A young cyclist's fatal collision with a bus was mainly caused by multiple "stark" blind spots and a design flaw in traffic lights, a coroner has found.
Max Patrick McDowall, 20, died on May 27, 2021 at an intersection in the inner-Brisbane suburb of Woolloongabba after he was hit by a bus turning left as he crossed the road on a bike path.
Brisbane City Council bus driver Andrew Rudnicki, aged 67 at the time with more than 30 years of experience, told police he did not see Mr McDowall approaching from behind and turned on a green light after giving way to oncoming pedestrians and a cyclist.
Coroner Donald MacKenzie on Thursday handed down his findings in Brisbane Coroners Court following inquest hearings in April.
"The blind spot mapping diagram is stark. When I mean stark, it is quite clear there are extensive areas from which Mr Rudnicki was unable to view Max on his bicycle," Mr MacKenzie said.
He said the intersection was up to standards at the time but its traffic light design did not give regard to the extensive blind spots on the passenger side of council buses and provide additional protection to pedestrians and cyclists.
Mr McDowall died at the O'Keefe Street intersection with a dedicated busway where the only vehicles turning left would have been buses, which has since had its traffic lights upgraded to separate vehicles from people crossing the busway.
"Max's family submitted ... if the light sequencing had been operational in the way it was changed following Max's death it would have been unlikely Max would have died. I agree completely," Mr MacKenzie said.
The coroner found Mr McDowall made a minor contribution to his own death by not noticing the multiple flashing indicators on the bus as he looked down and pedalled hard to speed up and traverse an uphill path across the intersection.
Mr McDowall had right of way to cross the intersection and Mr Rudnicki was initially charged with failing to give way but police prosecutors discontinued the case against him in March 2022.
Mr MacKenzie recommended Brisbane City Council review its incident reporting system and driver training as well as install external cameras on its entire fleet of 1260 buses to reduce blind spots.
He also recommended the council and Queensland government review every intersection in the Brisbane metropolitan area with a view to installing red arrow traffic lights to prohibit vehicles turning where pedestrians crossed on a "green man" light.
Mr MacKenzie said he appreciated the budget and logistical challenges in implementing his recommendations, including a review of 1000 intersections, but they were ultimately about saving lives.
"Max was obviously a cherished young man who was lost to his family too soon. His death has brought to attention a dangerous problem with pedestrians and bicycle safety at Brisbane intersections," he said.
"The positive is traffic light sequencing should prevent a repeat of this tragic collision."
