OF THE many tragedies he investigated, one incident stayed with NSW State coroner Kevin Waller his entire life: the Cowper bus disaster.
"I wouldn't be game to drive on the Pacific Highway. If I had to go to Brisbane, I would fly," he told The Daily Telegraph in 2012.
Mr Waller led the 1990 inquest seeking to understand what led to the brutal deaths of 21 people in what was Australia's worst road disaster at the time, when a semi-trailer veered onto the wrong side of the road, colliding with a coach.
What he uncovered was damning.
Head-on smashes were becoming "commonplace" on the "unforgiving" roadway.
"The fact was that the Pacific Highway as it existed between Newcastle and Brisbane was totally inadequate for the volume and size of traffic it must accommodate," Mr Waller wrote in his 1990 coronial findings into the Cowper smash.
"It was obvious to anyone who heard the evidence in the Grafton case or to anyone who has ever travelled on the Pacific Highway that it is far too narrow to enable vehicles to pass in proper safety.
"A few inches of passing space between large buses and trucks is a grossly inadequate margin."
The inquest delved into every scrap of evidence collected from the site at Cowper, including mechanical reports, witnesses and many other documents integral in retracing the moments leading up to the crash.
These documents revealed very little room for error on this straight stretch of the Pacific Highway: a maximum of one-metre between any two large vehicles passing each other on the highway. Either shoulder provided little respite to avoid such a collision.
"The bus was left with nowhere to go," Mr Waller wrote.
"Even if the driver had time to swerve violently to his left, where a table drain lay in wait."
The driving history of both men behind the wheel became an important aspect of the case.
Coach driver William Bergen had been driving Sunliner buses for 12 years.
"He had a bad record... with several speeding fines and other traffic offences. His licence has been cancelled twice," Mr Waller wrote.
Truck driver David Hutchins' driving record was "disgraceful", according to Mr Waller.
Since 1982 he had come under notice eight times in NSW for speeding and five times for other traffic infringements. His record was marred with 27 driving offences in seven years.
Months before the crash, Mr Hutchins was penalised for speeding again and driving too close to another heavy vehicle.
However, an autopsy of Mr Hutchins revealed the most alarming information. The drug ephedrine was found in his blood and organs in excess of more than 80 times the amount of a chronic user.
The stimulant was typically used to treat chronic asthma or rhinitis; a side effect was insomnia. Long-haul drivers at the time often used the drug to stay alert.
A pharmacologist, Judith Perl, told the inquest Mr Hutchins' would have built up a tolerance to the drug and required several tablets a day to feel the effects. Hallucinations were a side-effect and he could have been swerving to avoid "phantom vehicles".
Due to the high traces of ephedrine in Mr Hutchins' system, a second test was requested. It was conducted at the University of Sydney using more-sophisticated equipment. The results confirmed the original test.
THE HIGHWAY UPGRADE
Two months after the crash, disaster struck again. On December 22, two buses collided on the Pacific Highway at Clybucca, two hours south of Grafton. Thirty-five people died and the tragedy remains Australia's worst road disaster.
After conducting inquests into the Cowper and Clybucca crashes, Mr Waller's recommendation was simple: a dual-carriageway from Newcastle to the Queensland border would save countless lives. At the time, the road along Australia's heavily populated east coast was the busiest in the country - and the most dangerous.
His recommendation, alongside a detailed plan of how to enact it, fell on deaf ears for decades. He was publicly ridiculed by politicians and labelled a "bumbling fool".
"It was apparent that these super-safe sections of highway paid for themselves. But the one person in Australia who seemed unable to grasp this point was then Federal Minister for Roads and Transport himself, Bob Brown," Mr Waller wrote.
"He made some remarkable churlish attacks on myself and on the idea of a dual carriageway, but I never knew him to articulate a proper case against the proposal."
The dual-carriageway came with a hefty price tag at the time. In 1990, the project was estimated to cost $1.6billion. The highway upgrade, which is due for completion next year, has cost 10 times that amount.
Mr Waller advised that a two cent a litre levy on petrol sales would be enough to bring in revenue without raising the ire of motorists or becoming a burden to governments.
The concept was rejected by the Federal Government, however, two years later, they adopt the same strategy to finance spending programs.
The Office Of NSW State Coroner was established in 1988, and Kevin Waller held the role until 1992. In that time, he conducted inquests into major events including the Newcastle Earthquake, the Downunder Hostel fire at Kings Cross and the 1991 Strathfield Plaza massacre.