A coroner has found that inadequate warning signs and loose gravel from roadworks were to blame for a cyclist’s death in Kingston three years ago.
The 53-year-old cyclist, identified only as BX, died on February 22, 2022, after losing control of his bike on Mount Royal Road and colliding with an oncoming vehicle.
Coroner Leigh Mackey said the cyclist encountered loose gravel that had spread across the road following repair works by TasNetworks to fix a high-voltage underground cable.
Police testing found the gravel created an extremely slippery surface and friction conditions of just 0.17, which investigators described as “equivalent to driving on ice”.

“… The presence of the excavation and the gravel on that portion of the road presented an extreme risk to cyclists for losing control of their bike,” Coroner Mackey stated.
Her findings noted that warning signs complied with the relevant standards but failed to specifically address the heightened danger to cyclists.

“Whilst the signage was likely adequate to warn motorists as to the level of risk they faced from the roadworks and the excavation, the risk was far greater to cyclists,” the coroner found.
Evidence showed other cyclists had narrowly avoided coming off their bikes at the same location in the days before the fatal crash.
One rider reported nearly entering the oncoming lane when trying to navigate around the gravel a day earlier.
A WorkSafe Tasmania investigation found that signs alerting riders to a “cycling hazard” could have “potentially contributed to a heightened level of safety for cyclists during the period of roadwork activities”.

The Department of State Growth acknowledged in response that signage warning of a “loose surface” rather than a “rough surface” would have been more appropriate.
Coroner Mackey has now recommended that roadwork risk assessments treat cyclists as vulnerable road users and that signs clearly warning of loose surfaces be used whenever debris is present.
“Cyclists are particularly vulnerable to changed road surface conditions and the consequence of encountering them can be, as it was in BX’s case, catastrophic,” she said.
“The signage used in this case, albeit compliant with Australian Standards, did not address the risk to cyclists specifically nor did it successfully convey to cyclists clearly the nature of the risk that lay ahead.”

“Whilst the distinction between a rough and loose surface may mean little to a motorist it would be significant to a cyclist.”
The cyclist, who had more than 20 years of riding experience, was wearing appropriate safety gear including a helmet at the time of the incident.
The coroner said neither the cyclist’s speed nor the driver of the vehicle contributed to the fatal crash, noting the driver “was merely in the wrong place at the wrong time”.