Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Simon Cooper, Coroner, having investigated a death of Kim Marlene Anne Dougan

Find That:

(a) The identity of the deceased is Kim Marlene Anne Dougan;

(b) Mrs Dougan died in the circumstances set out in this finding;

(c) Mrs Dougan died as a result of multiple severe trauma sustained in a motorcycle crash;

(d) Mrs Dougan died on 1 December 2012 on the Midland Highway, south of Conara Junction in Tasmania;

(e) Mrs Dougan was born at Burnie in Tasmania on 31 January 1966, was aged 45 years; and was married and employed as a real estate agent at the time of her death; and

(f) No other person contributed to her death.


Mrs Dougan was married to her husband William for 24 years and they had two children, Ryan and Kayla. The Dougan family lived in Ulverstone and Mrs Dougan was employed as a real estate agent in Devonport. Both Mr and Mrs Dougan were keen motorcyclists. Mrs Dougan owned a black 2008 250cc Suzuki ‘Intruder’ motorcycle, number A618F, which was registered in her name. She had owned it for nearly four years.

Circumstances Surrounding the Death:

On 1 December 2012 Mrs Dougan and her husband were taking part in the state’s annual motorcycle toy run. In the past she had normally ridden as a pillion passenger on her husband’s motorcycle but on this occasion, for the third year in a row, she was the rider of her own motorcycle, the motorbike described above. Mr and Mrs Dougan were part of a larger group of riders. They left with that group from their home town of Ulverstone at about 7.30 in the morning. They rode to Perth where they stopped for breakfast at approximately 8.30am. At about 9.30am they re-commenced their journey, in the company of a number of other riders, heading south towards Hobart on the Midland Highway.

Mr Dougan described noticing wind gusts having increased and becoming stronger after they left Perth. He said the conditions made his bike “drift from the right-hand wheel track on the road to the left-hand wheel track on the road”. Sometime after leaving Perth Mr and Mrs Dougan became separated from each other because of heavy road traffic.

Mr Dougan stopped at Ross outside the pub in the centre of the town. He said that roughly half the group he was riding with were in front of him and half behind. While waiting at Ross, Mr Dougan learned of a motorcycle crash on the Midland Highway north of Ross. Contact was made by friends of Mr Dougan with Tasmania Police and on their advice Mr Dougan was taken to the Campbell Town police station where he was advised that his wife had been killed in a motorcycle accident.

As a result of the investigation in relation to this matter I find that the crash occurred just after 10.30am on Saturday, 1 December 2012, on the Midland Highway near that highway’s intersection with the Esk Highway. Three other motorcycle riders, Shane Bradley, Per Nielsen, and Lee McCulloch, were all following Mrs Dougan and witnessed the crash. Each estimated her speed as being no more than 90 km an hour (in an open speed limit section of the Highway). Like Mr Dougan, Mr McCulloch also described a strong crosswind blowing on the highway in the immediate lead up to the crash. He said he saw Mrs Dougan’s motorcycle “start to come across the south bound lane towards the left... [and he] suddenly saw a puff of smoke come from the back wheel of this bike”. Mr McCulloch did not see a brake light, but his attention was drawn to Mrs Dougan’s motorcycle because it “was actually riding off line”. Mr McCulloch saw that the rider (Mrs Dougan) was not leaning to the right (that is into the wind) something he was doing to keep his bike on course. He noticed Mrs Dougan’s bike continue to head to the left and saw it hit the metal Armco rail on the left side of the road. He saw Mrs Dougan hit the ground in the south bound traffic lane near the centre lines of that lane.  He saw Mrs Dougan’s helmet rolling on the road in the south bound lane after impact. Mr McCulloch said he was forced to take evasive action to avoid colliding with the crashed motorcycle. He stopped his motorcycle. He and his wife (who was his pillion passenger) immediately ran to Mrs Dougan. They attempted, along with other members of the public, to render assistance to Mrs Dougan. Contact was made with emergency services. However it was immediately apparent that, unfortunately, there was nothing that could be done for Mrs Dougan.

Police crash investigators attended the scene within an hour of the accident. Their investigation revealed, and I find, that the crash site was 56 metres south of the Esk Highway Junction on the Midland Highway. The crash itself occurred on a gently sweeping right-hand curve at approximately 10.38am. Upon their attendance the motorcycle was seen to be on its side, facing north, and positioned such that it was over the centre double white lines. Mrs Dougan’s body was still in situ, lying on her back with her body partially under the eastern Armco railing.

Mrs Dougan’s body was transported to the Launceston General Hospital where after formal identification pathologist, Dr Terence Brain, carried out an autopsy at the direction of the Coroner. As a result of that autopsy Dr Brain determined that the cause of Mrs Dougan’s death was multiple severe trauma consistent with having been sustained in a motorcycle crash. I accept that opinion.

Samples were taken during the autopsy from Mrs Dougan’s body and submitted for analysis to the laboratory of Forensic Science Service Tasmania. Aside from the presence of therapeutic quantities of paracetamol, as well as some caffeine, no drugs or alcohol were detected in Mrs Dougan’s blood.

The motorcycle which she was riding at the time of the crash was examined by Mr Paul Maclaine, a Transport Inspector and qualified diesel mechanic, employed by the Department of Infrastructure, Energy and Resources. Mr Maclaine has held that position for 19 years, and has conducted numerous examinations of vehicles involved in crashes (both serious and fatal) to determine their roadworthiness. Mr Maclaine examined the motorcycle ridden by Mrs Dougan at the time of the fatal crash. In summary he concluded, as a result of that inspection, that he was unable “to locate any defects which may have contributed to the crash”. It was his opinion, which I accept, that the motorcycle was, prior to and at the time of the crash, roadworthy.

The investigation conducted by the officers of Northern Crash Investigation Services, Tasmania Police, involved an examination of the scene (which was unremarkable), a review of the helmet and protective clothing worn by Mrs Dougan at the time of the crash (all of which was found to be appropriate – aside from her pants which were standard denim jeans), an examination of the road itself, the weather conditions at the time, a speed analysis, and a crash reconstruction.

A summary of that investigation is, and I find, that the crash occurred due to Mrs Dougan failing to properly control her motorcycle. It occurred in the context of strong crosswinds (reportedly up to 67 km an hour). Mrs Dougan had relatively speaking limited motorcycle riding experience. She had only held her P2 licence since June 2012, and according to her husband, would only ride her motorcycle no more than 15 times a year and then only in good weather. 

Tasmania has a system of mandatory safety courses for all persons seeking to be licensed to use motorcycles on the state’s roads. Those safety courses are provided as part of the learner course and the pre-provisional licence course. Course content is mandated by the state Department of Infrastructure Energy and Resources and delivered by the Driver Education Centre Australia (“DECA”). Neither course contains any requirement to address techniques for safe riding in adverse weather conditions.

The weather conditions in which Mrs Dougan was riding were ones that she was unlikely to have experienced in the past. They were certainly conditions in which she had never received any formal training as part of undertaking both motor cycle learner and pre-provisional safety courses. I am satisfied that those conditions together with her relative inexperience contributed to her initial loss of control of her motorcycle which in turn led her to crash into the rail post of an Armco railing on the eastern side of the Midland Highway.

The investigation revealed that the rail post of the Armco railing significantly contributed to the fatal injury sustained by Mrs Dougan. Many places now on Tasmanian highways are fitted with so-called “underrun protection”, a system designed to reduce the severity of injury to motorcyclists who come into contact, at speed, with Armco railing, in road crash accidents. The system operates such that it prevents a rider from impacting with the Armco rail posts by ensuring that a motorcyclist who has left his or her motorcycle will slide along the guard rail rather than under it and into a rail post, as happened in this instance.

There is little doubt that had underrun protection been fitted to the Armco railing at the crash site then it is possible that Mrs Dougan would have survived this crash. The absence of the underrun protection meant that when she lost control of her motorcycle her body slid under the Armco rail and crashed into a post rail. The contact she made with the post rail was so severe it caused her helmet to come away from her head and caused the injuries which proved instantly fatal.

One final matter is of particular note. Mrs Dougan was participating in the annual state motor cycle Christmas toy run. She had a large teddy bear strapped to the rear of her motorcycle. The surface area of that teddy bear was approximately 400mm wide by 600mm high. It was secured to the rear mudguard of the motorcycle with rope. It is the opinion of the accident investigators, an opinion I accept, that that teddy bear would have acted much in the same way as a sail in the reported wind gusts. There is little doubt that the effect of those wind gusts would have been significantly accentuated by reason of the presence of the toy teddy bear strapped to the rear of the motorcycle. This in turn would have caused Mrs Dougan additional difficulty controlling her motor cycle. Inexperienced motorcycle riders such as Mrs Dougan need to be mindful of placing anything upon their motorcycles which compromise safe riding.

Comments and Recommendations: 

I have reached the view that the circumstances of Mrs Dougan’s death require me to make the following recommendations.

First it is apparent that the crash which caused Mrs Dougan’s death occurred, in large part, because of her inexperience in riding a motor cycle in adverse weather conditions. I recommend that motor cycle training safety courses (both learner and provisional) be extended to include training in relation to the control of motor cycles in adverse weather conditions.

Second where possible steel Armco rail posts be fitted with underrun protection, particularly in areas identified as high risk in terms of motorcycle accidents.

I take this opportunity of conveying my sincere condolences to Mrs Dougan's family and friends.


Dated:  1 December 2014 at Hobart in the State of Tasmania



Simon Cooper