Brendan Mark Smith, 44, died instantly when a large limb fell onto his ute on Channel Hwy at Margate, during strong winds on February 9, 2014.
Coroner Olivia McTaggart said the state roads department failed to address the known risk of a tree or limbs falling onto the travelled part of the highway.
‘‘That risk eventuated and resulted in Mr Smith’s tragic death,’’ she said last month.
The father-of-two was getting groceries when he approached a stand of about 50 black gum trees, near the highway’s edge.
Fatefully, his teenage son planned to go with him, but his mother asked him to stay home due to the stormy weather and help her with washing.
During powerful wind gusts of more than 100km/h, a 22m tree snapped at the trunk and fell on Mr Smith’s ute, killing him.
Ms McTaggart said at first glance, Mr Smith’s death appeared a rare freak accident.
However, an investigation revealed the stand of trees, including the one that hit Mr Smith, was slated for removal about 15 years earlier, for road widening works.
The coroner said the trees should have been removed at that time, but acting under pressure, the department decided to keep them on conservation grounds.
This led to ‘‘ad hoc and compromised decision-making’’ without objective consideration of their actual environmental value, she said.
No further maintenance on the trees was done after one tree was removed and some limbs were cut in 2003, despite the concerning state of health of some of the trees and their known risk to motorists.
‘‘DIER was aware the trees posed a continuing danger in absence of an ongoing, planned regime for assessment, maintenance and removal. This regime was not implemented at all in the 10 years leading up to the death of Mr Smith,’’ Ms McTaggart said.
‘‘Considering the general condition of the trees, the known safety risk to motorists in retaining the trees and the high volume of traffic on the highway, DIER ought, at the very least, to have continued to assess and maintain the trees on an ongoing basis to minimise the likelihood of damage and injury from falling limbs and trunks.
‘‘If this had occurred, the risk of harm would have been reduced.’’
The coroner said proper assessments had been put in place to assess safety risks following Mr Smith’s death.
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