Record of Investigation into death
In the matter of the
Coroners Act 1995
I, Donald John Jones, Coroner, having investigated the death of
Judd Robert GREEDY
Judd Robert GREEDY died on or about the 5 of April 2009 at Symmons Plains Raceway at Symmons Plains in Tasmania.
Judd Robert GREEDY was born at Maitland in the State of New South Wales on the 14 of September 1980 and at the time of his death he was aged 28 year(s).
Judd Robert GREEDY was a single person whose occupation at the date of death was a Business Manager.
I find that the deceased died as a result of multiple blunt traumatic injuries sustained in a motorcycle accident.
CIRCUMSTANCES SURROUNDING THE DEATH: -
1.1 During the weekend of Friday 3 April to Sunday 5 April 2009, Round 2 of the 2009 Woodstock Bourbon Australian Superbike Championships was conducted at Symmons Plains in Tasmania.
1.2 The event was promoted and organised by International Entertainment Group Pty Ltd under permit from Motorcycling Australia and involved 120 competitors. The racing side of the event was under the control of the Clerk of Course, a Mr Tom Williams.
1.3 The Supersport category of motorcycles is the category below the premier Superbike class. Supersport motorcycles are required to be of no more than 600cc in capacity for machines with a four cylinder engine (as all machines in this race were) and must have an ADR compliance plate. They are therefore required to be road registrable, prior to limited allowable race modifications, and they race on road tyres. There are also safety modifications required, such as disc brake callipers having to be 'lock-wired' to the motorcycle, to prevent them falling off in the event that a securing bolt comes loose.
1.4 A Tasmanian Police Permit pursuant to Section 48 & 49 of the Police Offences Act 1935 had been issued for the event on the 11th March 2009 and authorised by Commander Frame. Two amendments were made to the Permit on 4th April 2009 by Sergeant DAVIS, acting on behalf of Commander FRAME. One related to the Permit being originally issued to the incorrect company - a different promoter was being used for this year's event. The other was due to the Permit being issued to expire at 12pm on Sunday 5 April instead of 12 midnight.
1.5 Regulations governing all aspects of motorcycle racing in Australia are covered by the 2009 Motorcycling Australian Manual of Motorcycle Sports and applied to this event.
1.6 The first two days of the event were utilised as practice sessions, qualifying sessions and some racing with the main races to be held on the Sunday.
1.7 At approximately 10:45 am on Sunday, 5 April 2009 Race 1 of the Supersports class began with 26 competitors.
1.8 On lap 4 of the race, Judd Robert GREEDY (Competitor no.# 99),who was leading on his Suziki GSRX 600, fell when exiting Turn 3. He and his bike slid to rest along the track proper on racing line. Before he was able to recover from the fall and get clear of the oncoming field he was struck by a motorcycle ridden by another competitor, William Jacob Horne (Competitor no#92). Greedy received fatal injuries resulting in instantaneous death. Another Competitor, Dirk Cole Odendaal (Competitor no.# 32) then collided with Greedy’s motorcycle causing him to fall. A third motorcyclist, Beau James McKenzie then ran over one of Greedy’s legs.
2. Safety Clothing worn by deceased
2.1 At the time of the crash GREEDY was wearing a black and silver one piece Joe Rocket racing leathers. The leathers contained spinal, knee, elbow, backside and thigh padding and had a zip up front with a Velcro fastener at the top of the zip.
2.2 He also wore a separately fitted Alpinestars kidney and back protector which was worn over his underclothing but inside the leathers.
2.3 Gloves worn were black and white Alpinestars 'GP Tech' with armoured knuckles and armour along the first and second fingers. Both the leather and gloves were still in good condition.
2.4 Black and white Alpinestars 'Supertech' motorcycle boots were worn with a zip-up fastening system with Velcro flap over the top. The boots also had a 'lock-in' strap at the top. The boots were dislodged from Greedy's body when he was struck during the crash. All fastening systems were found to be intact and in the fastened position. There is no evidence which would suggest there was a failure on the part of the boots which caused them to be dislodged other than the massive force of the impact.
2.5 He was wearing a black, grey and white AGV 'TI-TECH' full-face helmet. A sticker displaying 'AS1698' was evident, indicating it complied with current Australian standards. In addition a 'yellow dot' sticker was evident, indicating the helmet had passed race scrutineering. The helmet had suffered major damage, especially to the front in the chin area, with full thickness cracks through the shell. Some pieces of its internal padding had been dislodged when the helmet was torn from the deceased's head. What appeared to be a tyre mark was evident in the chin area. The strap used a standard 'double ring' connection which was still fastened, however the strap had been torn from its left side connection with the helmet shell.
2.6 All the above safety clothing and equipment is in compliance with the 2009 Motorcycling Australian Manual of Motorcycle Sports (15.1).
3. Cause of Death
3.1 A post-mortem examination of the body of the deceased was performed by Dr Donald MacGillivray Ritchey, a Forensic Pathologist on the 7 April 2009 at the Royal Hobart Hospital.
3.2 Dr Ritchey noted severe and massive injuries to the head, neck and shoulders of the deceased, together with fractures to the left ulna and radius and right tibia and fibula.
3.3 Dr. Ritchey commented:
"The cause of death of this 28 year old Caucasian man, Judd Robert Greedy, was multiple blunt traumatic injuries sustained in a motorcycle crash.
The autopsy revealed a well developed, well nourished adult Caucasian male with crushing injury of the skull (hemi-circumferential fracture of the lower occipital skull) and subtotal avulsion of the head and neck from the thorax. These injuries resulted in essentially instantaneous death."
3.4 A Toxicology examination revealed the presence of the following substances:
"Carboxyhaemoglobin – Negative
Alcohol (ethanol) – Negative
Valproic Acid – 16mg/L: sub-therapeutic
Codeine – present: less than 0.05mg/L: low therapeutic
Morphine – present: less than 0.03mg/L
Ibuprofen – 1.1mg/L: sub-therapeutic
Paracetamol – present: less than 1mg/L: sub-therapeutic. "
3.5 Dr Ritchey commented:
"Toxicology testing revealed the presence of low levels of analgesic medications in addition to sub-therapeutic blood concentration of Valproic acid (VPA). VPA is used as an anticonvulsant and a mood stabilizer in individuals with bipolar disorder."
3.6 A medical report was sought and obtained from Dr Peter Patrikios who had prescribed medication for the deceased. The report stated:
"I saw him [Judd Greedy] on the 8 of September 2008 and the 20 of March 2009. He told me that he had a motorcycle accident in Melbourne several years ago where he sustained a head injury and then four weeks later had a general tonic clonic seizure. He said that was diagnosed with epilepsy and has been treated with Epilim (Sodium valproate) since that time. He denied having any further seizures since then. He was treated with 500mg bd. He told me he had previously been investigated with EEGs and MRI scans in Melbourne. Given that he had not had seizures for a number of years, I did not see any indication to change his therapy. We do not change the dosing of anticonvulsants these days based on the blood tests but rather on the efficacy and side-effects. I did not provide him with a driving certificate and he did not request one from me."
3.7 There is further evidence that the deceased had consulted a Dr Alan West of the Maroochydore 7 Day Medical Clinic on the 23 March 2009 at which time he was suffering from a bilateral greater occipital headache. Dr West administered sodium valproate and prescribed Celestone Chronodose. Celestone Chrondose is a corticosteroid and was prescribed in this instance as an anti-inflammatory agent. It was administered by way of two injections, one on each side of the neck, just behind the ear. Dr. West said that lignocaine was added to the injections to relieve the headache, it being a fast-acting membrane stabilising agent (local anaesthetic).
3.8 On examination of the evidence produced to me, there is nothing to suggest that the deceased’s medical condition or the prescribing of these medications has contributed in any way to his ability to ride a motorcycle or to take part in racing competitions, I discount it as being a factor which caused or contributed to the fatal crash.
3.9 From an enquiry I made to Racesafe Motorsport Safety Services Australia, which is Australia's largest specialised motorsport safety service and the only organisation providing a full range of racetrack emergency services. I was informed that riders at the commencement of each season are able to lodge a form with the organisation setting out any medical conditions they may have or been suffering from and this is available to trackside medical teams who may be called upon to render medical assistance to an injured rider.
3.10 I have been unable to obtain evidence as to whether or not Judd Greedy had lodged any information with them, but anecdotally I am informed that they were aware of his medical history but did not see it as being such as to preclude him from racing.
4. Judd Greedy’s background
4.1 Judd Robert Greedy was born at Maitland Hospital on the 14 September, 1980. He attended St.Paul's Catholic School, Rutherford from Kindergarten to Year 6 where he was school captain in his last year there. He then went to All Saints College, St Josephs Campus, Lochinvar Years 7-10 and then onto All Saints College, St Mary's Campus Maitland Years 11-12.
Judd’s parents Rob and Julie Greedy provided the following background information about their son’s riding career:
"Judd became interested in his chosen sport at the age of about eight. The love of this sport grew, the older he got the more he loved it and the more determined he became to achieve his dream to become an Australian Champion and hopefully move into the world circuit and hopefully achieve some great results there….
About 1500 people attended Judd's funeral they flew in from nearly every state in Australia, he touched many people’s hearts. Many of the tributes talk about his kind nature, his big smile and larrikan ways in the pits. In Queensland his boss and many others refer to him as a "court jester". He spent a lot of time helping the young riders in the sport too; he would give them advice on the tracks and the lines that they should be taking, they too are going to miss him.
Judd broke many bones along the way and therefore knew what pain was all about especially when he broke his back, crushed L1 and cracked L2&L3. Therefore one of his favourite quotes was "Pain is Temporary" "Quitting is Permanent". So I suppose you can only keep telling yourself that he died doing what he loved doing best. When he was younger and we would be taking him to race meetings I would ask him "is there anything else you would rather be doing today mate" and his reply would always be "Mum, I'm doing what I love to do best and there is nowhere else I would rather be". We always thought that at least we knew where he was and what he was doing with his time at the weekends and we were all together as a family."
During the 2009 racing season, Mr Greedy was racing in the Supersport category of the Australian Superbike Championship for Bio-Magnetic/Trinder Bros Racing Team. He was the current leader of the Championship, having won Round 1 at Phillip Island on 1 March and was the holder of a Motorcycling Australia 'A Grade' racing licence.
5. Racing Experience
5.1 Judd’s racing experience and his motorcycling experience are set forth on his web page and I have included them here as indicative of his talent and expertise as a motorcycle rider.
Started racing at age 10
16 Junior Australian Dirt Track Title
3 Senior Australian Dirt Track Titles
32 State Dirt Track Titles
Commenced Road Racing at 16
1996 Australian 125cc Dirt Track Champion
1997 Won 125GP Road Racing State Championship
1997 Australian 125cc Long Track Champion
1998 Australian 125cc Dirt Track Champion
1998 4 Australian 125 GP Championship - wild card entry
1999 Won 250GP and Super Mono State Championships
2000-2001 did not compete for financial reasons
2002 Won Superbike Lites Pro Class (400cc road racing class)
2003 2 Privateer and 7 Overall Australian Road Racing Championship (600cc Supersport)
2003 US Debut in final road Formula USA Sportbike series at Daytona - finished 7 overall
2004 Nova Honda Satellite Honda Racing Team
2005 Factory Honda Superbike Rider, unfortunately a broken back in pre-season testing rode off most of this season.
2006 Sunstate Racing Honda
2007 Sunstate Racing Honda
Wildcard entry 2007 Philip Island World Supersport on specially imported Tenkate Honda CBR600
2007 4 ASC Supersport Privateers Cup
2008 Sunstate Racing Honda/Suzuki
2008 5 World Supersport Support Races
2008 Won ASC Supersport Privateer Championship, 5 Overall
2009 Bio-Magnetic / Trinder Bros Racing team
6. Initial Police Attendance Report
6.1 Sgt Davis of the Accident Investigation Unit attended and took various measurements of the scene and I have reproduced the relevant information below:
"The track at the crash site was constructed of hot mix asphalt, with an average width of 8.1 and a grass verge on the southern side of about 3.75 metres in width.
On the northern side was a gravel/sand trap followed by a section of air barrier fence attached to the fixed barrier. The weather was fine at the time and the track appeared to be clean, except for crash debris, and in good condition.
A 14 metre tyre scuff mark was observed on the exit of Turn 3, followed by paint scrape marks over a distance of 5.3 metres. These were attributed to the deceased’s motorcycle. At this point there was a deep gouge mark, followed by further scrape marks 5 metres in length. The deceased was lying about 13 metres to the south east of the gouge mark. There were leather scuff marks across the surface towards his body, attributed to him being propelled across the track. His body was lying almost parallel to the track edge, with his head to the west.
The southern end of the air barrier, adjacent to the end of the track scrape marks, had received fire damage.
The deceased’s helmet was located on the raised grass bank, about 1.5m above the track surface; on the southern side of the track about 15 metres from his body. His boots were located further down the track.
Motorcycle number 92, a Honda CBR600RR7, had slid over a distance of 31.4 metres and had come to rest on the southern verge of the track. Motorcycles numbers 32, a Yamaha YZF-R6, and 99, a Suzuki GSX-R600R3, had slid over a distance of about 44 metres and had come to rest on the southern edge of the track. All had been extensively damaged. The fuel tank of the Suzuki was peeled open.
Initial information was that the incident occurred during Lap 4 of the first ‘Supersport’ race at approximately 10:47am. The deceased had been leading the race when he lost control whilst exiting Turn 3 in the section of track known as the ‘Bus Stop’.
The ‘Bus Stop’ is a section of track that was added to the Symmons Plains circuit after a previous motorcycle fatality in 1998. It is used exclusively for motorcycle racing and has the purpose of slowing and straightening riders before they accelerate down the top straight. A ‘run off’ gravel/sand trap is placed on the outside of Turn 3 as an added safety measure. Prior to the construction of the ‘Bus Stop’ riders would have been accelerating from Turn 2 over a slight hump onto the top straight with no safety area between them and the concrete and steel barrier situated at the track edge. An overhead photo of a section of the circuit including the ‘Bus Stop’ is included in this report. Other points of note are also marked on the photo.
The deceased fell from his motorcycle onto the track at which time two other motorcycles had either crashed into him or his motorcycle. This collision had apparently caused an explosion with all three motorcycles coming to rest some distance down the track. The force of the collision had also caused GREEDY'S helmet and boots to be dislodged from his body."
7. Riders and Motorcycles involved
7.1 The following riders and motorcycles were involved in the crash and the motorcycles were examined by Transport Inspectors.
7.2 The following information was provided to the Inquest:
Motorcycle #99 –Ridden by the Deceased
Judd Greedy was riding a white Suzuki GSXR600R3 displaying race number 99. The build date from its ADR compliance plate was 4/08 with its VIN being JSICV111200100292. The motorcycle was inspected by Transport Inspector Timothy CHUGG at the Launceston Police Vehicle Compound on 9 April 2009 and found to have been in roadworthy condition, notwithstanding damage caused by the collision. The motorcycle was also inspected on 10 April 2009 by Chris HALL, of Hall Technical, as part of his investigation into the incident. Scrutineering reports show the motorcycle had passed scrutineering prior to the race.
The motorcycle was extensively damaged by the collisions. Damage included the windshield being torn off, broken handlebars, triple clamp, throttle, front brake lever and clutch lever. The seat and instrument panel had been torn off and there was fire damage to the main wiring harness. The fuel tank had also been torn open and had a large hole punched in the side. In addition the motorcycle was coated in dry chemical powder residue.
RIDER 2 - William Jacob (Jake) HORNE
Horne is a 17 year old male (15 July 1991) from Logan Village in Queensland.
In an Affidavit to police taken at the Launceston General Hospital on the evening of the collision he stated he has been competing in motorcycle races for 6 years and currently holds a C Grade licence issued by Motorcycling Australia. His only recollection was that he had struck the fuel tank of another motorcycle and hadn't had time to manoeuvre to avoid the collision due to his vision being obscured by riders in front of him. He estimated his speed at 100 kph at the time of the crash.
Horne was riding a white Honda CBR600RR7 displaying the race number 92 for the Motologic Racing Team. A build date of 04/08 was evident on its ADR compliance plate with the VIN JH2PC40U38M100427. The motorcycle's front steering had been torn from the main body and there was other damage consistent with the motorcycle impacting with the track and sliding. Scrutineering reports show the motorcycle had passed scrutineering prior to the race.
RIDER 3 - Dirk Cole ODENDAAL
Odendaal is a 20 year old male (20th March 1989) from Paradise Point in Queensland. In an Affidavit to police taken at the Launceston General Hospital on the evening of the collision he stated he had been competing in motorcycle races for 3 years. He holds an A Grade racing licence issued by Motorcycling Australia.
Odendaal stated he could not remember anything other than colliding with the deceased’s motorcycle although he estimated his speed at 120 kph at the time of the crash.
Odendaal was riding a white Yamaha YZF-R6 displaying the race number 32 for the Bio-Magnetic/Trinder Bros Racing Team. (He was the deceased’s team-mate.) A build date of 12/08 was evident on its ADR compliance plate with the VIN JYARJ15469A001095. The motorcycle was extensively damaged with only cables holding its steering to the main body and was coated with dry chemical powder residue. Scrutineering reports show the motorcycle had passed scrutineering prior to the race.
RIDER 4 - Beau James McKENZIE
McKenzie is a 23 year old male (3 February 1986) from Surfers Paradise in Queensland. He is the holder of a B Grade racing licence issued by Motorcycling Australia. In a statement obtained at my request by the Queensland Police Service McKenzie stated he had been road racing since the age of 12. In addition he stated that as he entered Turn 4 (which I believe is actually Turn 3) he could see a rider and bike on the track. He then stayed right and stated he saw HORNE pull to the left to overtake and then ride straight between the deceased’s legs into his chest. McKenzie further stated he believes he ran over one of the deceased’s legs as he was thrown across the track. It is not mentioned in his statement but in a subsequent telephone conversation to police McKenzie stated there were no warning flags being displayed at the time of the crash.
McKenzie was riding a blue and white Yamaha YZF-R6X displaying race number 46 and was a privateer entry. Its build date was 01/2008 with a VIN of JYARJ154X8A000529. McKenzie's involvement in the incident only became evident at a later date after analysis of photos and video (including that from his own motorcycle) and it was at that time enquiries were made with him. He did not crash during the incident. Having considered the evidence produced to me I am satisfied that some of McKenzie's recollections are incorrect.
8. Crash Findings
8.1 In making these findings apart from numerous affidavits and statements taken by Tasmanian Police, I have had access to video footage, video recordings from cameras fitted to some motorcycles, Google maps, other maps and sketches of the crash scene and various reports, including a report from Hall Technical (who undertake accident reconstruction and advise on Motor Racing Safety), being a report prepared for Motorcycling Tasmania.
8.2 I have attached to this finding a map depicting the shape of the track, however it is not to scale; it gives an indication as to its position, and I have marked the approximate position of the crash site with an arrow.
8.3 The deceased had qualified second out of the 26 competitors for the first Supersport race of the day. He had taken the lead prior to the end of the first lap and maintained that lead until the time of the crash. The video recordings I have observed show that it was a tight race with many riders riding in close proximity to their lead motorcycle.
8.4 While racing in Lap 4 of the race, as the deceased exited Turn 3, a right-hand corner, his rear wheel commences to slide out to the left. This slide mark measure 14 metres in length. This appears to have been caused by the application of slightly too much throttle. His engine can be heard to increase in revs as his wheels spin, and this can be heard on the recording from the camera on the rear of his motorcycle.
8.5 He has reduced throttle in an attempt to correct the slide, causing the motorcycle to snap back to the right. It is not uncommon in circumstances such as this for the result to be a 'high side'. A 'high side' is caused when sudden deceleration during a slide causes the tyre to grip, snapping the motorcycle violently back in the opposite direction and resulting in the rider being thrown off. There is anecdotal evidence that this is not an uncommon occurrence on this section of the race track.
8.6 The action taken by the deceased appears to have partially saved the slide, but on crashing, rather than being thrown clear of the motorcycle, he has fallen alongside it.
8.7 At this point he has manoeuvred around the right-hand turn and commenced to straighten for the straight which then passes under the overpass and continues to the hairpin corner.
8.8 The deceased and his motorcycle have then slid along the track and come to a stop on the 'racing line'. The racing line is the line that one would expect a rider to follow to effectively negotiate the corner at the optimum speed. The effect of this is that the deceased is lying on the actual line that all the other contestants would be expected to travel along.
8.9 Footage from the deceased’s motorcycle shows him lying almost alongside his motorcycle, on his back with his legs facing oncoming riders. He appears to have either been briefly knocked unconscious or at least stunned by his own impact. His helmet visor can be seen flying off during his crash indicating that at some stage his head has struck the ground. His visor can also be seen in photographs. After lying still for 2 to 3 seconds he slowly begins to sit up and leans across in front his motorcycle's camera. His movements indicate he is very groggy. Motorcycles can be seen overtaking in very close proximity to him at high speed.
8.10 After several more seconds, motorcycle number #92, ridden by Jake Horne, appears in the footage and rides straight into the deceased colliding with his helmet. Footage from the deceased’s camera stops at this point. Examination of his helmet revealed a tyre mark on the chin piece leading to the conclusion that the front wheel of Horne’s motorcycle has effectively torn the helmet from the deceased’s head, causing his massive injuries and instantaneous death.
8.11 Footage from the camera at the end of the top straight, the 'hairpin', and from the deceased’s motorcycle discloses that the deceased was struck approximately 9 seconds after initially falling.
8.12 Photo images and video footage suggest that Horne’s vision of the deceased was obscured by riders in front of him and the line he was taking through the turn.
8.13 Keevers on motorcycle #20, who was riding immediately in front of Horne, can be seen swerving to the right just before impact, leaving Horne with virtually no time to react. Horne can be seen attempting to take evasive action at the last moment.
8.14 The deceased has been partially thrown into the air and across the track by the impact, his boots and helmet dislodged by the force of the impact. Horne's motorcycle has almost simultaneously collided with the deceased’s motorcycle causing the fuel in it to ignite, resulting in an explosion.
8.15 The force of the collision and the explosion caused Horne and his motorcycle to be thrown into the air. Graphic photo images clearly show the magnitude of the force created with Horne somersaulting through the air before landing and sliding further down the track. He was able to limp to the side of the track and is seen lifting himself to safety on the raised grass bank adjacent to the track. His motorcycle was torn in two by the impact.
8.16 Odendaal on motorcycle #32 has then collided with the deceased’s motorcycle, causing Odendaal to be thrown from his motorcycle. Odendaal appeared to be knocked unconscious and lay motionless on the track for some time.
8.17 Photos and video show that the deceased’s legs have then been run over by motorcycle #46, ridden by McKenzie. McKenzie can be seen lifting his front wheel in an attempt to avoid hitting the deceased but this has not been possible.
9. Actions of Flag Marshals
9.1 Chapter 12.13 of the 2009 Motorcycling Australian Manual of Motorcycle Sports covers flag signals and their meanings. The relevant flags and their meanings in relation to this incident are:
Yellow Flag (stationary) - danger, ride slowly, overtaking is forbidden.
Yellow Flag (waved) - immediate danger, slow down, prepare to stop, overtaking forbidden.
Green Flag (stationary) - course clear.
Red Flag - Race or practice stopped prematurely. Competitors must slow down, must not overtake and must slowly proceed to the parc ferme, pits or other area indicated to them by officials.
9.1 The flag a marshal is required to display is governed by the nature of an incident and his/her location relative to it. Yellow and green flags can be displayed by marshals based on their own judgement of an incident. A red flag can only be displayed after being authorised by the Clerk of Course.
9.2 The marshal immediately before an incident is required to wave a yellow flag, the marshal immediately before the waved yellow flag location is required to hold a stationary yellow flag and the marshal immediately after an incident holds a green flag to signal that the course is clear.
9.3 Flag marshals in the immediate vicinity of the incident were Thomas Strang at Point 2, situated on Turn 1, Geoffrey Taylor at Point 3, situated in the 'Bus Stop' between Turn 2 and Turn 3 and Ricky Taylor (Geoffrey Taylor’s son) at Point 3.2, situated under the pedestrian bridge. The crash occurred almost in front of Ricky Taylor's location. All flag marshals were supplied with two-way radios which provided them with communication to the Clerk of Course and Race Control.
9.4 In this case, because the incident occurred between Point 3 and the Pedestrian Bridge, Thomas Strang (Point 2) was required to display a stationary yellow flag, Geoffrey Taylor (Point 3) was required to wave a yellow flag and Ricky Taylor (Point 3.2) was required to hold a green flag.
10. What action was taken by Flag Marshal Geoff Taylor when rider fell?
10.1 A finding which must be made in the inquest is ‘What action was undertaken by Geoff Taylor when the deceased fell from his motorcycle?’
10.2 Video footage taken from the 'hairpin' (Point 4) clearly shows Geoff Taylor waving a yellow flag for 7 seconds before the explosion. This footage also shows that 16 motorcycles passed Taylor’s point whilst he was waving his flag. None of these motorcycles appear to have slowed as required by the yellow flag. In the photos on the DVD produced to me, competitors can be seen lifting their front wheels under hard acceleration as they pass by GREEDY.
10.3 In his Affidavit, Geoff Taylor stated that he radioed Race Control and stated, "Race Control this is Point 3 we have a rider down". Both Geoff and Ricky Taylor in their affidavits agree that Race Control responded with words effectively asking for more information or to be kept informed.
10.4 Strang stated he held out his yellow flag almost immediately after he saw Geoff Taylor start waving his yellow flag. No footage has been made available covering Strang’s location or recording his action. Video analysis discloses that 7 seconds prior to the explosion (the time in which Geoff Taylor was waving his yellow flag) Horne was at the apex of Turn 1 and therefore already past Strang at Point 2.
10.5 In the video footage taken from the ‘hairpin’ location, Ricky Taylor can be seen holding his green flag. The crash occurred almost in front of him. He could not provide any further information in addition to what can be obtained from that elicited by video and photo analysis and his involvement after the incident was to extinguish what was left of the fire.
10.6 In the report from Hall Technical, Mr Hall stated:
"The yellow flag was displayed within 2 seconds of Greedy falling. However, only 1 of the following riders in position 6-18 in the race saw the yellow flag. The impact occurred 7-7½ seconds after the yellow flag was displayed. The red flag was not displayed until 8-8½ seconds after the impact."
10.7 It is clear on the evidence that Geoff Taylor quickly responded to the crash, he immediately waved the yellow flag as was required and immediately contacted the Clerk of the Course, Tom Williams. I am satisfied that his actions neither caused nor contributed in any way to the tragic crash.
11. Assessment of Possible Causes of Crash
11.1 It is necessary for this Inquest to consider all possible causes or contributing factors to the fatal crash, and in doing so I will consider the following matters:
Whether there was a failure by an official or officials to carry out his/her or their function(s) as required
Why did riders fail to observe or heed safety signals or actions of flag marshals?
Was there any failure of safety systems?
12 Rider Error
12.1 The chain of events culminating in Judd Greedy’s death was commenced by what appears to be error on his own part, but in saying that I will make further comment later in this finding as to the track itself. The greater tragedy is that having fallen from his motorcycle and having survived the actual crash he is then struck by another rider and receives fatal injuries 9 seconds after the fall and after 15 other contestants have ridden passed him as he lay stunned on the track.
13. Track Design
13.1 There is nothing to suggest that the design of the track itself caused or contributed to Horne colliding with Judd Greedy.
13.2 I accept the statements contained in the report prepared by the attending police officers and by Christopher Trentan Hall of Hall Technical, to which I referred earlier in my findings, that the circuit design and condition did not contribute to the to the collision between the deceased and Horne.
13.3 However, as a Coroner has a responsibility, whenever appropriate, to make recommendations with respect to ways of preventing further deaths and on matters that the Coroner considers appropriate (see Section 28(2) Coroners Act 1995), I intend to comment on matters relating to the area known as the ‘bus stop’.
13.4 A thorough investigation was carried by Christopher Hall on behalf of Motorcycling Australia and I adopt the measurements obtained by him.
13.5 The Symmons Plains circuit is approximately 2.43 kilometres long for motorcycle racing and races are run in an anti-clockwise direction.
13.6 Following a motorcycle fatality at the circuit in 1998, a review of the safety of the circuit was carried out. It was recommended that the first line of protection (Armco barrier) at (old) Turn 3 be shifted by 5 metres away from the track edge. That included the section of the circuit adjacent to where the deceased fell from his motorcycle.
13.7 Due to the difficulty in meeting that requirement, the circuit was not licensed for ASBK events for a number of years. Eventually, an alternative layout was adopted, and the current "Bus Stop" layout of Turn 3 was constructed. The ASBK Championship returned to Symmons Plains in 2007.
13.8 The circuit is generally 8 - 10 metres wide. The new "Bus Stop" section of the circuit is 10 metres wide in the length between Turn 3 (T3) and the overhead sign (approximately 80 metres between the exit of T3 and the end of the "new" concrete barrier).
13.9 Approximately 10 metres of straight-ahead run-off from the track edge at T3 has been provided and a W-beam (Armco) barrier has been constructed at the edge of the run-off area. The barrier tapers back towards the track edge at an angle of approximately 15° and abuts a concrete barrier section at about where the "Bus Stop" meets the original circuit. Air-fence is placed in front of the concrete barrier, and at its closest, it is positioned approximately 1½ metres from the track edge.
13.10 On race line, after apexing T3, the run-off length to the first line of protection is approximately 35 - 40 metres.
13.11 The "Bus Stop" section begins at Turn 2 (T2) which is a tight left-hand bend. There is then a short straight section before the right-hand bend of T3 which carries through approximately 90°. The apexes of T2 and T3 are separated by approximately 50 metres. After exiting T3, riders have a long straight section of approximately 650 metres to T 4 (there is a slight left-hand sweep to the "straight" after approximately 300 metres.
13.12 The narrowest section of the circuit, just past the over-track sign, was approximately 8 metres wide.
13.13 I have had the opportunity of viewing the area, at which time I was accompanied by a Police Officer who was able to travel ahead of me so I could obtain a clearer understanding of the actions of a motorcyclist travelling the specific section where the crash occurred and the action as I perceived of the motorcyclists approaching the crash scene.
13.14 Firstly from the evidence presented to me the motorcyclist following Judd Greedy was travelling between 100 to 120 kph.
13.15 A motorcycle being ridden at 100 kph is travelling at 27.78 metres per second and at 120 kph is travelling at 33.33 metres per second.
13.16 As the distance between Turn 2 and Turn 3 is 50 metres approximately, it would take a rider travelling at 100 kph less than 2 seconds to cover the distance and if travelling at 120 kph, 1½ seconds approximately.
13.17 Once a rider had completed the manoeuvre around Turn 2 the motorcycle needs to be leant over to negotiate the next Turn 3. From my observations of the motorcycle police officer and confirmed by him it was in the circumstances extremely difficult to observe the flag marshal at the location between Turn 2 and Turn 3.
13.18 Noting the short period of time to travel the section and noting that the riders are racing it is not surprising from my point of view to understand why many of the riders would not have had the opportunity to observe the flag marshal and it will be a matter to which I will refer in my recommendations.
13.19 Many people have expressed concerns in relation to the time lapse between the time of the fall by Judd Greedy and his being hit by the motorcycle which caused his fatal injuries.
14 Analysis of times and actions of riders and their positions in the race
14.1 At the completion of Lap 3, Judd Greedy was leading ahead of Ben Attard and Jamie Stauffer, who was approximately 0.9 seconds behind Greedy. Jake Horne was in 17th position and was 7½ seconds behind Greedy.
14.2 Chris Quinn was in 13th position, a little over ½ second ahead of Horne, and almost 0.7 seconds behind Anthony Quinn.
14.3 This gives a clearer indication of the tightness of the race and closeness of the motorcyclist.
14.4 According to Stauffer, Judd Greedy suffered a partial high-side as he accelerated out of Turn 3 and was pitched forward rather than over his bike. I have had the opportunity of viewing video footage of the crash, and this shows that Greedy’s rear wheel was sliding out to the left, when the tyre suddenly grabbed, his left–ward steering lock pushed the front of his motorcycle to the left, causing him to be pitched forward and to the right of his motorcycle. On falling from his motorcycle it is clear, on the evidence, that he has fallen heavily, his helmeted head has hit the bitumen surface causing his visor to dislodged, and he appears stunned from the fall.
14.5 Attard and Stauffer, who were close behind him when he fell, and both of whom had virtually unobstructed view of the fall, moved to the left of Greedy. Other riders following moved to the right of him.
14.6 Once Judd Greedy had fallen, a period of 8½-9 seconds elapsed before he was struck by Horne’s motorcycle.
14.7 It is necessary to analyse the position of the remaining riders to determine how the collision with Judd Greedy could occur.
14.8 I am again indebted to the in depth investigation undertaken by Christopher Hall.
14.9 From enquiries he made of other motorcyclists partaking in the event he deduced that the quicker riders would negotiate through Turn 3 at approximately 100 kph, and accelerating to 120 kph at or near the location where Judd Greedy had fallen from his motorcycle.
14.10 From this information it was estimated that the motorcyclists riding in positions 12-15 would be travelling some 3-4% slower that the quicker riders, and from this it was deduced that Horne would have been travelling at 95 kph approximately when he reached the apex of Turn 3 and would accelerated to 120 kph at the time that he hit Judd Greedy.
14.11 As I have previously indicated on exiting Turn 3, it would have taken riders 2 seconds or less to reach the position where Judd Greedy and his motorcycle had come to rest.
14.12 Again, as I have stated earlier, as the riders negotiated Turn 2 and entered the area known as the ‘bus stop’ they would have been preparing themselves to manoeuvre the next right-hander corner being Turn 3 a relatively short distance away, and undoubtedly, their focus would have been to the right of their motorcycle and the race line through Turn 3. As stated earlier this may explain why so many riders failed to observe the yellow flag.
14.13 As riders negotiated Turn 3 they would be in a position to look ahead along the straight to where Greedy and his motorcycle were on the track, however the view would be dependant upon the position of the rider or riders ahead as to whether or not that view was obstructed for any period of time.
14.14 The riders in position 2 and 3 were within 1 second of Greedy and would have observed him fall and be in a position to take evasive action to avoid him and his bike.
14.15 The riders in position 4, 5 and 6 would then have had a clear view of Greedy as they exited Turn 3 and take the necessary evasive action, which is clearly discernible from the video as the moved to the right of Greedy and his bike.
14.16 Ordinarily these 3 riders could have obstructed the view of the track, however the next rider was 3 seconds behind the rider in the 6 position, and the rider in 7 position would have a clear view of the track ahead and the fallen Greedy.
14.17 The next two riders in position 8 and 9 would also have had a reasonably clear view of the track ahead as they negotiated Turn 3.
14.18 Thereafter the gap between riders was 0.6 seconds approximately, which equates to 20 metres approximately of track at the speeds at which they would be travelling. Such a gap would have provided glimpses of the track ahead and glimpses of the fallen rider.
14.19 The rider in position 11 was likely to have reacted slower than the other due to his proximity to the rider in position 10, as at this point he would be relying to some extent on the movement of the bike ahead of him.
14.20 In his report, Hall made the following observation ,:
"When Horne arrived at Turn 3 he was in 17 position, he was 0.55 seconds behind the 13 placed rider. That would have placed 4 bikes within 15-20 metres ahead of him, each deviating to the right and blocking the view through the apex of T3 towards Greedy. It would have been very difficult for Horne to observe the fallen rider and bike when he was accelerating out of T3 while watching intently the movement of the rider directly in front of him. An indication of the situation facing Horne is clearly evident from [the footage obtained from McKenzie’s camera].
It was likely that each successive rider in this "freight train" out of T3 took a longer period coming out of the bend to detect the fallen rider ahead. Their view of Greedy and his bike on the track would have opened up as the bike in front deviated sufficiently to the right. Due to the delaying effect of human reaction times, the subsequent deviation to the right by each successive rider would then have got closer and closer to Greedy.
From the on-board video fitted to McKenzie’s machine, Cameron Keevers can be seen deviating to the right when he was about ½ a second from Greedy. Horne was directly in Keever’s slipstream at that stage, and would have been presented with less than 1 second within which to detect Greedy and his bike on the track and take evasive action once the deviation of Keevers had occurred.
Even though in race conditions, racing drivers and riders can have reaction times of around ¼ - ½ second, it can be seen that, under the prevailing conditions, Horne would have been left with negligible time within which to initiate any avoidance activity. It was not possible for him to avoid the fallen rider and motorcycle."
14.21 I agree with these statements and the estimates provided by Mr Hall.
15. Deployment of red flag
15.1 The yellow flag was deployed within 2 seconds of the crash, and 7 - 7½ seconds prior to the motorcycle colliding with Greedy.
15.2 The red flag was not displayed until 8 - 8 ½ seconds after the collision and 17 seconds after the fall.
15.3 Only one of the riders in positions 6 – 18 in the race observed to yellow flag.
15.4 In view of the failure of the riders to observe the yellow flag it is highly unlikely they would have observed a red flag.
15.5 The ultimate responsibility for stopping a race is in the hands of the Clerk of Course, and the person relies upon information given to him by the flag marshals around the course.
15.6 As soon as the flag was waved by Taylor, he radioed to Race Control stating "Race Control this is point 3 we have a rider down." An enquiry was made of him as to what the rider was doing, and it was his recollection he had informed them he was trying to get the bike up again and then there was a fire. He added "There was a gaggle of riders and then I saw the bike get hit and there was an explosion."
15.7 A flag marshal is not permitted to display the red flag without a direction given by the Clerk of Course.
15.8 It is for this reason that the flag marshal is required to radio in and report the incident and then receive the direction.
15.9 Clearly with today’s modern technology there should be a more effective manner of warning following riders of a fall or dangerous situation.
15.10 The delay in the deployment of the red flag is of concern, however I am unable to find that the delay in it being displayed contributed to the collision with Greedy, but the issue does need to be addressed by Motorcycling Australia.
16. Number of Flag Marshals
16.1 A number of concerns were expressed as to the low number of flag marshals in attendance for the event.
16.2 Geoff Taylor when spoken to expressed the concern, but it was his view the lack of numbers did not contribute to the death of Judd Greedy.
16.3 I assume the reasoning behind having two marshals at each location, one is able to see the motorcycles approaching and the other seeing them go pass and towards the next location.
16.4 It is obvious that two sets of eyes are preferable, I am unable to say that the placement of 2 marshals in each location would have made any difference to the events that occurred on this day.
17. Other matters arising
17.1 Anecdotal evidence refers to a number of falls occurring in the area where Greedy fell from his motorcycle.
17.2 No incident report forms have been produced as to previous falls in the vicinity of Turn 3 for the 2009 event, yet a flag marshal who regularly attends at Symmons Plains thought there had been at least 6 falls at Turn 3 during the course of the 2009 events and could recall a number of falls during previous seasons.
17.3 The Clerk of the Course was also able to recall that falls occurred regularly at the corner where Greedy had crashed.
17.4 The Motorcycling Australia steward for the meeting also recalled similar high-side types of incidents occurring in this location.
17.5 The absence of accurate reporting of incidents makes it extremely difficult to determine whether a particular issue or design defect exists which may lead to high-side crashes occurring at this location.
17.6 If regular reporting and investigation is undertaken, including the obtaining of statements from those involved in crashes at this location it may highlight a design fault or least give and indication as to its cause if it is so prevalent and this in turn could be a warning to participants so they are able to take adequate precautions to avoid such incidents or minimise them accordingly.
17.7 Another issue that was raised related to the run-off area adjacent to the location where Judd Greedy fell from his motorcycle.
17.8 The area played no part in the tragic death of Judd Greedy, and therefore any comments are on the basis of recommendations as I referred to earlier in these findings.
17.9 Christopher Hall in his report noted that the run-off was not a factor, but expressed concerns as to the nature of the run-off area and the close proximity of the barrier along a rider’s left, which limits the options available to riders in the event they are requited to take evasive action after exiting Turn 3.
17.10 He also noted that the close proximity of the barrier or air-fence could have the effect of deflecting a rider back onto the track surface and potentially onto the race line and into the path of oncoming riders.
17.11 Mr Hall made a further observation that whilst the run-off length available on the exit of Turn 3 complies with circuit construction guidelines, it was his opinion that the guidelines relate to situations where a rider is attempting to decelerate or has fallen; he did not believe the length was sufficient where a rider was accelerating and lost directional stability or have been forced from the race line after contact with another rider.
17.12 It was his concern that in such a situation the rider could collide with the barrier and effectively ricochet back onto the track in front of other riders.
17.13 A review should be had as to the suitability of the run-off in situations as foreshadowed by Mr Hall.
COMMENTS & RECOMMENDATIONS -
Whilst it may be trite to say, any form of motor racing whether it is cars or motorcycles, it is inherently dangerous, participants in the events push themselves and their machine to extreme limits and tragically this can sometimes have disastrous consequences.
It will never be possible to remove all risks and totally prevent injuries or deaths.
Every competitor, official and spectator is made aware of this every time they attend an event.
The only issue that has arisen from my investigation that may be directly attributable to the death of Judd Greedy is the failure of the flag system currently utilised in motorcycle racing at Symmons Plains.
I do not attribute fault or responsibility to any individual whether a rider or official.
I MAKE THE FOLLOWING RECOMMENDATIONS
1. Review of the location of the Flag Marshal at Turn 3.
It is clear in my view that having considered the race line and the direction of the track at this point, there is little opportunity for riders to observe a flag if being waved. The fact that only 1 of 18 riders observed the yellow flag highlights the ineffective placement of a Flag Marshal at the current location.
I am aware of some suggestions that riders may have deliberately ignored the yellow flag through fear of losing their placing in the race. Whilst one or two may be of that mind (I hasten to add that I am unaware of any rider having this belief) I am not satisfied that professional riders would place themselves and other in jeopardy merely to maintain their placing in a particular event. I believe that such conduct would readily become known and such person or persons would be precluded from partaking in future events.
2. Warning lights in lieu of or in addition to flags
It is obvious that the inability of riders to see the warning flag has played a significant role in the death of Judd Greedy.
While I acknowledge that flag marshals have been used for many decades as a warning and instruction system for riders and in a vast majority of cases have provided a sufficient level of safety, race bikes have developed into precision machine and the clothing worn is now more like something that would be worn in out of space, I am concerned as to whether safety precautions have advanced at the same pace.
Having toured the track at Symmons Plains it would seem that the placement of warning lights, either instead of or in addition to effectively placed flag marshals may reduce the likelihood of a similar situation as has taken the life of Judd Greedy.
Having perused the 2009 Manual of Motor Sport, I note that Paragraph 18.104.22.168 provides that flag signals may be supplemented by light signals namely, 1 or 2 flashing yellow lights, green light, and a red light to correspond with the yellow, green and red flags currently used.
The placement of lighting systems at flag marshal locations at various other locations around a track may reduce the number of incidents such as have occurred at Symmons Plains.
LEDs Light Emitting Diodes), either flashing or static, can be both bright and small and as such can be placed much closer to the edges of the track as opposed to a flag marshal. These lights are frequently seem in modern homes around decks or like those used on runways, they are unobtrusive until lit and do not pose any danger to persons using the area.
I acknowledge that it may be costly to establish but equally what price does one put on a life or a broken body.
I have recently been informed that Motorcycling Australia recently conducted a trial of warning lights at Ipswich in Queensland during Round 3 of the Australian Superbike Championship. From all reports the riders have given a positive response to their use and I recommend that Motorcycling Australia embrace this technology and require its installation at all venues.
3. Run Off or ‘Bus Stop’ design between turn 3 and 4
In light of the concern raised by Christopher Hall I would recommend that an immediate review be undertaken of this section of the track with particular reference to the fact that riders will be accelerating along the stretch adjacent to it and the effect of the closeness of the barrier and air-fence.
I make this recommendation in accordance with Section 28(2) of the Coroners Act 1995.
4. Displaying of Red Flag
Under the current practice the responsibility of directing the display of the red flag rests in the Clerk of Course and as can be seen from the present Inquest, there was a delay of 17 seconds after the fall before the red flag was displayed and this being 8 - 8½ seconds after the collision between Horne’s motorcycle and Judd Greedy. As I have found, this collision occurred 7 - 7½ seconds after the yellow flag was displayed.
For that entire time of 7 - 7½ seconds, Judd Greedy was in a very dangerous location on the race line with a number of riders following that same race line.
In my view there was ample time for a red flag to be displayed, and whilst it is highly unlikely that its display would have altered the outcome of this matter, it is a matter which should be addressed.
It is equally clear that a time delay must occur with the relaying of information back and forth between a flag marshal and the Clerk of Course which increases the risk of a serious incident arising.
A method of overcoming this delay would be to give discretion to the Flag Marshal that where a rider has fallen and is on the track that without reference to the Clerk of Course that he either wave the red flag or activate the red light.
While I acknowledge under the current rules a red flag causes the disruption of the race and requires a restart, it is my view that such an impost is of little significance if it saves a life.
The concern which may be expressed as to such a discretion being used too readily could be addressed by adequate training of Flag Marshals.
5. Accurate Recording and Investigation of Incidents during Race Meetings.
MotorCycling Australia should review the existing practice of recording incidents during race meetings.
This Inquest has revealed that race incidents have not been accurately recorded.
It is only with the accurate recording of these incidents that issues relating to track design may be highlighted and properly investigated.
Whilst I have not found that track design is an issue in this Inquest, the availability of accurate records of incidents, such as high-side crashes, would be of significant benefit to race organises to ensure tracks are as safe as practicable.
The importance of these recommendations can be gauged by posing the following question, "If Flag Marshal Taylor had been located in a more efficient location, and if he had and had used a discretion to display a red flag, or more importantly activate a red light, and if warning lights had been installed around the track, could the result have been different?." In my view, whilst one cannot speculate on such matters it is highly probable there would have been a different outcome.
Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased for their loss.
This matter is now concluded
DATED: Monday, 4 October 2010 at Burnie in the State of Tasmania.
Donald John Jones
Aerial View of Symmonds Plains Raceway (showing bend numbers and location of Fatal Crash with small arrow)