Record of Investigation Into Death (Without Inquest)

Corners Act 1995
Coroners Rules 2006
Rule 11

I, Timothy Hill, Coroner, having investigated the death of

Paul Nicholas DALLEY


Find That:

(a)  Paul Nicholas DALLEY died on 28 July 2012 at  Leith. 

(b)  Paul Nicholas DALLEY was born at Wellington, New Zealand on the 21 March 1946 and
       was aged  66 years at the time of his death.

(c)  Paul Nicholas DALLEY was a married man  and at the time of his death he was a retired mining engineer.   

(d)   I find that the deceased died as a result of positional asphyxia following a tractor rolling onto him.

Circumstances Surrounding the Death:

Paul Nicholas Dalley had been previously been married twice and had three children who are now all adults, from these marriages.    After the death of his second wife he met his current wife Pamela Dalley.   The couple resided at 20 Allport Road West, Leith a property they  moved to in  June 2011 after relocating  from Western Australia. 

The couple had been working tirelessly conducting extensions on the residence and also preparing the outside property to be a low maintenance area that they could enjoy in their retirement.  Ashley Duff a neighbour from 18 Allport Street West had become friends with Mr and Mrs Dalley and he would also assist the couple around the property when required as he is a builder.

In November 2011 Mr Dalley purchased a brand new Weifang tractor which he used around his property.    Mr Dalley was experienced in using heavy machinery and equipment having worked in the mining industry throughout his life.    The tractor was  fitted with a roll over protection system (ROPS).  Also fitted to the tractor was a hydraulic controlled front end loader.  Advice from the manufacturer of the tractor is that the front end loader is sourced from another manufacturer  and supplied as an uninstalled kit. 

On Saturday 28 July 2012, Mr Dalley and Mr Duff were putting in a new driveway at the back  of the residence.  Mr Duff was operating a small excavator to mark out the driveway and Mr Dalley was using the tractor and bucket to remove the dirt from the area and relocate it in various places around the property,  Mrs Dalley was spraying weeds in the garden before she went into the shed to refill her spray bottle.   

Mrs Dalley states that she could hear the tractor coming along the path as she was going into the shed but  then heard that it had stopped.  A short time later after filling her spray bottle  she left the shed to return to the garden, it was then that she observed the tractor laying on its side.  She immediately ran to the scene and  located her husband pinned under the tractor.  Mrs Dalley attempted to move the canopy that was resting across Mr Dalley but when she was unsuccessful she sought the assistance of Mr Duff.

Mr Duff states that the fibreglass sunroof of the tractor was resting across Mr Dalley’s throat.  He did not appear to be breathing.  Mr Duff was able to break the roof off freeing Mr Dalley and then  rolled him onto his back to attempt CPR which was unsuccessful. 

Emergency Service personnel attended.  Unfortunately Mr Dalley could not be revived.

An investigation was conducted by members of Tasmania Police and no suspicious circumstances surrounding Mr Dalley's death were identified.   

Mr Colin Jones, a Transport inspector from Department or Infrastructure Energy and Resources conducted an inspection on the tractor.    I have been provided with an affidavit from Mr Jones  who reported the following;

‘the tractor as inspected would be classed as mechanically sound; however partially deflated tyres combined with extra weight imposed by the front loader, may have contributed to the tractor rolling over.  Also it is recommended for machinery fitted with Roll over Protection to also be fitted with a seat belt’

Evidence at the scene and from witnesses suggests that at the time of rolling over, the front loader contained dirt.   The area where the tractor had overturned was a grassed area with an incline.  Evidence suggests that at the time the tractor was being driven down the bank on an angle. 

A post mortem conducted by pathologist Dr R Fernando found the cause of death to be most likely positional asphyxia due to the tractor pressing against Mr Dalley’s neck obstructing the air passages and chest cavity.    Toxicology testing of Mr Dalley’s blood did not reveal the presence of drugs or alcohol.

I am satisfied that no other person contributed to Mr Dalley’s death.

Comments and Recommendations:

I have decided not to hold an inquest into the death because the investigation into the death has sufficiently disclosed the identity of the deceased person, the time, place, the probable cause of death, relevant circumstances concerning the death and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act.

Having conducted an investigation I do not consider that the holding of an inquest would elicit any information further to that disclosed by the enquiries conducted.

From the investigation conducted it would appear that Mr Dalley has misjudged the decline and angle of the grassed bank.  This combined with the added bucket load and incorrect tyre pressure increased the likelihood of the tractor becoming unstable and rolling.  The tractor was not fitted with a seat belt for added safety. Before I conclude I wish to convey my sincere condolences to the family of the deceased.

This matter is now concluded.

DATED:        6 day of November2013.


Timothy Hill