Gerald Hoekstra, 46, and Ede Taric, 50, were taking part in the 2022 Desert Enduro Race in Victoria, when their vehicle crashed into a tree and rolled onto its side.
Both men survived the crash, but fuel leaked from the vehicle and caught fire. Other competitors stopped to help and used handheld fire extinguishers to try to put out the flames, but the fire could not be brought under control before the Country Fire Authority arrived around 12 to 13 minutes later.
The vehicle had passed its pre-race safety check and met the rules that were in place at the time. However, the coroner found that these requirements were not enough to protect the occupants in a serious crash.
One of the vehicle's fuel tanks had a cap and pipe sticking out beyond the safety frame. During the crash, the cap came off and fuel leaked out. The tank also did not have a valve to stop fuel from flowing out if the vehicle turned over.
The leaked fuel was then likely ignited by heat from the vehicle.
The case is a reminder that meeting safety requirements on paper does not always mean people will be protected when things go wrong.
The investigation also raised questions about the effectiveness of the fire extinguishers available to competitors.
Six handheld one-kilogram extinguishers were used by people at the scene, but they were unable to bring the fire under control.
The coroner found that a built-in fire suppression system could have acted more quickly and may have given the occupants more time to escape.
The investigation also found that vehicles were expected to allow people to get out within 10 seconds, but competitors were not required to prove they could actually do this.
In a serious crash, where people may be injured or trapped inside a vehicle, every second can make a difference.
Motorsport Australia has already made a number of changes following the deaths. These include requiring valves to help prevent fuel leaks, stopping parts of vehicles from sticking out beyond the safety frame and increasing the amount of firefighting equipment required.
Built-in fire suppression systems are also being introduced, but the rollout is happening gradually.
The coroner has recommended that these systems become mandatory for all off-road racing vehicles by the end of the 2026 racing season.
She has also called for competitors to be tested to make sure they can get out of their vehicles within 10 seconds, as well as clearer guidance for event organisers on the firefighting equipment they need to have available.
The case highlights a wider lesson for fire safety professionals beyond motorsport.
Fire safety should be based on what could actually happen, not just what the rules require.
The vehicle met the safety requirements at the time, but the crash, fuel leak and resulting fire created a situation where those measures were not enough to protect the occupants.
For high-risk environments, it is important to look beyond basic compliance and ask whether people would have enough time, equipment and protection to survive a fire.
This means considering how quickly a fire could spread, how people would escape, whether firefighting equipment is suitable and how quickly emergency services could reach the scene.
The recommendations from this case show how real-world incidents can highlight gaps in existing safety measures and help improve standards before another tragedy occurs.
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