Record of Investigation Into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Robert Pearce, Coroner, having investigated a death of
Regan Anne LITTLEJOHN
WITHOUT HOLDING AN INQUEST
Find :
(a) the deceased is Regan Anne Littlejohn born 18 June 2008;
(b) Regan died as a result of falling from a moving tractor onto agricultural machinery;
(c) the cause of her death was multiple blunt injuries;
(d) Regan died on 11 November 2010 at 61 Rawlings Rd, Lileah;
Circumstances Surrounding the Death :
Regan Littlejohn, aged 2 years, died on her family’s farm at Lileah in Tasmania on 11 November 2010. She was the youngest of 2 children of James Littlejohn and his partner Kirstie Fry. Mr Littlejohn operated the farm with his father Alec Littlejohn.
On that day James Littlejohn and his father were ripping and tilling the soil in a paddock on the farm in preparation for planting potatoes. Both were driving tractors. James was driving a 2009 model Valtra tractor purchased new by the farming business in May 2009. The tractor was pulling an implement which rips the soil with a rotary harrow.
The tractor is a single person vehicle that had not been modified for additional passengers. It has an enclosed cabin. Behind the drivers seat is a large 1300mm x 830mm window that opens outward by operation of gas struts. The widow is secured by a plastic lever type catch. Once the catch is released little pressure is required to activate the struts which automatically open the window.
The cabin is designed to allow the drivers seat to revolve 360 degrees and thus there is a space of about 230mm between the back of the seat and the rear window. The operator’s manual makes clear that children should not be allowed in the cabin or near the tractor or attached implements while the tractor is running. It also points out that passengers should not ride in the tractor unless in fitted seats and not on the platform in the tractor cabin.
At about 6.00 pm Ms Fry took her 2 children to the paddock in which the men were working. They had with them the evening meal. At about 6.30 Ms Fry and Regan rode with James Littlejohn in the tractor as they recommenced work so that the family could spend some time together. Ms Fry sat on a fold down platform to the side of the driver’s seat, although it is not meant for passengers. Regan was initially on her knee. However after a period Regan stood in the space behind the driver. There were some loose items on the floor on which she may have stood.
While Regan was in that position the window opened and she immediately fell through, out of the cabin and under the following implement. She suffered multiple injuries that were fatal.
Comments & Recommendations :
I am satisfied that the circumstances of Regan’s death have been thoroughly investigated by the police and by Workplace Standards Tasmania ("WST"). I do not consider that an inquest will reveal any more facts.
I am satisfied that the accident was not caused by any design, mechanical or maintenance fault with the tractor. Precisely how the window catch was operated by Regan so that the window opened is unclear. Someone of her age may have released it inadvertently or by playing with it. She may have pushed or overbalanced against the window. No defect in the catch was discovered. On one of the catch closing settings the window was prone to open unexpectedly, but the WST investigating officer concluded that the window was properly closed on a more secure setting at the time. In general terms the operator’s manual and information given at the time of purchase of the tractor warned of such risks.
This is an example of the risk posed by farm and agricultural machinery, particularly for young children. Such machinery is inherently dangerous. Young children behave in a spontaneous and unpredictable way. They do not properly appreciate risk or danger. Even a momentary lapse in supervision can have tragic consequences.
Children in rural areas of Australia are often around tractors, trucks and other mobile farm machinery. Injuries and deaths are common but are usually preventable. Toddlers are most at risk. Agencies such as WST and Farmsafe Australia Inc are already working to educate farmers on safe work practices. Incidences such as this one reinforce the need to continue and if possible intensify those efforts.
I convey my sincere condolences Regan’s family.
DATED: 6 July 2011 at Launceston in Tasmania