Mike Hall Inquest

An Observer’s Perspective on Legalistic Findings

On the second anniversary of the death of British endurance cyclist Mike Hall and the first anniversary since the A.C.T. Coroner’s report into his death was released, it is timely that a response is made.

The Inquest was held in Canberra from 24 to 26 September 2018. Coroner Bernadette Boss’s final report, released on 28 February 2019, comprises 13 pages and 62 paragraphs, the final two of which contain her conclusion and six recommendations.

While her report is consistent with the brief of evidence presented to the Court, I feel that the report is misleading and doesn’t address the many questions and contradictions raised at the Inquest., In my opinion, this report is unlikely to provide a complete and accurate account of the facts and circumstances surrounding the death of Mike Hall.

In the introduction to her report, Coroner Boss states that it is the role of a Coroner in Australia “to make findings in relation to the manner and cause of death … and whether a matter of public safety is found to arise in connection with the inquest.” Thus, the Coroner’s Court is not a criminal court; it does not bring charges, determine guilt or innocence, or impose sentences.

This article reproduces much of Coroner Boss’s report as well as observations and additional content written by me, Heath Ryan. These comments are mine and mine alone and, while I acknowledge that the Board of the Australian Cycle Alliance inc (‘Cycle’) supports my conclusions, these comments do not in any way reflect the position of Cycle or of the members of the Board of Cycle.

My views are based on my personal experience as an ultra-endurance cyclist: I raced across three continents in 2018, over 15,000 km of mostly country roads and often in the dark; and I was a participant in the 2017 IPWR which was cancelled after Mike Hall was killed. I also attended the first two days of the Coronial Inquest, had access to written notes from the third day, and was also present when Coroner Boss handed down her decision. Additionally, detailed analysis and research was undertaken by me, by Cycle and by others. I have not, however, been privy to the brief of evidence made available by the Court to the parties who had official representation at the Inquest (including Dragon Face Pty Ltd and Anna Haslock). 

While it is not my aim to disrespect the Court in any way, I feel the need to highlight some of the inherent weaknesses in a system of justice that is failing to protect vulnerable road users in Australia, and that ultimately is not adequately serving the interests of Australia.

[Below, some paragraphs have been removed for the sake of brevity. The original numbering has been retained. The full Report is available from the A.C.T. Coroner’s Court website.]

Scope of Enquiry

3. I am required by section 52 of the Act to make findings in relation to the manner and cause of death of a person whose death has been reported to me, and whether a matter of public safety is found to arise in connection with the inquest.

This is important because the Coroner’s Court is not a criminal court; it does not bring charges, find guilt or innocence, or dispense punishment.

4. It has been a long recognised common law function of coroners to also make comments and recommendations on appropriate matters, and certain provisions of the Act such as section 57 complement that power. That section also provides a process whereby I may report my findings to Government, and the Government may respond via the Legislative Assembly to my report. However, as the ACT Supreme Court said in The Queen v Coroner Maria Doogan; ex parte Peter Lucas-Smith & Ors; the Queen v Coroner Maria Doogan & Ors; ex parte Australian Capital Territory [2005] ACTSC 74 (“The Queen v Maria Doogan”) at [28], I am not authorised “to conduct a wide-ranging inquiry akin to that of a Royal Commission, with a view to exploring any suggestion of a causal link, however tenuous, between some act, omission or circumstance and the cause or non-mitigation” of the death of Mr Hall.

This report contains a number of comments (60 in total), followed by one concluding paragraph (paragraph 61). It then lists six recommendations (paragraph 62). 

5. Unlike other Australian jurisdictions, I am not prohibited by statute from making a comment adverse to a person identifiable from my findings. I am, however, required by section 55 of the Act to provide a form of procedural fairness to any identifiable person against whom I intend to make an adverse comment, whereby I must issue a formal notice with a copy of the proposed comment and invite submissions or statements in relation to the proposed comment. In this matter, I determined that I would not make any adverse comments against any identifiable person.

This is of huge importance. Coroner Boss commenced the Inquest by saying that she would NOT be recommending any charges be laid against the driver, Shegu Bobb. 

This made it sound to me, at the time, like her mind was already made up and her decision was virtually ready to be handed down. So, it was unclear what value the examination of the dossier of evidence, collected by the AFP and presented by Counsel Assisting, by those represented at the Inquest would have.

6. Although section 34A(1) of the Act provides that a Coroner may decide that it is not necessary to conduct a hearing for the purpose of an inquest if the Coroner is satisfied that the manner and cause of death are sufficiently disclosed and a hearing is unnecessary, I decided in this matter that it was appropriate to hold a hearing. Accordingly, a hearing was held on 24 to 26 September 2018.

So, that would mean that the manner and cause of death were NOT sufficiently disclosed by the AFP investigations? 

7. The following parties sought and were granted leave to appear at the hearing: the Australian Capital Territory, Dragon Face Pty Ltd (as the entity who organised the 2017 Indian Pacific Wheel Race), and Ms Anna Haslock (Mr Hall’s partner). I appointed Mr Ken Archer as Counsel Assisting me in this matter under section 39 of the Act.

The Australian Capital Territory: they spoke about the road design, the intersection, etc. 

Dragon Face Pty Ltd: this entity is owned and run by Jesse Carlsson and Sarah Hammond. 

Anna Haslock: at the time of Mike Hall’s death, Anna was the ex-partner of Mike Hall. 

Counsel Assisting is the term used to in the A.C.T. Coroner’s Court to describe the prosecutor of the Inquiry. His job was to present the brief of evidence as collected by the Australian Federal Police, who act as the local police in the A.C.T. 

Facts

8. The facts surrounding Mr Hall’s death were not in dispute. I adopt Counsel Assisting’s summary:

a. At 6am on 18 March 2017 Michael Hall set off from Fremantle in Western Australia, intending to ride to the Sydney Opera House. Mr Hall was competing in the Indian Pacific Wheel Race, an ultra-endurance cycle race designed to test people to their limits. There is no prize or reward offered for “winning” or indeed even for completing the race. The rules of the race required participants to travel alone. It might be inferred that this added to the mental as well as the physical stamina required to complete the distance. Mr Hall was an exceedingly experienced ultra-endurance cyclist and was rated as being one of the most experienced in the world. The race was designed as an individual, unsupported challenge. Competitors had to travel some 5500 kilometres along indirect and challenging routes, being expected to do so in 14 days (approximately 400km per day).

b. As the race was unsupported, participants carried their needs on their bike or purchased anything they needed en route. Stopping, starting and sleeping times were at the discretion of the participants, and the rules made it very clear that riders were entirely responsible for their own safety, logistics, welfare and how they chose to approach the journey.

c. Mr Hall was equipped with a GPS tracker and fans were able to remotely track his progress in the event. The GPS data indicates that he arrived in Cooma at approximately 7.48pm. He was in second place in the race at this time. At 2.53am Mr Hall began to travel north on the Monaro Highway towards the ACT. At 6.20am Mr Hall was struck by a car in the northbound lane at a point very close to the intersection of Williamsdale Road and the Monaro Highway. The driver of the car was Shegu Bobb.

True, Mike Hall was responsible for his own safety, logistics and welfare, and the organisers, Dragon Face, were not directly responsible for his day-to-day safety. 

However, all road users are indirectly responsible for the safety of other road users in that, for example, motorists are not allowed to violate road rules and kill or injure cyclists without being held accountable for any infringements they may commit.

Manner and Cause of Death

9. At my direction an autopsy was performed by Professor Johan Duflou on 4 April 2017. Professor Duflou reported that Mr Hall had multiple injuries to his head and intracranial contents, fracturing of the spine, and multiple chest and abdominal injuries. In Professor Duflou’s opinion, Mr Hall’s death was almost instantaneous. I accept that opinion.

10. Based on the evidence before me, I find that Michael Richard Hall died on 31 March 2017 at approximately 6.20am near the intersection of Williamsdale Road and the Monaro Highway in the ACT, as a result of head and other injuries suffered when he was struck by a car as he rode his bicycle on the Monaro Highway.

Matters of Public Safety

11. I note the submissions made with regard to the nature of the roads that were travelled over during the race and the inevitable fatigue experienced by participants in the extreme sport of endurance cycling. I note also the submission made in relation to the rules of the Indian Pacific Wheel Race and, specifically, the lack of any rules aimed at setting a standard of conspicuousness above that required by the Road Rules. However, I am of the view that any investigation of this particular race in the circumstances of Mr Hall’s death would be inconsistent with the principles enunciated in The Queen v Maria Doogan and therefore I restrict my findings to the general issue of cyclist safety.

Wow. In the first sentence above the Coroner notes the “inevitable fatigue”. Then she also notes that the rules of the race did not require participants to make themselves any MORE visible than was required by the Road Rules. But, citing a precedent, she says that she will not investigate the particulars of the race, but will focus instead on the safety of cyclists in general.

This doesn’t make much sense to me. It seems illogical that cyclists should need to make themselves MORE visible when riding on a road at night than the Road Rules require. If the Road Rules are well written, then following them should not just be the minimum to being seen and safe, but it should also be sufficient. Otherwise, our legal system would be able to say: “You didn’t do anything wrong, but you could have done better, so I will find you at fault anyway.”

It seems that Coroner Boss has decided early in her report to focus on “cyclist safety”. I fear this means: “Let’s look at what cyclists need to do to be safe” rather than looking at what motorists need to do to ensure they do not endanger other road users including cyclists. A human being was killed by someone who admitted being distracted, who admitted speeding, and who admitted he was overdriving (driving faster than his lights allowed him to see what was in front of him).

Let’s first look at the assumption by the Coroner that fatigue was inevitable. When I race for thousands of kilometres across continents, I am always careful to manage my need for food and water, as well as my need for rest and sleep. It is easier to be alert and awake riding a bicycle than it is to be alert and awake driving a car or a truck. If a cyclist is tired, they must either stop and sleep (as I did), or they risk falling off and injuring themselves.

The expert witness on fatigue was an expert on pilot fatigue. Airline pilots do not have the same blood flow rates as ultra-endurance cyclists, so I am questioning this expert witness's ability to offer an informed opinion as to whether Mike, an elite endurance athlete, was fatigued or not.

When cross-examined by lawyers for Dragon Face and for Anna Haslock, the expert witness on fatigue stated that he believed Mike was fatigued because Mike spoke slowly in one video at a food stop near Bairnsdale. Anyone who has ever met Mike or heard him speak knows that Mike had a slow and deliberate delivery when he spoke, and he had a strong northern English/Welsh accent.

We know from Mike Hall's GPS tracker that he had 7 hours of rest and sleep in Cooma that night; just three hours later he was struck and killed.

When the expert witness was asked whether he thought the driver, Shegu Bobb - who was 19 at the time and had been up in the night to a young child after going to bed at 9pm and leaving home early - was fatigued, the expert witness said that it was possible that the driver was also fatigued.

So, the expert witness on fatigue is not an expert on the fatigue of athletes, and he offers an opinion that both Mike Hall and Shegu Bobb could have been fatigued. But one was riding a bicycle; the other was driving a car.

Design of the Road

12. The evidence before the Court relating to the Monaro Highway was to the effect that it was typical of many rural arterial roads in Australia. From Cooma to the outskirts of Canberra the road is a single carriageway with short stretches of overtaking lanes.  The road is relatively busy with commuter traffic during the week and a reasonably steady flow of holiday makers and the transport of goods to and from the Southern New South Wales coast and the Snowy Mountains, particularly during the ski season.

I have studied Strava heat maps and can confirm that this road is also regularly used by cyclists.

13. Commuters can travel daily from as far away as Cooma to work in Canberra and there are a number of sizable semi-rural communities close to and just over the New South Wales-ACT border. In the seasons with shorter daylight hours, commuters often need to travel both to and from work in the dark. The majority of the road is unlit, including at rural intersections, and this was the situation at the area of the collision. There have been a number of fatal accidents on the section of the Monaro Highway between Canberra and the NSW border.

This is important because the Coroner’s description of this road shows that this road is typical of the majority of country roads in Australia. It is also typical of country roads in America, and in many countries in Europe. There is no reason why a country road being unlit should mean that cyclists should expect to be at risk of being hit and killed.

The point made by the Coroner is a furphy. Just because there have been “a number of fatal accidents” on that section of road does not mean that Mike Hall was at fault for his own death. Surely motorists who do not drive safely or to conditions are responsible for the incidents they cause.

14. As the road cuts through open country there is an abundance of wildlife in the area, with kangaroos being a particular hazard to traffic, especially outside daylight hours. Evidence was given of significant quantities of roadkill being visible on the side of the road between Canberra and the ACT border at the material time. Witnesses experienced in travelling the road gave evidence that they were watchful for wildlife and some of them had enhanced (additional) lighting fitted to their vehicles to assist in early detection of wildlife on the road.

This is also important because the motorists on that road – a road that had patches of fog that morning and was plauged by kangaroos due to a drought – should have been driving slower. However, all the witnesses except one stated that they were driving at the posted speed limit, 100 km/h. Only one witness said that she was driving at between 70 and 80 km/h due to the fog and the risk of hitting wildlife. It seems to me that this driver’s opinion that the road conditions required all drivers to drive below the posted maximum speed limit in order to be safe could be the gold standard for this road on this morning.

15. The speed limit between Canberra and Cooma is generally 100kph except through built up areas such as the village of Bredbo. The collision occurred at a section of the road where the posted speed limit is 100kph. Drivers experienced in the route gave evidence that traffic generally travelled at the posted speed and some drivers employed vehicular ‘cruise control’ systems during the daily commute.

First, no one ever admits to speeding, and only one driver took the fog and the risk of wildlife into account when deciding if it was safe to drive at the set speed limit.

16. The road in the vicinity of the collision site was 3.7 metres wide with verges of between 1.3 and 0.8 metres width. A short distance to the south of the collision site is a disused service station which provided a much wider area of verge. After the disused service station the verge narrows significantly, with less than the 0.8 metres recorded in other parts of the road in the vicinity. The verge at this point is unlikely to be suitable for a cyclist to ride on and cyclists would be forced further to the right at the approximate area of the collision than on other parts of the road.

In my opinion, Mike was likely on the 'white' fog line or just to the left or right of the fog line when he was struck and killed. However, Mike and other cyclists ride hundreds of thousands of kilometres every year on country roads without paved verges.

17. Where the verge to the left narrows, the northbound lane is divided to facilitate traffic turning in and out of Williamsdale Road. Along the left side of this section of the road are arranged guideposts with round reflective discs marking the left side of the road. The discs attached to the guidepost are at or about the height of a bicycle rear light. These guideposts are most likely in place to warn drivers of a culvert on that side of the road. This hazard is likely to have contributed to the narrowing of the verge at that point.

The road here goes from one lane northbound to TWO lanes northbound, with one designated a right-turn lane. So, while there was only a small verge where Mike was struck, the road was extremely wide.

The comment here about the round reflective discs on the guideposts is interesting. Mike’s rear light was extremely bright and looked nothing like a round reflective disc on a guidepost. His rear light ran off his dynamo hub. The legal required distance from which it needed to be visible from is 200 metres, yet it was easily visible that morning from 300-500 metres away.

The above comment in paragraph 17 is taken directly from the AFP’s reconstruction of Mike’s bike and bike lights. This reconstruction: a) used a battery not a dynamo and so the light was much duller, b) removed from the reconstruction Mike’s front light which cast a bright pool of light on the road in front of him, c) removed from the reconstruction Mike’s reflective clothing, d) removed from the reconstruction Mike’s reflective rear saddle bag, e) removed from the reconstruction Mike himself, a moving object, that would have provided contrast to any observer, f) placed the reconstructed bike far left of the white fog line, g) placed Mike’s bike near the red reflector guideposts off the road, and h) shone a spotlight from near Mike’s bike towards the camera in the police car that was filming this reconstruction.

Also, there is little connection in my mind, having examined the site, between the culvert, the guideposts, and width of the road. Mike was not hit because of a culvert many metres off the road; Mike was hit because of what the drivers on the road did.

18. A report was prepared at my direction and was tendered with the title Submission to the ACT Coroners Court, Review of Cyclist Fatality Case dated 15 December 2017, as well as a supplementary report dated 18 September 2018(together “the ARC Reports”). These were prepared by Associate Professor Jennie Oxley and Dr Steve O’Hern, both of the Monash University Accident Research Centre (MUARC). The reports identified elements of the Austroads Guides that relate to cyclists. In relation to roads with 100 kph limits, the recommendation is for a two metre clearance from faster vehicle traffic to be provided for cyclists and physical separation with a verge to provide a safe cycling environment compliant with Safe System principles. This clearance is expressly recommended for rural environments on un-kerbed roads.

Firstly, here we find out that the Monash University ARC report was completed in December 2017, and then a further submission was added in September 2018, just one month prior to the Inquest. Coroner Boss states that she will treat both submissions as one report.

But timing is important. One task requested of the people at Monash University ARC was to determin whether Mike’s lights were bright enough to meet the legal requirement. For this, they did a reconstruction of the electrics, and they concluded that the lights did meet the requirements of the A.C.T. Road Rules.

Secondly, minimum passing distance laws in force in the A.C.T. require vehicles travelling at 100 km/h to give cyclists 1.5 metres of clearance. So, it seems that the Coroner is saying that the report from the ARC at Monash University is recommending a two-metre clearance gap between motor vehicles and cyclists. This makes no sense. Why would an Accident Research Centre looking at a damaged bike and its lights recommend that passing distances be increased from 1.5 metres to 2 metres? I feel like the forest is being obscured by the trees. Mike was not hit by a motorist passing him at more or less than 1.5 metres. Mike was hit from behind. The bike was embedded in the front bonnet of the vehicle.

Let’s not forget that few country roads have physical separation between cyclists and motorist, so the final sentence above is also a red herring.

19. The authors of the reports specifically considered the vicinity of the collision site and noted that the “partial seal, variable condition of the shoulder” rendered it a road that would not be suitable for bicycle riding, particularly at night. Of significance, the authors also noted that the static rear light of the bicycle could have been misinterpreted by a driver for the static red reflectors on the guideposts, described above, which were set at much the same height and colour as the bicycle Mr Hall was riding.

If a report says that the verge of a particular road displays “partial seal, variable condition of the shoulder”, this is not the same as saying that this would is not suitable for bicycle riding at night. The Coroner has taken licence here. The VERGE may not be suitable for bicycle riding at a fast speed, but some people still use such a verge for cycling; for others, the rest of the road is also okay for riding on, as is allowed by law. 

Now, also remember that this report is being treated as ONE report by the Coroner, but that it was submitted in two parts, one in December 2017 before the AFP did their roadside reconstruction of the bike and its lights. This reconstruction was performed in 2018. In the AFP reconstruction, They concluded that the bike’s rear light looked like a static red reflector. The ARC reconstruction was performed in Monash University’s facilities, far from the static red reflectors of rural A.C.T. I suspect that the final part of the ARC report, submitted in September 2018, was commenting on the AFP reconstruction report, which inaccurately concluded that Mike’s rear light looked as dull as a static roadside reflector, and not on their own investigations.

20. While the authors of the reports were generally of the view that the relevant section of the Monaro Highway was compliant with Austroads recommendations, they opined that had there been wider, sealed shoulders and street lighting at the intersection with the Williamsdale Road, the risk to a cyclist may have been mitigated.

I opined once that had I been born into a rich family, I would now be living on a yacht and the risk of me living in a small rented apartment would also have been mitigated.

The reality is that Mike was fully compliant with the A.C.T. Road Rules and the road was also compliant, but a motorist hit and killed him. The Coroner is focusing on cyclist safety instead of focusing on the cause of Mike’s death – the dangerous actions by a motorist who was contravening the A.C.T. Road Rules.

21. Mr Michael Day, Manager of Traffic Signals for Roads ACT, gave evidence to the Court in relation to his attendance at the scene of Mr Hall’s death. His evidence was to the effect that he checked the road line marking, traffic facilities and signage to ensure they complied with ACT plans. Mr Day was asked questions in relation to the guide posts and culvert area, and he confirmed that the narrowing of the road, barrier and reflectors were present to prevent drivers from colliding with the culvert. He agreed that the culvert arrangement effectively eliminated the area for cyclists to be separated from motorised traffic on the road at that point.

The road was compliant. The culvert was a number of metres away from the road, and quite irrelevant to the death of Mike Hall.

Mr Michael Day, Manager of Traffic Signals for Roads A.C.T., was asked by the lawyer acting for Anna Haslock what his main activities at work were and what his area of specialisation was, and he replied that he specialised in traffic lights (intersection management lights). There were no control traffic lights at the intersection.

This expert witness was not an expert on anything relevant to the cause of death of Mike Hall. I stopped taking notes during his testimony as he was irrelevant to this proceeding.

22. The conclusion that inevitably flows from the physical evidence is that at or about the point of impact, Mr Hall had little choice but to be in the main traffic lane, having been forced into it by the structure of the road close to the intersection with Williamsdale Road.

No, this is an assumption. This was not presented as evidence at the Inquest. 

We were told that the wheel debris from Mike Hall’s rear wheel was about a quarter of the way into the intersection (meaning that he was hit six metres before that point), but we were not shown any photos of debris, nor told where that debris was located in relation to the fog line, the verge, etc. We were shown a graphic representation of where items were found by the AFP.

The Coroner has made an assumption, based on the verge being rough, that Mike would have had to have been in the main traffic lane. Mike may have been there, or he may have been on the fog line, or he may have been suffering through a bumpy ride in the verge, as he would have heard and seen the cars approaching him from behind and he would have placed himself where he felt safest.

What Coroner Boss is also saying here is that, because Mike’s bike was embedded in the bonnet of Shegu Bobb's car about half a metre in from the side of the car and assuming that Shegu Bobb was well to the right of the white fog line, Mike Hall had to be far into the main traffic lane. However, if Shegu Bobb was driving left of the fog line, then Mike still could have been riding on the fog line and not in the main traffic lane.

Unfortunately for those of us who want to know the truth, Shegu Bobb was not permitted by the Coroner, at the recommendation of Counsel Assisting, to testify or be cross-examined. This meant that no one other than the AFP had asked Shegu Bobb any questions about what happened that morning, and thus the only version of events available to the Court was the version of events presented by the AFP.

23. Evidence given in the proceeding was to the effect that the allocation of funding for road maintenance and design is linked to usage. Cyclists make up a very small percentage of road users on the Monaro Highway, therefore cycle traffic was given a low priority for funding. Although funding priority set on this basis has logic to it, there was no evidence of a risk-based assessment in terms of outcome. Although the likelihood of an incident involving a cyclist is low because there are relatively few cyclists on the road, the likelihood of death or serious injury to a cyclist colliding with a motor vehicle travelling at 100kph is very high. Given the ARC Reports opining that the physical structure of the road at the collision site may have contributed to Mr Hall’s death, it seems that some review of the intersection to evaluate the risk and further assessment of funding priority would be appropriate. I will come back to this matter in my recommendations.

Not so fast.

Firstly, Strava heat maps show that lots of cyclists use the Monaro Highway. There is no other road from Cooma to Canberra.

Secondly, it is illogical and irresponsible for governments in charge of road maintenance to say that they don’t have a responsibility to make those roads safe for cyclists because there are not so many cyclists using those roads.

Thirdly, saying that the likelihood of a cyclist being killed if hit by a motor vehicle travelling at 100 km/h is high is like saying that the likelihood of dying after being shot through the heart with a high-powered rifle is high. It’s simply irrelevant to road safety, driver behaviour and the adherence to and the enforcement of road rules.

Speed Limits

Paragraphs 24 to 27 dealt with the recommended speed at the intersection and whether it should be lowered from 100 km/h. Major intersections get lower speed limits sometimes, but T-junctions are not major intersections. For more details about the intersection, see the final recommendations by Coroner Boss.

28. There was no evidence that Mr Hall’s bicycle light was not compliant with the applicable legislation including the Australian Road Rules. These have since been incorporated identically into ACT legislation as the Road Transport (Road Rules) Regulation 2017 (ACT). Road Rule 259 relevantly provides:

259 Riding at night

The rider of a bicycle must not ride at night, or in hazardous weather conditions causing reduced visibility, unless the bicycle, or the rider, displays—

(a) a flashing or steady white light that is clearly visible for at least 200m from the front of the bicycle; and

(b) a flashing or steady red light that is clearly visible for at least 200m from the rear of the bicycle; and

(c) a red reflector that is clearly visible for at least 50m from the rear of the bicycle when light is projected onto it by a vehicle’s headlight on low-beam.

Mike was fully compliant with the A.C.T. Road Rules. However, let’s note that these rules were amended after Mike Hall was killed in 2017 to change the requirements of the colour of the rear reflector. Before Mike was killed, the A.C.T. required a rear reflector of no specific colour.

Paragraph 29 was about light brightness and simply quoted the regulations.

30. A question arises as to whether Mr Hall’s rear lighting arrangement met the required standard. The rear light was a seat post mounted “Supernova E3 tail light 2”. This brand of light is powered by dynamo and does not flash. The power to the light is provided by the wheels turning. There is a reflector built into the light. Road Rule 259, set out above, can be interpreted either as requiring a separate reflector or simply that a reflector must be on the back of the bicycle, allowing for it to be incorporated into the rear light. I am of the view that it is beyond the scope of my inquiry to settle this point but I recommend that the matter be considered and an amendment made to clarify whether a light and a separate reflector is to be fitted to achieve compliance.

This is all about tinkering and achieving compliance with rules. Whether a bike has a separate reflector at night, while the rear light is on, is not going to kept cyclists alive if a motorist is speeding, distracted or driving with faulty headlights.

31. While Mr Hall’s rear light may have met with the standards required by law, it was noted in both the ARC Reports and the AFP reconstruction that the rear light was difficult to see at 200 metres. This difficulty would have been exacerbated for a vehicle travelling at 100 kph, again as can be seen in the AFP reconstruction, and by the difficulty in distinguishing the rear light from the guideposts with red reflectors on the side of the road, also demonstrated in the AFP reconstruction. It is an important component of rider safety that any mandated lighting system achieve a high level of conspicuousness (or conspicuity, the term used by the authors of the expert reports). Having received evidence on this issue, including the photographs and videos of reconstructions, I am of the view that it is appropriate to make a recommendation that flashing rear lights should be set as the standard for bicycles ridden in low light conditions on rural roads.

Mike’s lights were compliant as seen in the previous nights video; there is no evidence that Mike Hall had changed any of his bike configuration over night. 

This video shows that Mike was easily seen from more than 200 metres.

So, why is the Coroner recommending all of Australia change their road rules from requiring cyclist to have rear red lights to requiring cyclists to have rear red FLASHING lights? This is not the law in any country I can find. Flashing lights are preferred by some cyclists, but the evidence between solid and flashing lights is mixed and not conclusive. And Coroner Boss is NOT a road safety expert. 

32. Mr Hall’s front light appears to have been compliant with the relevant standards. It has been submitted that the front light pooling at the front of the bicycle would have added to conspicuity. The conspicuity of the front light was not considered in the ARC Reports. A documentary filmed during earlier segments of the race was tendered into evidence and a relevant portion played to demonstrate Mr Hall’s conspicuity, including the pooling of light at the front of his bicycle. I have approached this evidence with some caution as the documentary crew were clearly travelling well below 100 kph when filming and were using camera equipment, which may have been more sensitive to light than the naked eye. Based on the evidence from other drivers who saw Mr Hall, it does not appear that the light pooling in front of the bicycle added to Mr Hall’s conspicuity.

Mike’s front light was compliant, as was his rear light. But the Monash University ARC report that investigated his lights did not even look at the way his front light would have pooled on the road in front of him and making him even more visible. Why do we have government-funded universities with centres for research, and then not use that expertise to establish the facts surrounding a crash that killed someone?

Instead, the Coroner has chosen to approach video evidence that showed his light pooling “with some caution”. Instead of getting expert evidence from the ARC, she instead gives priority to “evidence from drivers who saw Mr Hall”, and she concludes: “it does not appear that the light pooling in front of the bicycle added to Mr Hall’s conspicuity.” Really? Every witness saw Mike. Many said that they saw his dark clothing; but this is not possible. They actually saw his reflective clothing and his lights and the front light pooling on the road, but their brains remembered the dark patches between all those sources of light. Remember, dark clothing does not reflect light, and so you cannot see it. But all the witnesses saw Mike – except Shegu Bobb, who was distracted and had weak headlights and was possibly fatigued. And they all said Mike was riding left of the fog line. 

Headlights on Low Beam

33. The driver of the vehicle, Mr Bobb did not give evidence at the hearing and was not required for cross examination. He did provide a statement to police.

This is a real problem. Without Shegu Bobb giving evidence, the only source of information regarding the crash that killed Mike Hall is the brief of evidence presented to the Coroner by the AFP.

Shegu Bobb was prevented from giving evidence, at the request of Counsel Assisting presenting the case for the AFP, because they said his English was not good enough. And yet, he participated in three police interview, two of which were formal interviews. And he was offered a translator at the first formal interview but declined that offer.

Shegu Bobb was born and raised in Sierra Leone where the official language is English, so he likely spoke English, at least, as his second language for most of his life. He then moved to Australia and attended high school in English. So, he had spent at least eight of his 19 years in Australia.

34. Mr Bobb told police that his circumstances at the time were that he was living with his wife and small child to the south of the Williamsdale Road turn-off. He was working as a tiler and left his home early to head to his work site. Mr Bobb speaks English as a second language. He was listening to music as he drove his car. He is not an experienced driver and held a valid provisional licence.

Shegu Bobb had a young child, and we were told in the court room that he had been up during the night attending the childs needs. So it is possibly he was fatigued.

Shegu Bobb was listening to music – and singing, by his own admission in the court-presented statement – as he drove. There are very few radio stations available on country roads, and reception is often poor, and few stations would have had music a young person would sing to, so is it likely that Shegu Bobb was using his mobile phone as a source of music?

Shegu Bobb was an inexperienced driver, yes. But this is only part of the story. According to the Coroner during the Inquest, Shegu Bobb was in his first year of driving. This means that he was driving on NSW red P-plates. A quick Google search will tell you that NSW red P-plate drivers are limited to a maximum speed of 90 km/h anywhere in Australia. So, Shegu Bobb was required to drive in the A.C.T. at 90 km/h. However, the AFP stated at the Inquest that he was driving at the posted speed limit of 100 km/h. This is speeding, and Shegu Bobb should have been charged with exceeding the legal speed limit, but to this day he has not been charged with any offence.

The Coroner here says that he left home “early”. That is an interesting way to describe it. Shegu Bobb said in his 'informal' first interview with the AFP when he was in hospital in Canberra following the crash that he left home at 5:30am. In his second (first 'formal') interview he is quoted by the AFP as saying he left home at 5:00am. The use of the term “early” gives the impression that he had left home with lots of time to get to his place of work. It is likely that Shegu Bobb was running late for work, and was correct in his first interview where he said he actually left at 5:30am. Thus he would have been speeding (over 100km/h), on a dark road with fog patches and kangaroos.

There are two speed gantries in the first 50 kilometres on the road from Cooma to Canberra. The speed Shegu Bobb was driving at for that period would have been accessible to NSW authorities following the crash that killed Mike Hall. This data would also have shown when Shegu Bobb actually left Cooma. There is no evidence that the AFP acted to obtain that data.

If Shegu Bobb left Cooma at 5:00am and drove at 90 km/h, he would have reached the crash site at 6:05am – 15 minutes before the actual crash. I know this because I drove a reconstruction on 30 March 2019. I also stopped for petrol as Shegu Bobb stated he did in his interviews. If Shegu Bobb left at 5:00am and drove at 100 km/h, he would have reached the crash site even earlier than 6:05am.

But if Shegu Bobb left Cooma at 5:30am as he stated in this FIRST INTERVIEW with the AFP, and if he had been driving at 100 km/h (in excess of the red P-plate limit of 90 km/h), he would have reached the crash site at 6:35am – too late. I drove this myself on 31 March 2019 at 5:30am and I stayed within the speed limits and did not reach the crash site until 6:30am – and that was without a petrol stop which would have added five extra minutes to the journey. Thus, Shegu Bobb had to have been speeding – at over 107 km/h – as he drove from Cooma to Canberra in the dark with inadequate headlights. But the AFP chose to present evidence at the Inquest that Shegu Bobb was driving at the speed limit and thus was doing nothing wrong. 

35. During the interview Mr Bobb stated that he was in the habit of dimming his lights as he came up to the intersection with Williamsdale Road in case there were vehicles at the intersection. While it is not certain that he did not return his lights to high beam before the collision, the inquiry and hearing of the matter has proceeded on the assumption that the lights were on low beam at the time of impact. Mr Bobb expressed the view during his interview that his lights did not project light very far in front of his vehicle.

I don’t know any P-plate drivers who are in the habit of dimming their lights as they approach a T-junction. Evidence was presented at the Inquest, from notes in the brief of evidence taken by Senior Constable Potts during the first interview, that state Shegu Bobb said that he had dimmed his lights because there was a car in front. Shegu Bobb was driving in excess of 100 km/h and he caught up to another car. That car was in front of him, and so he dimmed his lights from high beam to his dips.

However, the Coroner and Counsel Assisting decided that the evidence that would be accepted by the Court was the wording in the second interview with the AFP – termed the first ‘official’ interview by the AFP – that stated Shegu Bobb dimmed his lights because there were cars somewhere ahead. The Coroner interpreted this as referring to the vehicles waiting at the T-junction to enter the Monaro Highway.

This is important because Shegu Bobb hit Mike when Shegu Bobb’s lights were on dim. There is no way that Shegu Bobb could have returned his lights to high beam because he hit Mike before the intersection where the other vehicles were waiting.

Also, by Shegu Bobb’s own admission in the first 'informal' interview with the AFP, his lights on dip were insufficient for him to see what was ahead of him as he drove at least at 100 km/h. His single remaining light only projected 15 metres in front of him. With two lights working (as we assume they were before the crash), Shegu Bobb, according to an expert witness, would only have been able to see 22 to 25 metres in front of him. However, in the third interview, a follow-up interview by the AFP, Shegu Bobb was asked is he could see half way across a football (soccer) pitch with his headlights on dip, to which he answered “yes”, according to the AFP. But no one was allowed to ask Shegu Bobb this at the Inquest because the Coroner had agreed that Shegu Bobb’s level of English may not have been good enough.

36. As Mr Hall’s bicycle was embedded into the passenger side headlight, that light was not operational after impact and could not be tested. The driver’s side headlight was tested by police and was found to be operating to the standard required for registration.

This is not what I heard at the Inquest. The expert told the Court that with both lights, Shegu Bobb would have been able to see 22-25 metres in front of him. The question was asked if that was legal in NSW, but the answer was mumbled and obscured. However, when a driver says to the police that he was unable to see with his headlights on dip, and he was driving with his headlights constantly on high beam for this reason, but that he had to dim his lights because there was a car in front, the obvious conclusion is that the driver’s lights were inadequate to see what was in front of him. 

The expert witness stated that Shegu Bobb was overdriving. This means not being able to see what is in front of you because your lights are too dim for the speed you are driving at. So, the Court was told that the lights of Shegu Bobb’s car were inadequate, and yet the Coroner has concluded that they were found “to be operating to the standard required for registration”.

37. Mr Bobb stated to police that he had noticed a truck parked to the side of the disused Williamsdale service station and shortly after he had felt an impact. He thought that he had hit a kangaroo and was shocked to see a bicycle embedded in the front of his vehicle. He got his phone and attempted to call for help.

This “truck” was mentioned by Counsel Assisting in the first hour of the Inquest on the first day. And yet, no photographic evidence of this truck was ever produced at the Inquest.

Shegu Bobb admitted to the AFP that he had been distracted by this truck. An expert witness then gave evidence that distraction lasts 7 seconds – that is, from the time the driver looks away until the driver is able to see where he is going and what he is doing is seven seconds. The truck would have been parked 150 metres before the intersection where Shegu Bobb hit Mike. So, a car going at 100 km/h would have travelled more than 150 metres in seven seconds. Thus, Shegu Bobb was distracted as he drove into the intersection and hit and killed Mike Hall according to his own admission, according to the brief of evidence presented by the AFP, and according to the evidence presented by the expert witness. 

And yet, the Coroner did not recommend Shegu Bobb be charged with driving while distracted. Why? 

38. There was no evidence that Mr Bobb had been using his phone prior to stopping his vehicle after the impact. It was suggested at hearing that the parked truck had distracted him from the road up to the point of impact. This was not supported by the expert witnesses’ evidence of distraction times.

There is no evidence that Shegu Bobb had been using his phone while driving because the AFP did not have the phone examined according to the evidence presented at the Inquest.

No, it was not “suggested” that Shegu Bobb was distracted. It was presented as a fact that Shegu Bobb had been distracted by a parked truck.

This was supported by the expert witnesses’ evidence of distraction times. So why has the Coroner contradicted the evidence presented by the expert witness? All the evidence provided proved driver distraction.

Clothing Worn by Mr Hall

39. Mr Hall was wearing dark coloured clothing. Regrettably, the clothing worn by Mr Hall was not dealt with in accordance with normal police procedures for retaining evidence. As a result, it has not been possible to test the clothing for reflective properties and therefore to conduct completely accurate reconstructions. Submissions were made that Mr Hall’s leggings had a reflective band at mid-calf and that the material over his shoulders was also reflective. This cannot be confirmed. It is accepted that coloured clothing in low light situations does little to enhance conspicuity; the use of reflective materials is a different matter.

Regrettably the AFP disposed of the clothing that Mike Hall had been wearing when he was killed and therefore it is not possible “to conduct completely accurate reconstructions”. 

So, the AFP got rid of Mike’s clothing with the reflective stripes on his leg warmings and with the white panels on his shoulders, and they returned to the family his saddle bag so that the reflective stripe on it is also not available as evidence before the Coronial Inquest, and then Counsel Assisting presented to the Coroner a case stating that it cannot be proven that Mike Hall was conspicuous on his bike that morning, and therefore the driver of the car cannot be charged with being negligent because the evidence is not available to prove negligence.

40. In one of the photographs tendered in evidence Mr Hall can be seen wearing the same or very similar leggings to those he was wearing at the time of the collision. The flash light used in this photograph returned a very high level of reflection from the bands at calf level. As the clothes were not retained, it has been impossible to conduct any test to establish whether a car light would have elicited the degree of reflectiveness seen through flash photography.

Translation: As the AFP destroyed the important evidence that would prove Mike was compliant with the Road Rules of the A.C.T. and that he was conspicuous, we will not charge the driver who killed him.

Visibility of Mr Hall

41. As the clothing was not retained, photographs of his body and evidence of witnesses passing a cyclist who is inferred to be Mr Hall on the Monaro Highway is all that is available to assess his clothing. Evidence from other drivers who passed Mr Hall close to the impact site was mixed in relation to his conspicuity.

Translation: Because we destroyed the evidence, we will have to rely on the witnesses who came forward voluntarily in March and April 2017 but whom we didn’t bother to interview until October 2017. 

42. Mr Quis gave evidence that he passed Mr Hall after he left his home in Michelago traveling north. Mr Quis had enhanced lighting that came on automatically with his high beams. At the time he passed Mr Hall, his lights were on high beam. He described Mr Hall as wearing dark clothing and being barely visible with dim lights. He stated that he had to take evasive action at the last minute to avoid him. He was surprised to see a cyclist on the Monaro Highway in the dark.

No. Mr Quis saw Mike’s reflective clothing but remembered the dark patches in between. He also saw Mike’s lights. Mr Quis then moved wider to the right to give the cyclist more room. But Mr Quis was probably surprised to see a cyclist on the Monaro Highway, as he was expecting kangaroos.

When asked in cross-examination where Mike was on the road, all the witnesses said that Mike was left of the fog line.

43. Mr Crivici’s evidence was to the effect that he had enhanced lighting fitted to his vehicle, although he could not recall if it was on at the time he passed Mr Hall. He stated that he had thought he saw a red light and thought it was a deer in the distance and was surprised when it turned out to be a cyclist. He stated that he was nearly on top of the cyclist when he saw that it was a cyclist. He did not recall any reflective material, only dark clothing. He confirmed that all he had seen was a white glow from the light, apparently the pooling of light from the front light of the bicycle.

This man’s evidence is suspect. He said in his testimony “I love deers”. So, he was looking for a deer after he saw the red light of Mike’s bike in the distance ahead of him. He was looking around for a deer and that’s why he didn’t realise sooner that the red light ahead of him was a cyclist. But he did see Mike’s dark clothing, which means he actually saw the reflective material around the dark clothing. He also saw the white pooling of Mike’s front light on the road.

So, a driver going 100 km/h in foggy conditions looking for deer who is interviewed seven months later is used by the Coroner as a basis to decide whether Mike’s clothing was reflective enough to make Mike conspicuous enough to be seen.

When asked in cross-examination where Mike was on the road, all the witnesses said that Mike was left of the fog line.

44. Mr Spulak’s evidence was that he was driving a six month old Hyundai i30. He was driving with high beam lighting along the Monaro Highway about five kilometres from Michelago. He stated that he was being watchful as there was a risk of kangaroos on the road. Suddenly Mr Spulak saw a cyclist in the road. By the time he saw the cyclist, he was almost on top of him and he had grave fears that there would be a collision. He was, however, able to swerve into the middle of the road and avoid a collision. He was unable to explain why he did not see the cyclist and was only able to speculate that the rider’s lights were covered by the position in which he was cycling. Mr Spulak was visibly shaken and distressed by the recollection.

Perhaps Mr Spulak wasn’t paying attention to what was in front of him, and perhaps that’s why “by the time he saw the cyclist, he was almost on top of him.” This is possibly distracted driving by a motorist driving in the dark where there are patches of fog and the risk of hitting kangaroos.

“He was, however, able to swerve into the middle of the road and avoid a collision.” Translation: he moved to the right to give the cyclist plenty of room as he passed the cyclist, as is required by the A.C.T. Road Rules. 

He was “only able to speculate that the rider’s lights were covered by the position in which he was cycling”.

Okay, so maybe Mike’s ass was behind his saddle and obscuring Mike’s rear light? Or perhaps Mike had crossed his legs in front of him on the top tube of his bike to hide his reflective stripes? Or perhaps speculation by witnesses seven months later should not be entered as evidence in a Coronial Inquest into someone’s death?

When asked in cross-examination where Mike was on the road, all the witnesses said that Mike was left of the fog line.

45. Mr Smith gave evidence to the effect that he saw a cyclist just before Michelago while he was driving his truck from Cooma to Tumut. He had his lights on high beam at the time. He described the cyclist as wandering in the lane and he moved his truck over to the south bound lane to give the bike a wide berth. He stated that he was surprised that the cyclist was not wearing reflective material. He stated that he saw the cyclist at the last moment. He found the cyclist very hard to see.

I believe this account is confused between one truck driver going south, and another driver who gave a wide berth to a cyclist he could not see.

There was a truck driver who gave evidence, and I took written notes, and this truck driver said that he was driving south from Tumut to Cooma (via the A.C.T.). He gave evidence that he had his speed set at 97 km/h. He saw lights coming towards him: “It was pretty bright.” At first this driver thought he was looking at a car with a missing headlight, and then he thought it was a motorcyclist because the light was so bright. Finally, the truck driver realised it was a cyclist, just as the cyclist turned right across his line of sight and into a petrol station. This was where Mike stopped for breakfast, what the truck driver saw was Mike turning right, and not a cyclist “wandering in the lane”.

This truck was travelling SOUTH not north, so he did not change lanes to give the cyclist a wide birth. This truck driver did however say that Mike was “swerving” all over the road. This quotation was the one picked up by the media immediately following the crash, and this gave readers of that article the impression that Mike was swerving all over the road, probably fatigued, and that he was on the wrong side of the road.

As an expert in endurance riding, I believe that Mike was turning right, safely and at a distance from the truck, to get breakfast. When the truck driver was asked in cross-examination whether he had to apply his brakes to avoid hitting Mike, the truck driver said no. So, in my expert opinion Mike made a safe right-hand turn.

Interestingly, there was another witness who said: “It’s a bit of a dangerous drive, really”, but who was nevertheless driving at 100 km/h in the foggy conditions, and who said he passed a cyclist wearing dark clothes with no lights, no reflective material, and no helmet. No other witness saw any such thing. The Coroner quickly dismissed this witness. I suspect he came across as an unreliable witness who was making stuff up.

46. Constable Craig Slater, a member of the NSW Police Force, was travelling south on the Monaro Highway. He gave evidence of his observations of a cyclist presumed to be Mr Hall a short distance from the collision site. He stated that he saw a light source and had difficulty recognising what it was. When he looked in his rear-view mirror he had difficulty making out the bicycle’s rear red light or distinguishing it from the guide posts on the side of the road. He was of the view that the cyclist was hard to see, given the cyclist’s dark clothing and lack of distinguishable lighting. Constable Slater expressed regret that he did not stop the cyclist to speak to him about his lack of conspicuity.

So, a member of the NSW Police Force sees a cyclist riding, with a bright front light, in the opposite direction to him. Perhaps at first he is not sure what he is looking at.

He then looks in this rear-view mirror to look again at the cyclist. He sees the cyclist’s rear light as he looks backwards in his mirror and drives away from the cyclist at 100 km/h, and he sees the cyclist’s clothing even though the lights of his car are no longer shining on the cyclist. And as a result of what he sees, the police officer decides not to do a U-turn to tell the cyclist that he is difficult to see – because the cyclist was not difficult to see.

47. Mr Maxwell gave evidence to the effect that he was a daily commuter on the Monaro Highway to and from Canberra. Mr Maxwell was driving a Nissan X-Trail fitted with spot lights on the front that came on automatically with the high beam. When he first encountered a cyclist Mr Maxwell was uncertain what he was seeing, but as he got close he saw a reflective material on the back of the legs in the calf region, moving up and down. Mr Maxwell was positive that the cyclist was wearing reflective material on his legs or shoes. He stated that he realised he was seeing a cyclist about 100 to 200 metres from him and had time to dip his lights and manoeuvre to overtake.

This sounds more accurate.

This man saw the reflective material on Mike’s calves. He saw it because: a) it was there, b) it was reflective, and c) it was moving up and down. Cyclists are visible to motorists in the dark because of their movement and because of contrast, not just because of the colour of their clothing.

This motorist, like the others, safely passed Mike by moving slightly to the right.

48. Ms Perrin gave evidence that she was driving a 2016 Mitsubishi Triton fitted with a light bar about 80 centimetres in length. She had the light bar fitted to illuminate the road better due to the hazards posed by wildlife on the Monaro Highway. About 200 metres past Lenanes Creek, Ms Perrin saw a cyclist. At the time she saw the cyclist, her lights were on full beam and the lights on the light bar were engaged. Consistent with other witnesses, Ms Perrin noted that it was odd to see a cyclist on the road in the dark. Ms Perrin stated that she could clearly see that it was a cyclist. Ms Perrin did not notice any reflective material on the cyclist’s back but she was certain she saw reflective material on his legs.

Ms Perrin is the second witness to clearly state that she saw Mike’s reflective material on his legs.

She also saw that Mike’s shoulders were white. The video evidence submitted to the Court showed Mike had white material on his shoulders but that it was not as reflective as the material on his legs. This is because the white material on his shoulders only reflected some light, and not as much light as his leg warmers. But Mike’s shoulders were still white, and they were still visible to this driver and probably to all the drivers who passed Mike. But, because the Coroner ruled that the white on Mike’s shoulders was not an official reflective surface (or something along these lines), she chose to discount this witness’s testimony.

Ms Perrin did say that it was not common to see cyclists on this road in the early morning hours. But she also said that she was driving at 70 to 80 km/h because THE ROAD HAD PATCHES OF FOG and because SHE WAS CONCERNED ABOUT HITTING KANGAROOS. 

Ms Perrin was asked by Counsel Assisting if she perhaps only saw Mike’s bare legs and if it was possible that Mike didn’t have reflective material on his legs. Ms Perrin REITERATED CLEARLY and FORCEFULLY that she could CLEARLY see the white reflective stripes on Mike’s legs.

And remember, Ms Perrin was driving at 80 km/h because she felt that driving at the posted limit of 100 km/h would be dangerous given the fog conditions and the risk of hitting kangaroos.

When asked in cross-examination where Mike was on the road, all the witnesses said that Mike was left of the fog line.

49. From the evidence of the witnesses it can be concluded that drivers with additional lighting to their cars were able to see Mr Hall well and in particular that he had reflective strips on his legs. Some drivers noted very specifically reflective material on or about the calf region. Drivers without enhanced lighting engaged had more difficulty seeing him and were left with an impression of dark clothing with few reflective properties.

In conclusion,

1. Mike had visible clothing or material,
2. Mike had reflective stripes on this legs,
3. Mike had a bright front light that pooled on the road in front of him,
4. Mike had a rear red light that was visible at more than 200 metres distance, and
5. Mike was riding left of the white fog line.

The witnesses were not interviewed by the AFP for over seven months.

50. It is more likely than not that Mr Hall was wearing material with reflective properties situated at calf level. This area is consistent with the grey coloured band that can be seen in photographs of Mr Hall’s clothes taken at the scene and at autopsy. There is no evidence of reflective material elsewhere on Mr Hall’s clothes. The clothing was not retained by police so its reflective capacity could not be tested, however, it is visible in the documentary footage tended. Clearly visible in photographs taken of Mr Hall’s bicycle at the scene is a single stripe of reflective tape-like material attached vertically to the back of Mr Hall’s rear saddle bag. It does not, however, appear to have been separately seen by any of the witnesses.

“There is no evidence of reflective material elsewhere on Mr Hall’s clothing.” Firstly, this is victim blaming. Mike was compliant and Mike was visible. Mike didn’t need to have more reflective material. He had visible reflective material on his clothing, and both his lights were bright and compliant with A.C.T. Road Rules.

But “The clothing was not retained by police…” because the AFP destroyed this evidence or allowed it to be destroyed prior to the Coronial Inquest. 

But also “Clearly visible in photographs taken of Mr Hall’s bicycle at the scene is a single stripe of reflective tape-like material attached vertically to the back of Mr Hall’s rear saddle bag.” This evidence was returned to the family at some point (importantly, it was not available for the AFP reconstruction which purported to show that Mike’s bike looked like a reflective guidepost) and was no longer available as evidence for the Court. This reflective tape-like material is just another piece of evidence that Mike was compliant and visible.

51. As Mr Hall’s clothing was not retained it has not been possible to conduct accurate analysis of Mr Hall’s conspicuity as he was riding on the Monaro Highway.

Because the Coroner cannot prove Mike was visible because the AFP destroyed this evidence, the Coroner will not say that Mike was visible, and thus she will not say that the driver who killed Mike, Shegu Bobb, should have seen Mike, and therefore she will not recommend charges against Shegu Bobb.

Why are charges not recommended against the AFP?

Possible offence

52. My role is not to determine the guilt or innocence of any person, however, I am required to do certain things if in the course of an inquest I come across evidence of an indictable offence.

So, is there evidence Shegu Bobb is guilty of an indictable offence?

Some legal material omitted here (paragraphs 53 to 56) can be read in the full report available from the A.C.T. Coroner’s Court website.

57. Section 6 of the Road Transport (Safety and Traffic Management) Act 1999 (ACT) creates an offence of negligent driving. Negligent driving causing death is punishable by a term of imprisonment not exceeding two years. It is not therefore an offence that may be dealt with on indictment and as such not subject to section 58 of the Act.

Negligent driving causing death is one charge I was interested to hear about from the Coroner.

58. In order to make a referral to the Director of Public Prosecutions (DPP), I must have reasonable grounds for believing that an indictable offence has been committed. When a statute prescribes that there must be "reasonable grounds" for a belief, “it requires the existence of facts which are sufficient to induce that state of mind in a reasonable person”, per George v Rockett [1990] HCA 26 at [8]. For reasonable grounds to be established, the potentially relevant evidence must be something more than a theoretical possibility.

Translation: I must have evidence in order to have reasonable grounds.

59. I am of the view that there is an argument that Mr Bobb was negligent in his driving. However, having regard to all the evidence before me and noting in particular the conflicting evidence in relation to Mr Hall’s conspicuity for other drivers, the loss of evidence crucial to determining the conspicuity of Mr Hall’s clothing and accoutrements, the physical environment of the road at the relevant location, and the high standard of negligence required by section 29, I do not have reasonable grounds for believing that Mr Bobb has committed an indictable offence.

“I am of the view that there is an argument that Mr Bobb was negligent in his driving.”

But, because the Coroner does not have the required evidence because some was destroyed by the AFP (and some was not collected by the AFP) … “do not have reasonable grounds for believing that Mr Bobb has committed an indictable offence.”

In short, because the indictable offence committed by Shegu Bobb when he killed Mike Hall cannot be proven because the AFP destroyed the required evidence required to prove guilt in a court of law beyond a reasonable doubt, Shegu Bobb will not be held accountable for his negligent driving.

60. I am not at liberty in the coronial jurisdiction to make a referral to the DPP in relation to summary matters. I will, however, refer the matter to the AFP for consideration as to whether a section 6 charge has been committed. All the submissions made to this inquiry will be forwarded to the AFP to assist in their consideration.

In conclusion, the evidence the Coroner has will be forwarded to the AFP for their consideration, and if they want to bring any charges against Shegu Bobb they can do that. But it was the AFP who failed to bring any charges against Shegu Bobb in the first place, so they are unlikely to bring any charges now, either, given that some of the required evidence is gone.

Conclusion

61. Mr Hall’s death was avoidable, which makes the loss of this remarkable person even more keenly felt by his family and the community. It is unfortunate that the investigation into his death has been to some degree compromised by the loss of significant evidence in the form of his clothing and bicycle accoutrements. There is, however, sufficient evidence for his death to be the catalyst for changes that will enhance rider safety into the future.

If Mike Hall’s death was avoidable, then what recommendations should be made so that this DOESN’T HAPPEN AGAIN?

The below recommendations from the Coroner look at both the design and the definition of the intersection where Mike was killed. One recommendation is to possibly lower the speed limit at that intersection. But, if Shegu Bobb was speeding, then lowering one limit that is ignored to a lower limit that is still ignored is not going to help make our roads safer for cyclists like Mike Hall.

The recommendations also go on to suggest that the road rules across Australia be updated to require cyclists to have a separate rear red reflector as well as a rear red light. This will do nothing to help keep cyclists safer.

The most curious recommendation suggests that all state and territory road rules in Australia should require cyclists to have flashing red rear lights. However, Coroner Boss is not an expert, and she has not cited any of the many international studies into bicycle safety and the pros and cons of either solid or flashing rear lights.

If she is really concerned that the red reflective guideposts along the Monaro Highway are the same height as cyclists, then perhaps a quicker way to improve safety for cyclists on that road is to have all those red reflective guideposts lowered so motorists speeding in foggy conditions will not be confused. I also still have to question the Coroner and ask if drivers are now expected to run into said reflectors

Sarcasm aside, how can future deaths like that of Mike Hall be prevented in Australia, and, more specifically, in the A.C.T.? 

Recommendations

62. Drawn from the facts and circumstances of Mr Hall’s death I make the following recommendations:

a. The ACT Government should conduct a review of the intersection of the Monaro Highway and Williamsdale Road to evaluate risk to road users, and a reassessment of funding priority in accordance with the review’s findings.

b. The ACT Government should define a clear outline of what constitutes a major intersection on the ACT portion of the Monaro Highway.

c. (c) The ACT Government should give consideration to the speed limits that should apply to major intersections along the ACT section of the Monaro Highway.

d. Standards Australia should conduct a review of AS3562-1990 relating to bicycle lighting, and the Standard be either updated or replaced.

e. The ACT Government should amend its relevant legislation to require a flashing rear light when riding a bicycle in low light conditions on rural roads. However, I also commend this recommendation to all Australian State and Territory Governments, for consideration of changes to the Australian Road Rules.

f. The ACT Government should amend its relevant legislation to clarify whether bicycles require a wholly separate reflector to be on the back of the bicycle, or whether the reflector may be integrated into the rear light. However, I also commend this recommendation to all Australian State and Territory Governments, for consideration of changes to the Australian Road Rules.

• RECOMMENDATION 1: The AFP need to hold drivers of motor vehicles accountable for their actions by charging them for the offenses they commit. Included in the list would be: negligent driving causing death, distracted driving, driving a vehicle with inadequate headlights, and speeding.
• RECOMMENDATION 2: The AFP need to fully investigate crashes where someone is seriously injured or killed, whether the victims are motorists or cyclists or pedestrians. That would include checking mobile phone use, checking speed gantries and other security video evidence to establish speed and other facts of the case.
• RECOMMENDATION 3: The AFP need to retain all evidence for all court hearings including coronial inquests. The AFP also need to present all evidence at court, including all interviews and not just the interviews they choose to call “official”.
• RECOMMENDATION 4: The AFP need to do their job, which is enforcing the laws of the A.C.T., and not judging the guilt of innocence of offenders.
• RECOMMENDATION 5: The AFP need to let the judiciary do their job, which is to determine the guilt or innocence of offenders, and to then punish offenders as they see fit.
• RECOMMENDATION 6: The decisions of the judiciary need to be publicised – in part by the mainstream media – so that: a) the public know they, the public, will consistently and fairly be held accountable for their actions when driving motorised vehicles on public roads; and so that b) those entrusted to look after public safety and act in the public interest – including the AFP – are exposed to public scrutiny and are held up to the highest standards. 
• RECOMMENDATION 7: Those not acting in the public interest, those not fairly and consistently enforcing the law as required by their job descriptions, those obscuring or destroying evidence, and those not being forthcoming with the whole truth in our courts of law, need to also be held accountable for their actions. 

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