Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Donald John Jones, Coroner, having investigated a death of
Joshua Phillip STEIN
WITHOUT HOLDING AN INQUEST
Find That :
Joshua Phillip STEIN died on or about the 3 October 2009, at Sandy Cape Track near Garnet Point, Temma in Tasmania.
Joshua Phillip STEIN was born at Burnie in Tasmaniaon the 22 March 1991 and was aged 18 year(s).
Joshua Phillip STEIN was a mill worker at the date of his death.
I find that the deceased died as a result of a Traumatic Head Injury
Circumstances Surrounding the Death :
Mr Stein resided with his mother and brother at Smithton in Tasmania. He played football for the Smithton and Irish Town football clubs and was well liked in the community.
On the evening of the 2 October, 2009 members of the Irish Town Football Club travelled to Temma for the end of season celebration.
Just prior to arriving at Temma a 1990 Toyota utility (registration EU 6433) driven by Mr Bon Radford was involved in a crash. The vehicle rolled and suffered significant damage but remained drivable and was driven to 805 Temma Road, where the other team members were gathering.
During the evening the team celebrated the end of the football season, drinking and socialising. At around 11-00pm 15 members of the group travelled to Jack Smith’s residence which is approximately 10 km south of Temma. They travelled along a four wheel drive track at Sandy Cape, the journey taking about 1 hour.
During the return journey from Jack Smith’s residence, the vehicle being driven by Bon Radford, the Toyota utility which had been crashed earlier, became bogged on a side track. Mr Michael Williams manoeuvred his 1992 Toyota Landcruiser into a position behind Mr Radford’s vehicle with the intention of towing it free. At this point of time the vehicle had sunk into the mud up to its axle and was firmly bogged.
Mr Matthew Febey attached a snatch strap (a heavy duty nylon or polyester strap that can stretch and spring back to it's original length) owned by Mr Williams to the towing assembly on Mr Radford’s vehicle. Mr Williams attached the other end of the snatch strap to an attachment point on the front of his vehicle. Whilst the recovery equipment was attached a number of the occupants alighted from the vehicle. Mr Joshua Stein, Mr Brett Fowler, Mr Simon Walsh and Ms Danielle Jago remained in Mr Williams vehicle. Mr Radford was the only occupant of his vehicle.
As would be expected, lighting in the area was non-existent and illumination was obtained by using torches and the vehicle’s headlights to aid in connecting the snatch strap.
Having connected the strap, Mr Williams reversed his vehicle away from Mr Radford’s vehicle. During this process part of the towing assembly on Mr Radford’s vehicle has broken free and smashed through the front windscreen of Mr Williams’ vehicle. The broken towing assembly has continued through the vehicle eventually striking Mr Stein in the head before leaving the vehicle and landing some 90 metres behind it.
Mr Stein suffered severe head injuries and died at the scene before emergency services personnel could attend. The area where the incident occurred has little or no mobile phone coverage. Team members unsuccessfully performed CPR on Mr Stein, however due to the massive injuries he was unable to be resuscitated.
A post mortem examination conducted by Pathologist Dr Ruchira Fernando found that Mr Stein died from a traumatic head injury.
Toxicology testing conducted by Miriam Connor from Forensic Science Service Tasmania revealed that Mr Stein had a blood/alcohol level of 0.083 g/100ml.
Both vehicles involved in the incident when Mr Stein died were examined by Transport Inspectors from the Department of Infrastructure, Energy and Resources. Both vehicles were found to be unroadworthy. However, the defects identified in both vehicles would not have contributed to the death of Mr Stein.
The towing assembly that was fitted to Mr Radford’s vehicle at the time of Mr Stein’s death was examined by Mr Barrie Hayes. Mr Hayes holds university qualifications in Metallurgy. Mr Hayes found:
The rectangular hollow section (RHS) part of the ball coupling tongue body was excessively corroded on internal surfaces and was in an unsafe condition for use.
The tongue plate has been joined to the RHS hitch by an external fillet weld around all four sides. It was evident water had accumulated at the closed end and caused corrosion. The extent of corrosion was consistent with what would be expected from sea water. Wall thickness had been reduced by corrosion from 4mm to 2.mm along the top of the RHS, 2mm along the sides and 1 mm along the bottom. Average loss of wall thickness would have been greater than 50 percent. On a pro rata basis gross trailer mass of 1.5 tonne would have been more than halved.
The towbar as marked on the identification plate is a genuine Toyota accessory.
The ball coupling that failed is regarded as being non-genuine. The design is vulnerable to corrosion and fatigue. There is some indication of poor quality welding. The internal services of the RHS appear to have had no protective coating.
The snatch strap was examined by Mr Philip Sievers from Rope N Chain Company. Mr Sievers found:
The strap itself shows fair wear and tear. When they are in this condition they may last another twenty uses or may break the next time they are used.
The shackle used with the strap is a 4.75 tonne SWL and has a safety factor built in at 5 – 1. Therefore, the shackle would be stronger than the strap used which is good as the strap should always break first.
Tasmania Police conducted an investigation into the circumstances of Mr Stein’s death. That investigation found that:
The snatch strap was attached to the tow ball on Mr Radford’s vehicle. Snatch strap user’s guidelines and current accredited 4WD training courses all advise that the snatch strap should never be attached to the towing ball in this type of recovery operation.
During recovery operations using a snatch strap, all bystanders (other than the drivers’ of the two vehicles involved in the recovery) should be at a safe distance (1.5 times the outstretched Recovery Strap length) to the side of the recovery operation and NEVER in the line of the recovery.
There were no suspicious circumstances surrounding the death of Mr Stein.
Comments & Recommendations :
I find, accepting the evidence of Dr Fernando that Mr Stein died from a traumatic head injury.
After reviewing the evidence I am satisfied that the fatal injuries suffered by Mr Stein can be directly attributed to the failure of the towing assembly on Mr Radford’s vehicle. The towing assembly had deteriorated over time affecting its structural strength. I also note that there was some evidence of poor quality welding on the ball coupling.
It is also clear from the evidence before me that both Mr Radford and Mr Williams were not aware of the dangers of attaching snatch straps to tow balls when completing recovery operations.
The trip to Temma started as an end of season celebration for members of the Irish town Football Club but turned into a tragic day for the club and Mr Stein’s family.
Having considered all the material before me I recommend that the motoring public, particularly those using 4WD vehicles be made aware and reminded of the dangers of using snatch straps in recovery operations. It is important to correctly attach (following the manufacturers recommendations) the recovery strap to a motor vehicle. A standard tow ball or vehicle tie-down point is not designed for this purpose and may result in the strap or a vehicle component detaching from a motor vehicle and striking and seriously injuring or killing a person. Only attach the strap to a vehicle recovery point or device that is suitably rated for use with the strap.
Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased.
This matter is now concluded
DATED : Tuesday, 28 September 2010 at Burnie in the state of Tasmania