RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Olivia McTaggart, Coroner, have investigated the death of
Kenneth Kim Pohlner
WITHOUT HOLDING AN INQUEST
I have decided not to hold a public inquest hearing into this death because my investigations have sufficiently disclosed the identity of the deceased, the date, 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.
FIND THAT:
(a) Kenneth Kim Pohlner died on 12 May 2011 on the Arthur Highway approximately 4.3 kilometres south of the township of Murdunna in Tasmania.
(b) Mr Pohlner was born at Oakleigh in Victoria on 18 February 1955. At the time of his death he was aged 56 years. He was a married man who was a bus driver by occupation.
(c) Mr Pohlner died of multiple blunt traumatic injuries that he received as the driver of a motor vehicle involved in a crash.
Background:
Mr Pohlner at the time of his death was residing with his wife, Suzanne, at Bellerive. He was known by his middle name ‘Kim’. In 1981 he married Suzanne and the couple had two children. Between 1997 and 2003 the family lived in Malaysia before returning to Australia. In 2004 the deceased commenced driving passenger buses. Since that time he has been engaged in that occupation both in full time and part time capacities.
In 2007 Mr Pohlner and his family moved to Tasmania. He commenced working for the coach company known as ‘Tassie Link’ in 2008. At the time of his death he was employed as a part time coach driver by Tassie Link. He held the appropriate licence to drive passenger coaches/buses.
Mr Pohlner was a healthy man without any significant medical problems. He did however suffer from elevated blood pressure, which was managed by way of medication. He was last seen by his general practitioner on 4 April 2011. On that date his blood pressure was noted to be well controlled.
Circumstances:
For approximately six months before his death, Mr Pohlner in his employment had been driving the Tasman Peninsular coach service. This service required day and night time driving. There were two shifts; the day shift commencing at 4.30am and the afternoon shift commencing at 3pm.
In relation to afternoon shift the coach driver was required to drive the coach from Moonah to Port Arthur. The driver would leave the bus at the Port Arthur depot and then drive a company sedan back to the Moonah office. The dayshift driver would drive the company car to Port Arthur leave it there and then drive the coach back to Hobart.
On Thursday 12 May 2011, Mr Pohlner was working afternoon shift. He commenced duty at the Tassie Link (Moonah office) at 3pm. On this day he was driving a Scania 55 seater coach. He had driven this coach before and was conversant with its controls and handling. Mr Pohlner left the Moonah depot at approximately 3.15pm. He drove the coach to Hobart, Eastlands, Sorell and then to Port Arthur along the Arthur Highway. He collected passengers during the journey. The coach was scheduled to arrive at Port Arthur at approximately 6.10pm. There is no evidence to suggest the coach did not arrive on time.
After concluding his coach duties Mr Pohlner has commenced to drive back to Hobart in the company owned Hyundai Elantra sedan registered number EV-1415. He had driven this vehicle on many occasions and was familiar with its controls and handling. On the available evidence it would appear that he left Port Arthur around 6.15pm.
At approximately 6.40pm, Mr Pohlner was driving the Hyundai along the Arthur Highway in a northerly direction. He was approximately 4.3 kilometres south of the township of Murdunna. The road in this area is constructed of a bitumous material with gravel verges on either side. The central road marking consists of double continuous white lines. There are painted road edge lines on either side. At the time the roadway was wet however it was not raining. It was dark and there were no street lights.
Mr Pohlner negotiated a sweeping left hand curve. On exiting the curve the rear of his vehicle lost control. It commenced to rotate clockwise across the double continuous white centre line onto the incorrect side of the road.
At this time Mrs Jeanette Noye was driving a Holden Commodore sedan, registered number DQ-6674, in a southerly direction on the Arthur Highway. She was approaching the curve the deceased was exiting. Mrs Noye was travelling on the correct side of the road at a speed of approximately 80km/h. I am satisfied on all of the evidence that Mrs Noye was driving in a proper and appropriate manner. The speed limit applicable to that section of road is 90km/h.
Mrs Noye observed Mr Pohlner’s vehicle directly in front of her. She stated that she did not have time to brake or swerve. The front of Mrs Noye’s vehicle crashed into the driver's side of Mr Pohlner’s vehicle between the A and C pillars.
The point of impact was in the south bound lane. Both vehicles came to rest on the eastern side of the double continuous white lines in close proximity to the point of impact. Mrs Noye was conveyed by ambulance to the Royal Hobart Hospital suffering a fracture in the lower leg, cuts and bruising. Mr Pohlner was pronounced dead at the scene.
I note that shortly after the collision the driver of a vehicle travelling in a northerly direction applied her brakes as she approached the crash scene. That driver’s vehicle lost traction and commenced to slide. The driver rectified the movement of the car by steering input. This in itself is a clear indicator the road was both wet and slippery.
A post mortem examination was conducted by forensic pathologist, Dr Donald Ritchey. He determined the cause of Mr Pohlner’s death was multiple blunt traumatic injuries sustained in the crash. Toxicology of a post mortem sample of Mr Pohlner’s blood showed that he had not consumed alcohol or drugs before the crash.
Comments and Recommendations:
I am satisfied that a full and detailed police investigation has taken place into this incident. The investigation included a detailed inspection of the scene undertaken by an experienced crash investigator First Class Constable Kelly Cordwell of Tasmania Police Crash Investigation Services. Upon review of all the evidence I am able to find as follows;
• Both drivers were properly licensed at the time;
• Both drivers were wearing their seatbelts;
• Both vehicles were registered and in a roadworthy condition;
• Alcohol and/or drugs were not factors in the crash;
• The roadway was wet and slippery but it wasn’t raining;
• The speed limit at that location is 90km/h.
Both vehicles involved in the crash were inspected and as indicated above found to be in a road worthy condition. I note that in April 2011 Mr Brett Lazdins, an employee of Tassie Link, reported what he believed to be a defect with the front right tyre of the Hyundai – it was pulling to the right. This perceived fault was reported to the company. Mr Lazdins was the last person to drive the Hyundai prior to the deceased’s fateful trip. Mr Lazdins indicates the vehicle was still pulling a little to the right but it was only slightly noticeable. In my view it is highly unlikely that this feature had any influence on the circumstances surrounding the crash.
The critical curve speed for the curve the deceased was negotiating has been calculated using formulae to be 105km/h. This is the theoretical maximum speed at which a north bound vehicle, under normal circumstances, can negotiate the curve travelling and staying wholly within its lane. Road tests after the crash also confirmed that at a speed of 100kmph it was difficult to maintain a vehicle wholly within the northbound lane. Sergeant Rodney Carrick, Officer in Charge of Accident Investigation Services, stated in his affidavit that the critical curve speed for the section of road in question would have been lower if the road was wet due to a lower co-efficient of friction.
There was no evidence in the investigation that can assist in determining the speed of Mr Pohlner’s vehicle before the crash. However the evidence of the wet road and the critical curve speed leads me to conclude that a vehicle on the curve in question, travelling in excess of the speed limit of 90kmph whilst the road was wet was at risk of a loss of control. I am unable to determine the reason why Mr Pohlner’s vehicle initially commenced to rotate clockwise. On the evidence I am able to exclude mechanical failure, intervention of any third party, or an intention to deliberately harm himself. I am aslo able to exclude a medical event on the basis of Dr Ritchey’s report.
As the the road was wet and slippery and the loss of control may well have been the result of braking or an over correction of the steering as he exited the corner. He may have tried to avoid an animal on or near the road. It is possible that his speed may have been too high for the condition and curve. All of these scenarios are unfortunately speculation only. Once Mr Pohlner lost control of his vehicle I am satisfied that he would have been unable to regain it. The evidence indicates that there was a significant steering movement to the right,presumably when Mr Pohlner attempted to gain control of his vehicle.
The Department of Infrastructure, Energy and Resources (Roads and Traffic Division) conducted a post crash review of the scene. An audit of the Department’s crash data base revealed there had been two crashes, inclusive of the present investigation, within a one kilometre radius of this crash in the past five years.
The review stated that the skid resistance data for the road shows that the values are within the acceptable range. It also stated that there was no failure or cracking in the road surface within 300m south of the point of impact. Further the review determined that the presence of vegetation in the area prevents full drying during the winter months resulting in frequent wet surface conditions. I accept these conclusions from the review.
The review recommended the installation of ‘Slippery When Wet’ signs to encourage moderation in driver speed. I am satisfied that the recommended signs have been installed and that these signs will be of benefit to road users in this area.
I am satisfied in the circumstances that there is no requirement for any formal recommendations arising from the tragic death of Mr Pohlner.
I express my sincere condolences to Mr Pohlner’s family.
DATED: 21st day of March 2012 at Hobart in the State of Tasmania