Record of Investigation into Death (Without Public Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Glenn Hay, Coroner, have investigated the death of
Jeffrey Ray WILLIAMS
I have decided not to hold a public inquest hearing into his death because my investigations have sufficiently disclosed the identity of the deceased person, 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 That :
a) Jeffrey Ray Williams (Mr Williams) died on the 21 day of March 2011 at Brighton in Tasmania.
b) Mr Williams was born in Tasmania on the 19 day of September 1935. At the time of his death he was aged 75 years. He was a married man who was a self-employed farmer by occupation.
c) Mr Williams died as a consequence of mechanical asphyxia, secondary to being trapped under the wheels of a tractor. He also had significant chest and abdominal injuries.
Background :
Mr Williams lived with his wife, Joyce at Brighton in Tasmania. They had been married for 54 years and together they had four children. Mr Williams worked all of his life as a farmer in both livestock and crop farming. Mr Williams farmed some 600 acres of the Brighton property for approximately 40 years. He was described as a fit and healthy man.
On the 24 day of February 2011 Mr Williams woke up about 7.45am. He was shaking quite a lot and to his wife, looked quite yellow. An ambulance arrived at his residence but, by that time, he felt somewhat better and decided not to go to hospital.
Later that day he consulted doctor Hilary Williams at Richmond and presented as having a syncopal episode. He indicated that he had risen too quickly when needing to go to the toilet urgently and suffered a leg cramp and a brief state of unconsciousness. He denied any associated chest pain or palpitations. Blood tests were ordered as the doctor thought that his syncope was the result of being hypotensive after getting up too quickly. I note the deceased did not have the requested blood tests nor did he return to consult the doctor.
Syncope is defined as a transient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery. The term syncope excludes seizures, coma, shock, or other states of altered consciousness.
On the 21 day of March 2011 Mr Williams attended at the saleyards at Bridgewater. He was there for a period of time but unfortunately the investigation has failed to reveal his time of arrival and departure. Whilst at the saleyards he spoke to a friend, Mr David Rowlands, a person he had known for a period of approximately 5 years. During the course of conversation Mr. Rowlands enquired as to his health as he looked very pale but Mr Williams indicated that he was fine and 'fighting fit'.
Circumstances :
Mr Williams arrived back at his residence sometime during the course of the afternoon. His wife at this stage was out visiting her aunty and Mr Williams has commenced to plough a paddock on a hill on the property. He was operating his blue New Holland TD95D tractor with an A Jarrett disc plough attached to the rear of it. The tractor had dual rear wheels and Mr Williams had owned it for a number of years.
Mr Williams' grandson observed the deceased in the tractor ploughing on the hill when he got home at about 4.30pm. After finishing his homework sometime around 5.30 to 6pm his grandson decided to ride his push bike up to where his grandfather was working.
He rode to where his grandfather's utility was parked at the bottom of the paddock and noticed that the tractor was stopped on the hill and the door to the cabin was open. He thought it was an unusual place to stop and drove the utility towards it. As he got closer he noticed the tractor had gone through a fence and that his grandfather was pinned under the inner rear wheel on the side where the fuel tank is located.
His grandson noticed that he tractor was still idling and shouted out to his grandfather but got no response. He gently touched his grandfather's cheek but again got no response. He looked purple and appeared to be not breathing. His grandson notified is his father (Mr Williams' son-in law). Emergency services were also notified to attend the scene.
Mr Williams' son-in law then attended the scene. He was unable to discover any signs of life in Mr Williams. He reached into the cabin and turned the ignition to the tractor off and awaited the arrival of others.
Findings and Comments :-
A full and detailed investigation has taken place. I am satisfied there are no suspicious circumstances surrounding this death. The investigation also included 'Workplace Safety Tasmania'. I note the investigating police made a request for Workplace Safety Tasmania to attend the scene on the evening of the incident. Unfortunately members of that office did not and only attended at the request of my Associate the following day.
I note that Mr Williams was a farmer and made his living from farming the property where the incident occurred. In my view this incident has occurred in a work place. By not attending on the evening of the incident Workplace Safety Tasmania did not have the opportunity of commencing investigations whilst the body was still in situ which may have been of some benefit to them in the investigation. Having said that, it may not have been readily apparent at the time to WST that the accident had occurred in a workplace.
Mr Williams has been ploughing an area of ground with a 17° (25%) down-slope. The tractor has crashed through a horizontal wire with vertical wooden stay fence, which was located adjacent the paddock he was ploughing. The tractor has come to rest with the wire entangled in the disc plough, which were down and cutting into the earth.
Mr Williams was trapped under the inner rear wheel on the left side of the tractor. The cabin door, which is located directly in front of the left rear tyres, was open. I note that the cabin door on the right hand side of the cabin near the steering wheel was closed.
Mr Williams was lying parallel with the tractor with his head towards the plough and his feet towards the front of the tractor. In my view it is highly likely, having regard to the fact the left hand door was open, that Mr Williams got out of this door as opposed to the door closest to the steering wheel.
Of interest is the fact that Mr Williams' head was towards the plough. I would have expected that had he been trying to get into the cabin at the time of the incident his body would have been forced forward and his head would have been towards the front of the tractor. I believe the evidence and the position of the body is suggestive of Mr Williams getting out of the cabin at the time of the incident and he (more likely than not) lost balance and/or fell onto the ground with his head towards the plough and his feet towards the front of the tractor. I believe the deceased was exiting the tractor down the steps on the left hand side (ploughed paddock side) when the tractor park brake has failed. He has lost balance or fallen onto the ground and been dragged by the tractor through the fence. Photographs numbered cp25 and cp26 clearly depict fence wire being caught on the deceased's clothing. The inner left hand wheel has then come to rest on the deceased's upper body causing asphyxia and death.
I am unable to make a definitive finding as to why Mr Williams initially stopped the tractor on a downhill slope. Prior to getting out of the tractor he placed the forward gear lever into neutral, and applied the park brake. He left the engine idling which clearly indicates he intended to get back into the cabin.
Inspection of the scene and tractor revealed, inter-alia, the following:
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The tractor was located facing downhill
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Located on a grass area of a paddock
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Left side operator's cabin door was in the open position.
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The forward and reverse gear lever was located in the neutral position
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The main gear lever consisting of 1, 2, 3 and 4 gears was in first gear position
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The range gear lever was in intermediate gear
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The park brake was on
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The plough discs were located on the ground in the cutting position
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Wire from the wire fence was under and around the plough
Manipulation of the park brake lever revealed it could be moved upward one further click on the ratchet. To do this the park brake lever had to be pulled upward fairly hard to get the lever to move. There was difficulty in releasing the lever because of the upward pressure that had been applied.
Under the direction and supervision of Workplace Safety Tasmania personnel the tractor was driven down the hill (17°) down-slope. Whilst descending the hill the driver stopped the tractor. The park brake was applied into the full-on position and the footbrake was released. At this time the plough was in the raised position. The tractor commenced to move forward for a short distance. Clearly the park brake was not restricting the movement of the tractor whilst located on a down-slope and in neutral.
The tractor was subsequently inspected by Mr. Rodney HILL, a mechanic with 35 years experience in the Agricultural industry. Mr. HILL worked regularly with the New Holland brand. The inspection revealed the following:
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The hand brake would not hold the tractor.
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Hand brake cable required adjusting as lever was coming to the end of its stroke.
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Hand brake would not have held tractor on a 17° slope.
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Tractor may have stayed stationary for a short time after the operator left the cab (with the hand brake on). Due to resistance in the 4wd system, when a tractor is operated in 4wd for a long period of time, it will create a resistance in the drive train, commonly known as 'windup'. This would be released by selecting neutral with the engine running after a short time.
The park brake works on the drive shaft giving four wheel braking when the tractor is in 4 wheel drive. I note the tractor was in 4 wheel drive at the time of this incident. There was still an amount of adjustment available in the park brake to make it more effective.
The failure of the park brake has been the causative factor in this most unfortunate incident. The tractor was left out of gear with the engine running which should be regarded as contributory factors.
I note that Mr Williams was a very experienced farmer who was described by those who knew him as being very careful in the operation and maintenance of machinery. However, it is essential that owners and/or operators of this type of machinery ensure they are maintained in accordance with manufacturer's specifications. When stopping and/or parking machinery the operator should always follow manufacturer's recommended operating procedures.
There is evidence that on a day approximately three weeks prior to this incident Mr Williams suffered a short lived medical episode which involved a brief state of unconsciousness. There is further evidence from Mr. David Rowlands, on the day of the incident at the Bridgewater Sale Yards, that the deceased looked very pale.
Notwithstanding the above comments there is no evidence to suggest that Mr Williams at the time of this incident suffered any form of medical event.
In closing I wish to convey my sincere condolences to the deceased's family.
Dated:- 11 October 2011 at Hobart in the State of Tasmania.