It was a wet and dark evening when Queensland policewoman Wendy Anne Evans was hit and killed by a bus while holidaying in Hobart, but the traffic lights were partly to blame.
Coroner Simon Cooper on Monday made an urgent call for the review of traffic light operations at the intersection where the 46-year-old was killed in July 2016.
"Had those lights not operated in such a way that the traffic and pedestrian lights both turned green at the same time, but rather the pedestrian crossing light turned green a period of time prior to the traffic light turning green, then it is likely in my view that Ms Evans would not have been killed," he said.
Dressed in black and carrying a white plastic shopping bag, Ms Evans waited for 30 seconds for the pedestrian light to turn green. But the traffic lights turned green at the same time.
"It was dark at the time, raining and the roadway was wet," Mr Cooper said.
"A (public passenger) bus driven by Stephen Murray Hartstonge was stopped in Macquarie Street facing the same red light at the same intersection waiting to turn right to Campbell Street."
As Ms Evans crossed the road, she was hit by the exterior right-hand mirror of the bus, knocked to the ground and beneath the wheels, suffering "massive and un-survivable head and chest injuries and died almost instantaneously".
A police re-enactment at the scene could not replicate the exact circumstances of the accident, but illustrated that the bus driver had "ample opportunity" to see Ms Evans coming.
In the re-enactment, a police officer acting as Ms Evans did not see the bus until it suddenly appeared in her peripheral vision, immediately before it would have hit her.
The coroner recommended the Department of State Growth "urgently review" the operation of the traffic and pedestrian crossing lights at the intersection.
Hartstonge, aged 60 at the time of the crash, was convicted of negligent driving causing death and handed a three-month suspended jail sentence in March 2018.
Magistrate Chris Webster granted Hartstonge a restricted licence, enabling him to keep his bus-driving job.
The Department of State Growth has been contacted for comment.