RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Christopher Webster, Coroner, having investigated the death of
William Edward Pegg
WITHOUT HOLDING AN INQUEST
I have decided not to hold a public inquest hearing into his death because my investigations have sufficiently disclosed his identity, the time, place, cause of death, relevant circumstances concerning how the death occurred and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest hearing would elicit any information further to that disclosed by the investigations conducted by me.
I FIND:
(a) William Edward Pegg (Mr Pegg) died on 14 April 2009 at Jameson Street, Glenorchy, Tasmania, aged 65 years.
(b) Mr Pegg was born in Hobart on 13 January 1944. He was widowed and had a daughter who did not reside with him.
(a) Mr Pegg died as a consequence of multiple blunt traumatic injuries suffered in a motor vehicle accident.
Background:
Mr Pegg was born in Hobart and married in 1968 however his wife passed away in 2008. They had a daughter who grew up to live in the greater Hobart area.
Mr Pegg spent much of his working life as a heavy vehicle driver, both in public transport and on commercial work sites and was a well respected workmate and employee. He was admired by many who knew him.
Prior to his death Mr Pegg had been employed on a part-time basis for approximately 3 years as a truck driver for All Earth Works Pty Ltd.
Circumstances:-
All Earth Works Pty Ltd was contracted to complete subdivision earth work at Jameson Street on behalf of the owners of the property. Work had been proceeding at the site for some time and was well advanced. About 7.50 am on Thursday 14 April 2009 Mr Pegg and two other work colleagues were in the process of loading a 25 tonne Caterpillar C322C excavator onto a Mack Prime Mover and Low Loader Float that had been driven to the work site by him.
Mr Pegg had reversed his truck up Jameson Street and parked it on the roadway outside the work site. The location on which the truck was parked is a steep downhill section of roadway and the float was parked close to the kerb so the ramps could be dropped across the footpath and so avoid damage from the excavator’s movements.
It is likely the vehicle was parked with park brakes engaged and the engine was running but witness evidence does not confirm the location of Mr Pegg at this time. One stated Mr Pegg parked the truck, exited the cabin and walked toward the float. When he was told not to worry about putting the ramps down he then got back into the truck. Another stated that he did not see Mr Pegg once he commenced loading the excavator onto the float.
The excavator proceeded from the worksite closer to the float and then its bucket was used to pull the float ramps down. Normally a switch in the cabin of the prime mover is operated by the driver and the ramps are then pushed down by hand. The steep incline in Jameson Street increased the effort needed to do this and it was decided to push the ramps down with the excavator bucket.
Once the ramps were down the excavator began to move up the ramps of the float. As the excavator passed over the tipping point of the ramps and onto the bed of the float, the trailer and prime mover started to creep down the street. The drive wheels of the prime mover were seen bouncing as a result of weight lifting off the axles and the ramps were heard to scrap against the road surface as the vehicles moved slowly down Jameson Street. The bouncing of the prime mover suggests that the brakes were working on the truck.
On seeing that the float and prime mover were moving the driver of the excavator tried to reverse off the float in an attempt to remove weight and return the correct weight to the drive wheels of the prime mover. It was intended that this would allow all brakes to be effective and so prevent the vehicles moving further, however this actually resulted in the speed increasing. The excavator operator then attempted to stop the vehicles from moving by placing the bucket of the excavator onto the ground however the prime mover and float proceeded further down Jameson Street. They ‘jack-knifed’ immediately before crashing into the safety railing on the southern side of road, near the corner with Kenbrae Avenue.
Mr Pegg was found partially under the front of the right hand front wheel of the float. He appeared to have been crushed and pushed down the road by the wheel. Emergency services attended but could not provide assistance due to the obvious and extensive nature of the injuries he had suffered.
Investigation:
A post mortem examination of Mr Pegg by Forensic Pathologist, Doctor Donald Ritchey, determined the death was ‘multiple blunt traumatic injuries sustained in a motor vehicle crash’. Mr Ritchey further stated ‘it seems likely that he was knocked from his feet by the front portion of the trailer and became trapped and crushed by the weight of the trailer apparatus including the front-most rear wheel on the right side of the trailer.’
Mr Pegg was a heavy smoker and had been under treatment for hypertension blood pressure at the time of his death however there is nothing in his medical records that identifies as a contributor in the circumstances of his death.
Toxicology testing indicated a ‘greater than therapeutic’ level of diltiazem. This is a calcium blocking agent that is used in the treatment of hypertension and was prescribed to Mr Pegg. The testing authority indicates that the level was not toxic and was not likely to have had any effect on Mr Pegg that contributed to his actions prior to his death.
The weather at the time in Jameson Street was fine. The road surface was of a bitumous material, in good condition and dry. Neither weather or road conditions contributed to the circumstances of this incident.
The movements and actions of Mr Pegg immediately prior to his death have not been confirmed and it is difficult to establish how, if at all, he contributed to the circumstances leading to his death. Witnesses and evidence do not clarify matters. It is suggested that when loading machinery onto the float, when it is on sloping ground, someone is needed in the cab of the prime mover to attend to the brakes. It is not established whether Mr Pegg was at any time in the cabin of the truck or how he came to be near the float during the loading operation when the vehicles started to move.
An inspection of the Mack Prime Mover, registration A56TK, revealed there was a contaminated brake assembly on the right side first axle and while, not roadworthy at the time of the incident, this defect was not detrimental to the park brake holding the truck. It appears the park brake was properly engaged in the vehicle at the time of the fatality.
An inspection of the trailer was found it to be not roadworthy due to the lack of brake effort on both the service and park brake applications of the first and third axle. Testing revealed this was due to poor brake adjustment though several brake components were past their allowable wear limits. The trailer had damaged suspension components and displayed excessive wear on all torque rod bushes. The defects on the trailer suspension, combined with the lack of brake effort and the subsequent load of the excavator on the slope of Jameson Street, resulted in the drive wheels of the truck rising and the faulty trailer brakes not being able to hold the vehicle combination. It was further suggested that had the trailer have rear stabiliser legs fitted and in use they would have reduced the weight transference from the trailer to the prime mover.
The inspection report indicates that a major contributor to the fatality was the defective trailer and loading of the excavator on the steep slope of Jameson Street.
On the arrival the investigating police officer immediately notified Workplace Standards as it appeared there were obvious issues with safety at the site, given the steep location at which the loading of the excavator had been attempted and it appeared, to an inexperienced person, dangerous. The approximate gradient of the roadway was measured at 15 degrees and there does not appear to be any other contributing environmental factors at the time. The Armco railing into which the truck crashed is situated on the southern side of the road and suggests that there had been previous safety concerns in respect to the street for traffic travelling on the downhill section of the roadway.
When no obvious criminal matters arose from the initial police investigation Workplace Standards Inspectors pursued their investigation which resulted in a successful prosecution under the Workplace Health and Safety Act 1995.
Findings & Comments:
I am satisfied that a thorough and comprehensive investigation has been conducted in this matter by both Tasmania Police and Workplace Standards.
I accept the determination of the court in relation to the proceedings initiated by Workplace Standards against All Earth Works Pty Ltd and a company official. I find that further such action is not necessary.
I accept the determination of the inspection conducted on the trailer that reported defects with it and indicated that it not roadworthy at the time, particularly in relation to braking and suspension requirements. I find that this, combined with the attempt to load the excavator onto the trailer while it was parked on sloping ground, was a major contributing factor in the circumstances that led to Mr Pegg’s death.
I accept the determination of Dr Ritchey that Mr Pegg died of multiple blunt traumatic injuries sustained in a motor vehicle crash.
I find that I am unable to conclude if any action by Mr Pegg, immediately prior to his being crushed, directly contributed to the circumstances that resulted in his death.
I conclude this matter by conveying my sincere condolences to Mr Pegg’s family.
DATED: 30 April 2012 at Hobart in Tasmania.