Coronial Findings

Record of Investigation into Death

Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

I, Rodney Eric Chandler, Coroner, having investigated a death involving an "All Terrain Vehicle"



The deceased died in September 2003 at the Royal Hobart Hospital in Hobart.

The deceased was born in Queensland and was aged 16 years at the date of his death. He was a student.

I find that the deceased died as the result of head injuries suffered in an accident on Saturday 30 August 2003 at Margate when riding a Suzuki LT 250F All Terrain Vehicle (the ATV).

At the time of his death the deceased was in the care of medical staff at the Royal Hobart Hospital.


On Saturday 30 August 2003 the deceased attended a party in Margate. The ATV was housed in a shed at that address. During that afternoon the deceased and others took the ATV for a ride within the confines of the property. At about 7.30 pm the deceased and some other guests began drinking alcohol. Approximately one hour later the deceased took the ATV for a further ride along the property's driveway. Some 20 minutes later it was realised by several of the guests that the deceased had not returned to the party. Shortly afterwards they found the ATV beside a left hand bend of the driveway. It had left the driveway, collided with a wire fence and overturned. The deceased was lying nearby. It was apparent that he had suffered serious head injuries. He was subsequently conveyed by ambulance to the Royal Hobart Hospital and admitted to its Intensive Care Unit. A rapid deterioration in the deceased's condition occurred and he subsequently died.

The accident has been investigated by officers of the Accident Investigation Service of Tasmania Police. That investigation has revealed that:

  • Immediately prior to the accident the deceased was riding down a downhill section of the driveway and negotiating a left hand bend. In this area the driveway had a pronounced crown from its centre to either side. Some small rocks were located on the right hand shoulder of the bend.
  • Heavy rain had fallen during the afternoon of 30 August and the surface and shoulders of the driveway were very soft.
  • Tyre marks showed that the ATV failed to negotiate the left hand bend and moved onto the right shoulder of the driveway. Markings in the area of the right shoulder and markings and scratches on nearby rocks indicated that the ATV began to overturn at that point. It seems then to have rotated over a wire fence which it partially demolished before coming to rest upside down on the other side of that fence.
  • It was not possible to identify the precise moment that the deceased became separated from the ATV. However, after the accident he was found upon the fallen fence a short distance to the rear of the ATV.
  • The deceased was not wearing a protective helmet.
  • The deceased had little prior experience riding motorcycles or all terrain vehicles.
  • The deceased had no training or instruction in the safe and proper use of an All Terrain Vehicle.
  • Prior to the accident date the deceased had ridden the ATV on one occasion only, that was about 6 weeks previously.
  • A blood sample taken from the deceased following the accident revealed a blood alcohol reading of 0.024 g/100 ml.
  • An inspection of the ATV by a Transport Inspector employed by the Department of Infrastructure, Energy and Resources concluded that it was in a poor roadworthy condition. It was particularly noted that: 
  • The brake applying to the left front wheel was not operational;

  • The levers operating the brakes upon the right front and rear wheels all travelled excessively;

  • In static tests the brakes upon the right front and rear wheels could only be locked upon maximum effort;

  • Excess movement existed within the right rear wheel hub and the components for the rear suspension which had the propensity to effect the handling characteristics of the ATV;

  • A separate test carried out by the Accident Investigation Service showed that the ATV could be manually pushed with both rear and front brakes fully applied.
  • After the accident, testing of the ATV tyres found the pressure for both front tyres to be 2.5psi and the left rear tyre pressure to be 7psi. The right rear tyre had a broken bead seal (presumably caused in the accident) and its tyre pressure was 0psi.
  • The owner of the ATV did not own a low pressure tyre-gauge and a gauge designed to check the pressure of car tyres was used to check the pressure of the ATV's tyres. That gauge was designed to provide a minimum reading of 10psi whilst the recommended maximum pressure for the tyres fitted to the ATV was 5psi. As such the owner's gauge was not a suitable tool for use on the tyres of the ATV.
  • The excessive pressure of 7psi in the left rear tyre of the ATV may have inclined the vehicle to be pushed to the right when negotiating a left hand curve.


I am satisfied that this accident occurred when the deceased, while riding the ATV, failed to negotiate a left hand bend on a downhill section of a private driveway. The deceased became separated from the vehicle when it left the driveway and overturned. It is not possible, upon the evidence, to determine whether the ATV made contact with the deceased before it came to rest.

I am unable to identify any one factor, which explains the deceased's failure to maintain control of the ATV. However, the accident investigation does, in my view, reveal a number of factors, which had the very real prospect of contributing to this accident and to its tragic consequence. These factors are:

  • The deceased's total lack of training in the operation and safe use of All Terrain Vehicles;
  • The deceased's relative lack of familiarity with the ATV and its handling characteristics;
  • The nature of the driveway in the area where the accident occurred, notably a relatively steep descent to a left hand bend with a substantial road crown;
  • The gravel surface of the driveway and its shoulders made soft by recent heavy rain;
  • The presence of alcohol in the deceased's system;
  • The failure on the part of the deceased to wear a protective helmet;
  • The unsatisfactory condition of the ATV's braking system;
  • The excessive tyre pressure in the left rear tyre of the ATV;
  • The unsatisfactory state of the ATV's suspension;

I conclude by extending my sincere condolences to the family of the deceased.

Dated the 22nd day of July 2004.

Rodney Eric Chandler

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