It might have saved another life.

Now I know that the stretch of road where Karl died was a notorious road crash hot spot, as we can see from the table of official crash statistics below.

Four people have been killed there, with a total of 24 incidents and/or casualties in the seven years to 2016.

7 years FINAL

Had the Coroner considered these figures when I wrote to him (they were readily avilable to him if he only asked), he might have reconsidered.

Here is what I said in my request:

Death of Karl Langheinrich_Wendy Sarkissian Inquest Request 281116

Key Points

Among the key points I made are the following:

  1. I believe that weaknesses in the investigation of and response to the previous double fatality in the exact spot where Karl died indicate that appropriate consideration is not being given to road infrastructure in road planning in the Tweed Shire. Further, the NSW Coroner, in investigating Karl death, did not fully take into account the circumstances of the earlier crash and fatalities. I believe that there were weaknesses and inconsistences in the approach taken by Tweed Shire Council, the NSW Police and the NSW Coroner’s office, which, taken together, support my request that an inquest be held into Karl Langheinrich’s death.
  2. That 2015 crash occurred eight metres from where our vehicle left the road and fell into the Tweed River. I now believe (from an eyewitness account of the 2015 crash I heard firsthand on 17 November 2016), that if the second vehicle in the Bevelander head-on crash had not hit a tree (and stopped there on impact), it would have probably fallen into the river as well, potentially killing several children who were passengers in the van. Further, the Bevelander vehicle was stopped from going over the cliff only by the fact that it hit that van (a much larger vehicle); that impact brought the Bevelander vehicle to a standstill.
  3. Local residents (see: http://www.goldcoastbulletin.com.au/news/gold-coast/male-driver-67- dies-after-vw-golf-slides-of-kyogle-road-and-into-tweed-river/news- story/25960ef59a5673df4888edb9927bfb53), local, attending police and other police I spoke to after the crash, reiterated that the crash site is a known dangerous location, where many other vehicles crashes have occurred (not resulting in fatalities).
  4. Taking my formal witness statement on 19 February in Nimbin, Constable Brian Rogers noted that, “The location is known for fatal accidents.” (Constable Brian Rogers to Wendy Sarkissian, Nimbin Police Station, 19 February 2016). That view was expressed to me by all the police officers I spoke to following the crash.
  5. It has been accepted that the Bevelander fatal crash on 22 January 2015 was a loss-of-control crash on a tight curve (resulting in two fatalities, including one child). It is now widely accepted that unprotected roadsides on slippery roads with tight curves are antithetical to the safe system approach adopted as policy by all Australian Transport Ministers in 2004.
  6. A close photographic inspection of the site by Kevin Cracknell (an experienced emergency services worker) three days after the crash and a detailed subsequent photographic and site inspection by me and Kevin Cracknell three weeks after the crash revealed serious deficiencies in the roadway. We noted water pooling and a deteriorated roadway surface, as well as significant wheel rutting on the fog line (which would certainly be the entry point into the corner if water was present in these indentations, as that would also create a potential hazard). Additionally, we observed the presence of debris from previous crashes at the site. At that time, it appeared that the box culvert had recently been blocked. Had the box culvert been blocked or full at the time of the 2016 Langheinrich crash, that would have created a water hazard on the road surface. (Later inspection in 2017 found a spring bursting out on the earth and rock wall where both crashes occurred.)

Erosion showing spring crash site 012117

A spring bursting out on the rock/earth wall:  a probable contributor to water pooling at the edge of Kyogle Road, 2017

7. While the local police have been caring and supportive to me, the actions of the NSW Police Crash Investigation Unit do not reflect a consideration of the seriousness of this issue or and understanding of the clear the relationship between the Langheinrich crash and the Bevelander crash. Most importantly, the lack of attendance by the Crash Investigation Unit at the Langheinrich crash indicates that they did not connect the Langheinrich crash with the previous fatalities at the time and consider that it might be valuable it investigate why there had been three fatalities in exactly the same spot. I was advised by Senior Constable Mick Kelly that, “Murwillumbah police have been trying to get the Accident Investigation Unit to take action on that road for the last twelve months.” (Senior Constable Mick Kelly to Wendy Sarkissian, 14 February 2016).

Other police reported to me following our crash that repeated police requests for action from the Crash Investigation Unit since the first double fatality in 2015 have been ignored.

8. As the Police Crash Investigation Unit did not attend the second crash in 2016, I can only conclude that they did not connect the circumstances and context of this crash with the previous 2015 double fatality (a year earlier). Police told me that the Crash Investigation Unit determined that the fact that it was a single vehicle crash meant that driver error was the reason for the Langheinrich crash. That was their reason for not attending the crash. They did not pay attention to the similar characteristics of the two crashes.

9. A serious question arises for me: what specialist local resources were available to compensate for the fact that the Sydney-based Crash Investigation Unit did not attend? Who else could have been brought in to investigate the February 2016 crash in a professional manner?

Police advised me directly immediately after the crash, that had there been a guardrail in that location, Karl probably would not have died.

10. These are systemic weaknesses that must be addressed by a comprehensive analysis of how the road remained in a dangerous state while so many voices (particularly from local police) were raised in support of repairing that road and installing guardrails.

11. I firmly believe that the NSW Coroner has a responsibility to hold an inquest into Karl Langheinrich’s death, as I believe that the Coroner is also partly responsible for the lack of coordination among agencies and for the significant oversights and neglect that have occurred, contributing to Karl Langheinrich’s death on the Kyogle Road.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s