Byline: JEREMY CALVERT
LAP five of the 2000 Australian Formula One Grand Prix.
Ralf Schumacher steers his hurtling Williams around turn two of the Albert Park circuit, shadowed by Jacques Villeneuve's BAR Honda.
Whether Schumacher brakes early on the approach to turn three, or Villeneuve's concentration lapses will never be clear, but the BAR spears into the Williams' rear at sickening speed.
In a moment that will later be replayed to a packed Melbourne Coroner's Court time and again the BAR Honda launches skyward at more than 280 km/h, like an F-111 at takeoff.
Graham Beveridge, 52, working as a spectator marshal at turn three, has a clear view through a 40cm high gap in the debris fence in front of him.
Event organisers, fearful of track invasions, have instructed Mr Beveridge to closely guard the 4m-long gap, one of 200 around the circuit.
Watching a storm of machinery and debris careering towards him, Mr Beveridge has no time to move.
The 38cm-wide right-rear wheel of Villeneuve's car hits the 40cm gap at a fateful angle, passing through the hole organisers had always thought too small to be dangerous.
It slams into Mr Beveridge's chest at 145 to 175km/h. The impact causes the left ventricle of his heart to rupture. The injury is not survivable.
Most people will know nothing of the tragedy until a post-race TV interview with victorious driver Michael Schumacher, who, on behalf of all drivers, expresses regret over the death of a marshal.
Over the past 2 1/2 weeks State Coroner Graeme Johnstone has called a parade of witnesses in an attempt to answer the question of how such a thing could happen.
That the accident was unlikely is a given, but the fact that the gaps in the debris fence had never been considered a safety risk is something that confounded the State Coroner and, no doubt, Mr Beveridge's family.
``I can't understand why with all these people, with this vast wealth of experience, the penny didn't drop,'' Mr Johnstone said.
The fence used at the Albert Park circuit consisted of a 1m moulded concrete base topped with a 1.5m wire mesh debris fence.
Every 10th wire section, each 4m long, was lifted 40cm to allow emergency access to and from the track, meaning that on 800m of the circuit marshals and spectators, who stood closer to the action than at any other track in the world, were totally unprotected from debris at chest height.
Who was ultimately responsible for risk evaluation and approval of this dubious design was something Jim Kennan, SC, counsel assisting the coroner, would find frustratingly difficult to establish.
Management of the Australian Grand Prix is a three-tiered affair.
The Australian Grand Prix Corporation is the local promoter responsible for the organisation of the event. It has a contractual agreement with the Confederation of Australian Motor Sport to work in tandem on many aspects of running it. Both the AGPC and CAMS are bound by the regulations of world motorsport's governing body, the International Automobile Federation (FIA).
As top officials, including AGPC chief executive officer John Harnden and CAMS director of racing operations Timothy Schenken, gave evidence, Mr Kennan described what he saw as their tendency to shirk responsibility as a perfect circle of blame.
Finger-pointing between the organisations was complicated by the involvement of Brown and Root, the engineers who designed the debris fence, and by the decision of top FIA officials to shun the inquest.
Whoever should shoulder ultimate responsibility, and Mr Kennan said it was clearly the AGPC, it appears risk assessment procedures -- in not only the design of the fences, but also the positioning of spectators and grandstands -- were seriously deficient. Witnesses from the AGPC and CAMS would give evidence that a huge reliance was placed on the FIA safety regulations.
Yet these are only
intended to be minimum standards, not
necessarily tailored to Albert Park.
The apparent lack of research into the circuit's risks gave rise to the disturbing proposition that other freak accidents might easily occur.
The threat of an entire car clearing the 2.5m fence was voiced by experienced marshal Michael Burton.
Mr Burton, a British Formula One marshal, told the court that cars had cleared fences twice at Silverstone in England, despite fences being nearly twice the height of those at Albert Park.
Reflecting on the 1955 Le Mans disaster, when a runaway Mercedes bounced over a safety wall and killed 82 spectators, puts in perspective the devastating consequences such a crash could have at Albert Park.
And yet the court would hear the AGPC resisted raising fence heights, even when this was twice recommended by FIA safety supremo Charlie Whiting, first in 1998 and again before the 2001 event.
Ross Ray, QC, representing the AGPC and CAMS, strenuously denied the allegations, but the fact it has taken four years, and a tragedy, for the AGPC to revise fence heights suggests, at the very least, a painfully slow bureaucratic process standing in the way of urgent safety changes.
The AGPC and CAMS came under further fire for their failure to recognise turn three as a trouble spot.
On the first lap of the inaugural race in 1996, Martin Brundle smashed his Jordan into the wall at turn three in a high-speed airborne accident eerily similar to the accident at this year's event.
No formal review of the crash was ever conducted in what Mr Kennan described as an extraordinary oversight.
Since the March crash the AGPC, which was commended by the coroner for its co-operation, has implemented significant safety changes.
These include newly-designed overlapping access gaps in the debris fences providing total protection from debris.
Fences will be almost doubled in height over 40 per cent of the circuit and continuing reviews of spectator areas may see corporate boxes and grandstands moved, and a larger buffer zone placed between standing crowds and the track.
Satisfied with the work done, Mr Johnstone has indicated he will not stand in the way of the 2002 race, the staging of which was subject to the results of the inquest.
When the most highly tuned cars in the world scream into action at a revised Albert Park circuit in March 2002, they will do so in a far safer environment for spectators and marshals.
But, as usual in such circumstances, it is tragic that the cost of such commonsense changes is a lifetime of grief for one family.