AT A depot in Melbourne's industrial western suburbs, David Lawrence Kalwig moved around his 1986 Louisville prime mover, checking the tyres and air brakes.
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The coroner has released her findings into the 2007 Burnley Tunnel crash which left three motorists dead.
It was 7am on a Friday, and Kalwig, a truck-driving veteran of 17 years, needed to hit the road. He had two hours of deliveries to make before heading back to the Brooklyn yard to load up again.
Some time after 9am, the 41-year-old trundled out of the depot driveway for a second time and headed towards the West Gate Bridge. It was March 23, 2007, and what unfolded over the next hour would destroy lives and, in the words of the Coroner, affect ''the psyche of the state''.
But it was another truck that triggered the series of events that left three men dead and Kalwig in prison. At 9.54am, a tyre blew on Donald Micallef's prime mover, forcing the driver to pull into the left lane more than a kilometre into the busy Burnley Tunnel.
Mr Micallef told the Supreme Court at Kalwig's 2009 trial that he was sitting in his cabin, about to make an emergency phone call when he saw in his side mirror a truck approaching from behind. ''I braced the wheel because I expected the truck to impact into the back of my vehicle, and in a few seconds that's what happened,'' Mr Micallef told the court.
Kalwig's prime mover, towing a refrigerated trailer, had entered the tunnel shortly after Mr Micallef and was travelling in the left of the three lanes at between 65 and 70km/h.
A Mack prime mover was ahead of Kalwig in the same lane, but had slowed to a crawl after seeing Mr Micallef's stationary truck ahead, the driver looking for a gap in traffic to enable him to change lanes.
Exhibiting what the trial judge later called ''negligence and … complete stupidity'', Kalwig did not notice that the Mack truck was almost stationary until he was metres from it.
What followed was absolute carnage, compressed, incredibly, into a mere three seconds. Kalwig swerved into the centre lane, pushing a car carrying a woman and her two-year-old son into the right lane.
Kalwig's truck then bounced into another prime mover travelling in the right lane, and back into the centre lane, where it smashed into the back of a Mazda Astina driven by champion cyclist and father of one, Damian McDonald. Mr McDonald's car was shunted forward into a Subaru station wagon, which in turn veered into the fuel tank of the prime mover in the right-hand lane and spun around into the truck's path.
Incredibly, the Subaru driver survived unhurt, climbing through the window of her car and escaping as vehicles around her caught fire.
The deaths of these three men and the subsequent disruption to the city of Melbourne, both physically and psychologically, in the wake of this collision not only left three families bereft of their loved ones, but left a fear in the minds of many using the Burnley Tunnel as to its safety
Mr McDonald, 34, was not so lucky. His car was forced into the left lane by Kalwig's truck and smashed into a Toyota van driven by courier Geoffrey Kennard, and a Holden ute belonging to plumber and father of two young girls, Darren Sporn.
Mr Sporn's ute, and Mr McDonald's Mazda were both crushed between the tunnel wall and Kalwig's truck. The two men died in a fire caused by a ruptured petrol tank.
Mr Kennard, 51, died when his car was crushed between Kalwig's truck and the back of Mr Micallef's prime mover.
''Tragically, your failure to act responsibly when you drove through the tunnel has led to the pointless and entirely avoidable death of three men, all of whom were, by all account, good men too,'' Justice Mark Weinberg said while sentencing Kalwig to a minimum of two years and nine months' jail for dangerous driving causing death.
Hundreds of people were evacuated from the tunnel, which was closed for three days, choking roads across Melbourne. ''The deaths of these three men and the subsequent disruption to the city of Melbourne, both physically and psychologically, in the wake of this collision not only left three families bereft of their loved ones, but left a fear in the minds of many using the Burnley Tunnel as to its safety,'' Coroner Jennifer Coate said in her finding, released on Wednesday.
Judge Coate has made a number of recommendations, the most notable of which is that authorities should consider banning lane changes in future tunnels. But none of this will assuage the pain of the families left behind.
''There are no winners today; we take no comfort from this verdict, '' Mr McDonald's widow, Bree, said after Kalwig was jailed. ''It does not bring him back. It does not help his wife, son, mother or siblings understand why this had to happen.''