Record of Investigation into Death (With an Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Catherine Rheinberger, Coroner, have investigated the death of
Richard Kenneth McGavin
With an Inquest held at Hobart Magistrates Court in Tasmania
Find That:
Richard Kenneth McGavin (“Mr McGavin”) died on the morning of Thursday 10 May 2012 on Ringarooma Rd, Scottsdale, Tasmania.
Mr McGavin was born in Geelong, Victoria on 20 July 1959 and was aged 52 years.
Mr McGavin was employed as a Supervisor with Fulton Hogan.
Mr McGavin was previously married to Leanne McGavin and has two adult children, Matthew and Daniel. Mr McGavin was in a long term relationship with Tessiana Pene, they had become engaged about three years ago.
I find that Mr McGavin died as a result of multiple crush injuries to his head, chest and abdomen.
At the time of Mr McGavin’s death he was not being treated by a medical practitioner.
Circumstances Surrounding the Death:
Mr McGavin was a supervisor for 9 years on an ultra-high pressure (UHP) water cutting road maintenance crew working in Tasmania for Fulton Hogan.
Mr McGavin was well regarded by his employer having an excellent safety record for management, traffic control and general worksite induction. He was a well-respected team leader and was recognised throughout Australia as a leader in his industry.
On 21 December 2012 Mr McGavin and his crew travelled to Tasmania taking equipment for work to commence in the New Year.
On 17 January 2012 Mr McGavin and his crew returned to Tasmania to commence work water blasting road surfaces.
The crew would work wearing appropriate safety equipment including hi-vis clothing and ear, eye and foot protection. When working on roads the road would be blocked and monitored by a traffic control company, Statewide Traffic Control.
The road work involved using a water cutter which is a truck equipped with a water blaster attached to the rear. The machine travels at less than walking pace and blasts the road surface removing excess tar which is raised to the surface, rejuvenating the skid resistance of the road. The speed of the vehicle is determined by the operator of the cutter who is observed by the driver on a camera and monitor.
On the morning of 10 May 2012 Mr McGavin and his crew commenced work setting up the site on Ringarooma Road on the Legerwood bound lane then changing to the Ringarooma bound lane.
Statewide Traffic Control set up the traffic controls at the work site. This was set up to an approved management plan and consisted of using reducing speed signs of 100kmh, 80kmh, 60kmh and 40kmh. Further signs indicated a lollipop man and there was a worker with a stop/go sign at the beginning of the work area. The two lanes of traffic were divided by witches’ hats along the broken white line in the centre of the road allowing work to be safely conducted in one lane and the other to allow the safe flow of traffic.
Initially the west bound lane was closed going towards Legerwood as the road was cleaned. About 8 50am the lanes were changed around with work being performed in the east bound lane towards Ringarooma.
Two trucks were operating in the area with a man operating a machine behind each truck. Mr McGavin was operating the water blaster behind the front truck which was about 50 meters in front of the second truck.
As this was happening a Red International Prime mover towing a Simplot trailer laden with potatoes driven by Mr Robert Walker (“Mr Walker”) was travelling towards Legerwood from the Ringarooma area. The truck was observed by Larry and Dianne Steenkamer to be stopped at the lollipop man at the commencement of the site, before commencing to drive through the site. The truck was estimated to be travelling at 20-30 kilometres per hour when it veered to the right and into the closed off lane where the work was occurring.
Troy Field was the driver of the UHP water cutting vehicle which Mr McGavin was operating behind. He was watching Mr McGavin operating the water cutter and observed the International truck approaching from behind in the monitor. He could see the truck was in the work lane and was going to collide with Mr McGavin and the truck that he was driving. He tried to accelerate his truck quickly to warn Mr McGavin but it was too late and he saw the truck strike Mr McGavin and then felt the truck strike his truck with force jolting him in the cabin of his truck.
Mr McGavin received terrible injuries and was immediately observed to be deceased. He was covered with a tarpaulin at the scene. Ambulance and police were called and attended the scene.
The driver of the International Truck, Mr Walker was examined by a paramedic, Peter James at the scene. Mr Walker advised him that he had ‘passed out and woke up when he felt a bang’. On examination Mr Walker was found to be in a cardiac rhythm called ‘supra ventricular tachycardia’ commonly called SVT. This condition can cause a patient’s blood pressure to become critically low and cause the person to become sync opal or faint. Mr Walker’s blood pressure was 89/61 which is considered low.
A post mortem examination was conducted by the State Forensic Pathologist, Dr Christopher Lawrence on 11 May 2012. He concluded that Mr McGavin died from massive crush injuries of the head, chest & abdomen. Toxicology was conducted and was unremarkable, being negative for alcohol and illicit drugs. Evidence of cigarette smoking and caffeine were present.
Due to the nature of Mr McGavin’s injuries he was formally identified by fingerprints.
Vehicle Inspections
The vehicles involved in the collision were inspected by Mr Nigel Hodges, a Transport Inspector.
The International Prime ED1274 being driven by Mr Walker towing the Simplot trailer was found to be in an unroadworthy condition due to a cracked rear cross member and non-compliant weld repairs to a steel rime. No defects were found on this vehicle which would have caused or contributed to the collision.
The Simplot tri-axle potato XT9873 trailer was found to be in an unroadworthy condition due to worn/loose shock absorbers, minor cracking in the front right spring hanger, loose lock nut on a brake booster yoke on the right rear axle and incorrectly fitted marking plates. No defects were found on this vehicle which would have caused or contributed to the collision.
The Volvo FM9 truck Registration SB35BY (South Australia) used for the UHP road cutting was inspected and found to be unroadworthy due to a broken windscreen and minor oil leaks from the engine area. No defects were found on this vehicle which would have caused or contributed to the collision.
Matters Relevant to Mr Walker
Toxicology in relation to Mr Walker detected no alcohol or significant drugs.
A few days after the collision Mr Walker was examined by Associate Professor McTaggart, a Cardiologist. He also reviewed the ECG taken after the collision which he confirms showed a supraventricular tachycardia at the rate of 200. Associate Professor McTaggart concluded the following:
“One must conclude that the syncope was indeed due to a rapid arrhythmia perhaps initially faster than the 196 heart rate said to be recorded. Even with a normal heart this may be sufficient to produce syncope.”
Police conducted an interview with Mr Walker on the 16 May 2012.
Mr Walker stated that he had been driving trucks for between 20-25 years and that he had been driving a heavy combination for the last 12 years and that he would drive about 60 – 70,000 km a year.
He stated that he had started in the morning about 6 30am. He was driving and stopped at the Ringarooma recreational Ground because he was ‘felling a bit hot and a bit funny’. He thought the best thing to do was stop and have a cup of tea and a biscuit, which he did.
He described the feeling as ‘just funny, light headed’.
He stopped for a few minutes, after which he felt better.
Mr Walker said that he remembered coming up out of Ringarooma and there were workman signs. He said he knew they were there as he had been through the area about three quarters of an hour earlier. He approached the lollipop man and changed a gear because he thought the lollipop man was going to change the sign but he left it on slow and that’s the last thing he remembers.
He did not remember seeing Mr McGavin, just feeling a bump and then stopping the truck. He looked out and saw the grass next to him and saw the truck that he had hit had a big black hose coming out of it.
Mr Walker was asked if he could give an explanation for the accident. He replied:
“I cannot give you an explanation of that, I just don’t know what happened.”
A report was forwarded by police to the Assistant Director of Public Prosecutions, Mr Daryl Coates SC, with the above information with a recommendation that no charges be laid against Mr Walker.
Mr Coates SC replied in a letter dated 17 July 2012. He agreed that no charges be laid and stated that the evidence suggests that Mr Walker was driving in an appropriate manner prior to the collision and that the evidence suggests that he had a cardiac rhythm called supra ventricular tachycardia whereby his blood pressure became critically low causing him to faint which meant he lost control of his vehicle and veered into the closed lane.
Workplace Standards conducted a separate investigation into the incident. The principal investigator Mr Steven Collins concluded:
“In my opinion, the tragic loss of life in this case was neither through poor systems of work, nor poor management, by the Department of Infrastructure, Energy and Resources or Fulton Hogan Pty Ltd, the employer of the deceased Mr McGavin.”
Fulton Hogan Pty Ltd investigated improvement opportunities and in a report dated 29 May 2012 indicated the following additional control measures to further reduce the likelihood of this event occurring again:
“• Provision of hands free wireless communication headsets between truck operator and water cutter operator (to be implemented immediately).
• Reduce space between traffic cones that delineate the work area, being a distance than the spacing of the recognized standard (to be implemented immediately).
• Investigate the possibility of contractors providing 900mm tall visibility traffic cones.
• Installation of flashing or strobe lighting to increase visibility of vehicle and plant while working (in planning).
• Provision of approved traffic controller training for the water cutter work crew (scheduled).”
Comments and Recommendations:
This was a tragic accident caused by Mr Walker fainting due to rapid arrthymia. He had never experienced this condition before and had no real warning that he was likely to faint whilst driving. Mr Walker was driving appropriately towards and through the road works until he fainted.
Fulton Hogan responded appropriately in supporting Ms Pene and in reviewing their work practices. There are no other matters to be investigated or to be explored.
I support the recommendations of Fulton Hogan.
Before I conclude this matter I would like to extend my sincere condolences to Ms Pene, Mr McGavin’s family and work colleagues.
This matter is now concluded.
DATED: 28 March 2014 at Hobart in the State of Tasmania.