Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Donald Jones, Coroner, having investigated a death of
WITHOUT HOLDING AN INQUEST
Find That :
‘The deceased’ died November 2009, at , Irishtown.
‘The deceased’ was a married person whose occupation at the date of his death was a Truck Driver.
I find that the deceased died as a result of injuries consistent with a motor vehicle crash.
Circumstances Surrounding the Death :
On Wednesday the 25 of November 2009, a single vehicle truck crash occurred on Grooms Cross Road, Irishtown. Grooms Cross Road is a rural road that generally runs in an east /west direction, where a speed limit of 100km/h applies. Traffic flow on this road could best be described as light.
The roadway is a two lane system separated by single broken white centre lines, one lane for east bound vehicles and one for west bound vehicles. There are no painted edge lines present. Both sides of the roadway are bound by a grass verge and a wire fence.
The deceased and driver of the prime mover, was employed by Falcon Transport where he worked on a casual basis as a truck driver. He had worked for the company since February 2009 and the truck he was driving at the time of the crash had been allocated to him. He was therefore very familiar with the truck and its controls. ’The deceased’ was reported to be an excellent and particularly careful driver with many years experience driving heavy vehicles. ’The deceased’ was the holder of a basic driver’s licence with heavy combination endorsements.
‘The deceased’ did not regularly drive in this area whilst working for Falcon Transport, however he had driven in this area on a number of occasions in his previous employment.
’The deceased' started work at approximately 6.30am, he attended Fonterra at Spreyton where he loaded 18,000 litres of mother liquor (milk product) and then made his way to the Circular Head area where he was to deliver the milk.
At approximately 8:25am as Mr P was travelling in a westerly direction on Grooms Cross Road at Irishtown, he was being followed by another driver..(Mr. G)
"Mr. G." stated that he caught up with ’deceased’s' truck about one to one and a half kilometres west of Irishtown. Mr Gibson noted that the large hill west of Irishtown slowed the truck down to a very low speed. He then followed the truck for about another 200 to 300 metres before it came to a sweeping right hand bend. ‘Mr. G.’was not sure how fast they were going but believed it would have been less than 80km/h. As the truck started to go into the corner the rear of the tanker appeared to bounce he didn’t don’t know what caused this, but noted there was nothing on the road. The trailer wheels then left the travel portion of the roadway however the truck’s wheels stayed on the road. The trailer’s right hand wheels stayed in the air for quite some time and then the trailer started to roll. ‘Mr G’ thought the turn table might break, but it didn’t and then the truck and trailer rolled very quickly, before coming to rest on the driver’s side.
Emergency services arrived some time later and attempted to provide medical assistance to ’the deceased’ who was trapped in the wreckage. The vehicle suffered extensive damage to the majority of the cabin area of the vehicle, making it difficult to get into the prime mover. A short time later he was pronounced deceased.
At the time of the crash the weather was fine and the road surface was dry. The road surface was constructed of bitumen and aggregate and devoid of any noticeable defects.
Accident and Investigation (AIS Burnie) officer Colin Willcox states,
…"Both outer tyres on the driver’s side drive tyres were deflated consistent with crash damage. All tyres displayed good tread pattern and were in roadworthy condition. The rear axles were partly dislodged due to broken retaining bolts that retained the mounts for the driver’s side lower torque rods. These bolts were non genuine on the driver’s side. I cannot be 100% certain if these bolts were a contributing factor by breaking prior to the crash or if they broke as a result of the crash damage.
The presence of the red melted plastic on the roadway for approximately 28 metres, indicates the mudguards dropped dramatically on the left side of the vehicle, This may have been caused by the weight transfer as the prime mover attempted to negotiate the right hand curve, however, I believe under normal circumstances such a weight transfer would cause the guard to bounce and contact the tyre intermittently, rather than stay in constant contact with the tyre.
There was a large amount of the melted red plastic deposited onto the roadway, and also a large quantity still on the rear tyres of the prime mover. The melted plastic on the roadway and the statement from Mr. G cause me to suspect that the bolts may have broken prior to the crash, Mr Gibson stated, "As the truck started to go into the corner the rear of the tanker appeared to bounce. I don’t know what caused it, but there was nothing on the road."
I am unable to determine when these bolts were fitted to the prime mover. The owner of the truck was interviewed and indicated that he had not had any work done on the suspension since he owned the truck. After speaking with AJL Burnie and obtaining service records in relation to the work conducted on the prime mover, they also did not perform any work on the suspension. I believe this bolt may have been installed prior to Mr C purchasing the prime mover.
The major concern with the non genuine bolts fitted to this prime mover were shearing force of the bolts. The genuine bolt had a shear factor of 13.251 tonne, while the non genuine part had a shear factor of 4.077 tonne. The diameter of the bolts were considerably different with the genuine part measuring 15.95mm, while the non genuine part measured 14.31mm."
According to Transport Inspectors, prior to the crash, the tanker trailer would have been classed as mechanically sound and roadworthy except for the minor defect of a worn suspension torque rod bush and this would have minimal effect on the behaviour of the trailer.
Comments & Recommendations :
I find the deceased died as a result of cerebral trauma consistent with a motor vehicle crash.
An analysis of the deceased’s blood revealed "No apparent significant toxicology."
Whilst I am unable to make a definitive finding that the non genuine retaining bolts used on the suspension contributed to the crash, the evidence of Mr Wells suggests it may have been a significant factor, and this is consistent with the observation of Mr G.
I note that according to Mr Wells the factory fitted bolt is a hardened manganese, medium carbon steel with a high outer hardness value and low internal hardness, made primarily for carrying a uniaxial load. The replacement bolt fitted was was an aftermarket bolt, being a section of threaded bar. This bolt was manufactured of low grade steel commonly used for threaded bar and flat plate for the fabrication of tanks and beams, and was not suitable for the purpose of a replacement bolt in these circumstances as it possessed no special properties relating to it's intended use. The examination of the bolt showed the threaded bolt to be almost 2mm smaller than the factory bolt.
There is no evidence to suggest any contribution by the deceased to the crash. On the evidence his speed was not excessive, nor did his driving contribute to it.
The observation of Mr G strongly suggests the non genuine retaining bolt or bolts have failed, causing the bouncing movement immediately before the crash.
I would recommend that publicity be given warning of the dangers of fitting after market parts unless they possess the same or equivalent properties of the part they are replacing.
Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased for their loss.
This matter is now concluded
DATED : Friday 21 May 2010 at Burnie in the state of Tasmania.
THE FINDINGS HAVE BEEN DE-IDENTIFIED AT THE REQUEST OF THE SENIOR NEXT OF KIN IN CONSULTATION WITH THE CORONER.
FAILURE TO OBSERVE THIS AT ANY TIME OF PUBLICATION WILL BE IN CONTRAVENTION OF SECTION 57 OF THE CORONERS ACT 1995