Angus Carruthers Collins suffered fatal head injuries when he was crushed in a collision with a cement truck while cycling in West Melbourne on February 2, 2023.
The 22-year-old had been riding at the intersection of Dock Link Road and a shared-use bike path on Footscray Road where construction works on the West Gate Tunnel project were being undertaken by CPB Contractors and John Holland contracted by Transurban.
As Mr Collins approached the intersection at 40km/h, an illuminated green bicycle signal gave him right of way to cross.
At the same time, cement truck driver Arthur Kalaitzis was travelling along Footscray Road, approaching the intersection which had an illuminated green light that was combined with the green bicycle signal, requiring him to give way to cyclists.
As Mr Kalaitzis turned left, Mr Collins was hurtling down the path and attempted to break hard but was unable to stop in time to avoid a collision.
He lost control of his bicycle and slid underneath between the truck's first and second axles, and was run over.
He was killed instantly.
Mr Kalaitzis was not charged with any criminal offences as a result of the incident.
There had been a number of complaints and near misses on the same stretch of road in the years leading up to Mr Collins' death, coroner David Ryan said on Monday.
Mr Ryan, in handing down his findings, noted there were numerous risks on the road, including poor quality and blurred signs and markings, large concrete piers obstructing sight lines and ambiguous right-of-way signs.
He rejected a submission from the contractors who challenged that the mitigation measures were insufficient and that they weren't aware of the risks.
"The corrective action taken by CPB Contractors and John Holland in response to the RSAs (road safety audits) was not sufficient to mitigate these risks," he said.
"Further, the contractors were aware that their mitigation measures were not effectively reducing the risks to cyclists at the intersection as a result of being informed of various complaints by cyclists and road users."
Mr Collins' death was a preventable tragedy which has devastated his family and caused significant distress to Mr Kalaitzis, the coroner found.
"This case highlights the pernicious risk that exists at intersections between left turning vehicles and cyclists that are travelling straight ahead," he said.
"The law as to who has right of way is not well understood."
He recommended the Department of Transport and Planning consult with authorities to formulate and implement a public safety campaign to highlight the risks at intersections.
The department should also consider mandating road safety audits be closed by an independent road safety auditor and not the contractor that is carrying out the works.
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