Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Rod Chandler, Coroner, having investigated the death of

A young male


Find That:-

The deceased died in January 2009 on Coles Bay Road at Coles Bay.

The deceased was aged 19 years. He was unmarried and employed as an Apprentice Brick Layer.

I find that the deceased died of blunt trauma of the head as a result of a motor vehicle crash.

Circumstances Surrounding the Death:-

In early January 2009 he commenced work on the building of a resort at Coles Bay. At this time he was accommodated with some co-workers at a residential facility located approximately ten kilometres from the Coles Bay township.

In January 2009 the deceased finished work at about 4.30pm. He returned to his accommodation where he consumed a small quantity of alcohol. At about 6.30pm the deceased with six of his work colleagues, left his accommodation and drove to the Iluka tavern ("the tavern") in Coles Bay where they intended to have dinner. They travelled in two vehicles including the deceased’s Holden Commodore single cab utility. ("the utility")

At the tavern the group had dinner and drank beer. At about 8.00 pm two of the party left. About an hour later they returned and left again. Meantime the deceased, with the others, remained at the tavern drinking beer and playing eight-ball.

At about 10.30pm the tavern closed. The deceased decided to drive the utility back to his accommodation. His four co-workers decided to travel with him. Two of his friends sat with the deceased in the utility’s cab. The other two, sat in the vehicle’s tray. The deceased was wearing his seat belt.

The deceased drove the utility in a general southerly direction on Coles Bay Road heading toward his accommodation. As the vehicle exited a sweeping right hand bend opposite the entrance to the Edge of Bay Resort its left hand wheels left the bitumen surface and ran onto the gravel shoulder. The deceased steered the utility to the right in an attempt to return the utility to the bitumen surface. However, this action caused the rear wheels to slide whereby the utility then rotated 180 degrees in a clockwise direction and crossed to the incorrect side of the roadway. It then dropped into a 2.39 metre deep culvert and landed on its wheels. The deceased struck the rear of his head on the utility’s B pillar and his face on its steering wheel. None of the other four persons sustained serious injury.

One of the passengers removed the deceased from the utility via its passenger side door. He had suffered a severe head injury. Three of the passengers then carried the deceased from the vehicle up to the roadway. The police emergency number 000 was called.

An ambulance arrived at the crash scene at about 11.10 pm. Its officers attempted resuscitation without success. It was apparent that the driver was deceased.

Toxicology results from post mortem-blood show the deceased to have had ‘A highly elevated blood alcohol concentration’ ‘[0.216 g/100ml]’.

An investigation of the circumstances surrounding the crash was undertaken by Tasmania Police. Its salient findings are that:

  • At the time of the crash the weather was fine, the road dry and its bitumen surface in good condition,

  • A 20mm lip exists between the bitumen edge and the gravel verge on the eastern side of the roadway. It is the opinion of the investigating police officer that this lip contributed to the deceased’s initial loss of control of the utility by grabbing the inner part of the rim on its left hand wheels.

  • The culvert referred to above is located on the western side of the roadway. It is surrounded by a concrete edge level with the gravel verge. The culvert drops over an embankment and was 2.39 metres deep.

  • The crash occurred within a 100 kph speed zone,

  • At the time of the crash the utility was estimated to have been travelling at a speed of approximately 83 kph,

  • The critical speed for the crash bend has been calculated at 101 kph. This indicates the speed at which the bend can be safely negotiated by an alert and sober driver,

  • The deceased held a provisional driving licence. As such he was not permitted to drive with any alcohol in his blood,

  • The Forensic Scientist makes this comment upon the effect of alcohol upon a person’s ability to drive;

"A blood alcohol concentration of 0.216g/100mL would significantly impair driving performance to the point of being unable to properly control a motor vehicle. It has been estimated that the relative risk of a driver with blood alcohol concentration of between 0.14g/100mL and 0.18g/100mL being involved in an accident is approximately 20-50 times that of a driver with nil blood alcohol. It will be expected that at a blood alcohol concentration greater than 0.18g/100mL the relative risk of accident involvement would be even greater."

  • Inspection of the utility revealed both front tyres to be void of tread at their extreme inner edges. Checks and tests also revealed the wheel track of the vehicle’s front and rear to be below manufacturer’s specifications due to the fitment of after-market rims and tyres. However, it is unlikely that these deficiencies were factors causative of the crash,
  • Following the crash January 2009 officers of the Department of Infrastructure, Energy and Resources conducted a review of the crash site. The review was undertaken in an endeavour to reduce the risk of similar type crashes occurring in the future. It recommended that a W-beam safety barrier be installed to prevent vehicles from leaving the roadway and dropping into the culvert,

The surviving occupants of the utility were all interviewed by Tasmania Police. One of the passengers made these comments of the deceased when they were leaving the tavern, "The deceased was slurring his speech. I could tell he was drunk, we were all drunk" and "I don’t remember suggesting that the deceased shouldn’t drive". Another passenger says, "Before we left (the tavern) I had drunk about ten 10oz beers and the deceased had drunk about the same" and "the deceased and I both had a conversation about who was going to drive. I offered but the deceased said he would drive." On the subject of alcohol another passenger says, "I drunk about four 10oz beers and three 15oz as well as a Bundy and coke. I don’t know how much the deceased had to drink but I’m pretty sure he was drunk." On the same subject that passenger also said, "the told me in conversation that he was drunk."

It was the evidence of one of the passengers that some time before leaving the tavern he had made arrangements for an unidentified person to transport himself and the others back to their accommodation. He said that he told the others, including the deceased of this arrangement. However, the person had not returned to the tavern by the time it closed as he had taken another group home. Nevertheless, it was the passenger’s expectation that he would return. It seems that this person was in fact returning to the tavern to collect them when he came upon the crash scene. The passenger travelled with this person back to their accommodation where he was able to inform his work foreman of the crash. Despite police enquiries, the identity of the person who drove the passenger at this time has not been established.

Officers of Tasmania Police also interviewed the tavern’s Food and Beverage Attendant. The attendant has been employed in this position for six years. She was working at the tavern for all of the time that the deceased and his colleagues were present. After the tavern closed that night she described them in these terms, "None of the group appeared overly intoxicated, were stable on their feet when leaving and all happy."

Findings, Comments & Recommendations:-

I am satisfied that a thorough and detailed investigation has occurred into the death of the deceased and there are no suspicious circumstances.

I accept the opinion of forensic pathologist and find that the deceased died as a result of a blunt trauma of the head sustained in a motor vehicle crash.

It is apparent that this crash occurred because the deceased, when negotiating a right hand bend, permitted the utility’s left hand wheels to run off the bitumen surface and onto the gravel shoulder. The deceased has then lost control of the utility whereby it has crossed to the opposite side of the roadway and then dropped into a relatively deep culvert. In the course of these uncontrolled movements the rear of the deceased’s head has impacted upon the B pillar within the utility’s cab causing his fatal injury.

It is plainly obvious that the deceased’s failure to safely negotiate the right hand bend and to maintain control of the utility was directly attributable to his alcohol-impaired driving capacity. As I have noted his blood alcohol reading was 0.216 g/100mL which is more than four times greater than the alcohol limit permitted for a fully licensed driver. The deceased, as a provisional driver, was not legally permitted to have any alcohol in his system.

It is my conclusion that alcohol was the primary factor causative of this crash and the deceased’s consequent death. A secondary contributory factor was the 20mm gap between the bitumen edge and the gravel verge which in all probability contributed to the deceased’s initial loss of control of the utility. The other secondary contributory factor was the absence of a roadside barricade which, if it had been in place, would have prevented the utility from dropping into the culvert.

I note that DIER has recommended the installation of a barricade in the area of the culvert. I note too that the police officer responsible for the investigation of this crash has recommended that the gap between the bitumen seal and the gravel verge in the area of the crash be filled. I support each of these recommendations.

The deceased’s tragic and needless death is another graphic reminder of the very real danger of drinking and driving. It should also serve as a reminder that it is incumbent upon all members of the community to be alert to the risk of serious road crashes and that it may at times be necessary to take steps to protect persons from their own recklessness or stupidity. In this instance it was clearly apparent to the deceased’s companions that he was seriously affected by alcohol. The attendant, as an experienced worker in the hospitality industry should have been similarly aware. However, regrettably, none of these persons made any attempt to dissuade the deceased from embarking on his fateful journey.

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

DATED:Thursday, 20 August 2009 at Hobart in the State of Tasmania.

Rod Chandler