IN THE CORONERS’ COURT OF THE NORTHERN TERRITORY CORONERS’ FINDINGS Section 34 of the Coroners Act 1993 I, Elisabeth Armitage, Coroner, have investigated the death of TWO MEN whose deaths occurred on 28 March 2024, at Arnhem Highway, Kakadu in the Northern Territory. These are road deaths 16 and 17 of 2024.
Introduction: To date 50 persons have lost their lives on Northern Territory roads in 2024 compared to a total of 31 lives lost in 2023. Over the decade 2012-2021 on average 40 people lost their lives and 470 people suffered serious injuries on Territory roads each year. The average of 40 deaths per year was 3.2 times the national rate.1 The Territory death rate on roads is by far the worst in the country and this year the death rate is trending to be the highest ever over the last 10 year period. The current road toll has been described as “disgraceful” and “outrageous” by Senior Territory Police members and the former Infrastructure Minister, Joel Bowden.2 In light of the terrible and increasing loss of life on our roads and consistent with my function to ensure the coronial system in the Territory is administered and operates efficiently,3 and my power to comment on public safety connected with a death,4 it is intended to publish anonymized findings into all road deaths in 2024. It is hoped that by making findings about the circumstances of these deaths public, this will improve individual and agency awareness as to the causes of road fatalities, with the ultimate objective of saving lives and reducing the road death toll in the future.
The ‘Fatal 5’ factors which are considered to give rise to the greatest risk of road crash death and serious injury are:
• Drink/drug driving
• Failure to wear a seatbelt
• Excessive speed
• Distraction (eg. mobile phone)
• Fatigue 1 Northern Territory Government, Towards Zero Road Safety Action Plan 2024-2028 2 Fia Walsh, “‘Disgraceful’ road toll in crosshairs as NT road safety plan released”, NT News, 25 July 2024 3 Section 4A of the Coroners Act 1993 4 Section 34(2) of the Coroners Act 1993
In the Northern Territory:5
• 41% of fatal crashes involve alcohol, which is perhaps not surprising given that the Northern Territory has the highest per person alcohol consumption in Australia (in 2016 it was 27% higher than the national average6), and 25% of adult NT residents consume alcohol at a level that puts them at risk of long term harm7
• 33% of fatal crashes include the failure to wear seat belts
• 30% are speed related
• 7% are fatigue related
• 73% of fatal crashes occur in rural and remote areas, and on these roads ‘over-turned’ and ‘runoff’ incidents account for 47% of crashes
• Although Aboriginal people make up approximately 30% of the population they are overrepresented in road fatalities, accounting for 50% of fatalities and 30% of serious injuries It is known that inappropriate speed is often accompanied by other risky driving/riding behavior, such as non-seatbelt wearing and alcohol/drug involvement. The following diagram shows factors relating to speed fatalities for 2012-2021.8 On 28 March 2024, a 30 year old Caucasian male driver of a Toyota HiAce van was carrying one 27 year old Islander descent male front seat passenger and one 20 year old male in the rear cargo hold seated on a makeshift seat (the surviving passenger).
The HiAce van was travelling along a straight stretch of the Arnhem Highway in the direction of the Stuart Highway, approximately 50kms west of the South Alligator Bridge, when it became involved in a single vehicle ‘run-off’ incident. It vaulted off a mound of dirt and became airborne. It hit a tree and rolled and landed on its roof. The surviving passenger managed to escape. He suffered non-life threatening fractures and injuries.
Passers-by stopped and attempted to render assistance to the driver and front seat passenger who were still inside the van but, before they could gain access to the interior, the van caught alight and became 5 Northern Territory Government, Towards Zero Road Safety Action Plan 2024-2028 6 Unnikrishnan R., Zhao Y., Chondur R., Burgess P., “Alcohol attributable death and burden of illness among Aboriginal and Non-Aboriginal populations in remote Australia, 2014-2018”, Int J Environ Res Public Health, 2023 Nov; 20(22): 7066 7 Alcoholpolicy.nt.gov.au accessed 4 October 2024 8 Northern Territory Government, Developing a new Towards Zero Road Safety Action Plan 2024 2028 Discussion Paper, pp19-20
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engulfed in flames. Tragically, the driver and front seat passenger passed away in the flames and became Territory road fatalities 16 and 17 of 2024.
The speed of the vehicle at the point of ‘running-off’ was estimated to be 160 km/h, where the sign posted speed limit was 130km/h. Although the driver had been drinking alcohol, his alcohol level at 0.039% was not over the legal limit but that level is associated with disinhibition. His front seat passenger had an alcohol reading of 0.082%. The surviving passenger said that both deceased persons wore seat belts.
In this crash, which claimed 2 lives, it seems that at least one of the Fatal 5 was present: speed.
Cause of death: Driver and front seat passenger 1(a) Disease or condition leading directly to death: Combination of smoke inhalation and thermal Injuries 1(b) Morbid conditions giving rise to the above cause: Reported single motor vehicle collision (driver) Following autopsies, the Forensic Pathologist, found:
• The presence of burnt remnants of a seatbelt on the driver.
• In both the driver and passenger, soot was present in the trachea and the oesophagus and lower airways. The presence of soot in the airways indicates that the individual was alive and breathing during the fire. This suggests the driver and front seat passenger survived the initial impact of the collision and were exposed to smoke and fire afterward.
• In both the driver and the passenger cherry-red discolouration was found in the blood, viscera and body cavities. Cherry-red discoloration is often associated with carbon monoxide (CO) poisoning, a common finding in fire-related deaths. Although the carboxyhaemoglobin levels of 15% found in the driver and 13% found in the passenger are above normal levels, those levels are below those typically associated with fatal CO poisoning (which usually exceeds 30-50%). These levels indicate that while carbon monoxide exposure was significant, it may not have been the primary cause of death.
• The extensive charring of the bodies suggests that the fire was intense and prolonged. This makes it challenging to identify injuries that might have been caused by the collision itself or during the fire. A base of skull fracture was identified in the passenger. Due to the extensive thermal damage, it is difficult to determine if there were any other traumatic injuries (e.g., fractures, internal haemorrhage) from the collision. Thermal damage can mask or destroy evidence of such injuries.
• An alcohol level of 0.039% in the preserved cavity blood of the driver is associated with a mild level of intoxication which is associated with disinhibition; however, the alcohol level may have elevated post mortem due to decompositional changes.
• Given the findings, it is reasonable to conclude that the cause of both deaths was most likely related to the motor vehicle collision and subsequent ignition, with inhalation of smoke and thermal injuries sustained in the fire. The presence of soot in the airways confirms that both men were still alive when the fire started, and the cherry-red discoloration with elevated
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carboxyhaemoglobin levels suggests that CO inhalation contributed to these deaths.
Police investigation: A coronial investigation by police found no suspicious circumstances surrounding these deaths.
Circumstances: The driver and passengers were work colleagues working on various building projects in Jabiru. Having started work at 6 am, they signed off work at about 1 pm on Thursday, 28 March 2024, at the start of the Easter long weekend.
The three men left the Jabiru Sports Club in a white Toyota HiAce van. At that time, the driver and both passengers were in the front seat. The van had a bench seat at the front that could legally carry three occupants. The rear of the van was designed for cargo transport and had been modified to carry tools of trade.
They attended the Jabiru Service Station where they fueled up the van and bought a bag of ice for their beer. When they departed the service station to travel to Darwin, the surviving passenger moved to the rear cargo area and sat unrestrained on a makeshift chair.
About 30 - 40 minutes later they stopped at the South Alligator River and fished a culvert for about 10 minutes. They were seen by a Park Ranger who waved to them as he drove past. He did not see them drinking but did observe 'middy' and VB beer cans next to them while they were fishing. A short time later the three men continued their travels towards Darwin. According to the surviving passenger, it was at this time that they began drinking as the beers had sufficiently chilled from the ice purchased earlier from the service station in Jabiru. The surviving passenger said he was drinking Carlton Dry Stubbies, the other two were drinking VB, and they had each consumed three rounds before the crash.
A short time after leaving the culvert, the van stopped for roadworks for approximately 5 minutes.
There were a number of cars stopped, and one of those was a Toyota Hilux. Shortly after passing through the roadworks, the driver of the Hilux was overtaken by the HiAce “going very fast”. This was confirmed by the surviving passenger who said the driver always liked to speed and they were travelling at 160 km/h.
At about 2pm a family were travelling in a Ford Ranger towards Jabiru. They were approaching the HiAce from the opposite direction along a straight stretch of road. The HiAce was about 100 metres from the Ford Ranger when it quickly drove across the lane in front of the Ford Ranger and off the road. It crossed the dirt and travelled into the bush. The driver of the Ford Ranger said that he did not see any signs of tyre deflation or the van swerving in the lead up to this maneuver and instead described the van as leaving the road as though the driver was purposely driving to a known dirt track.
However, the surviving passenger said that he heard a loud pop and believed it was the rear left tyre popping. He felt the van drop and jump on the road for a period before veering to the right. He said the driver applied brakes straight away.
The van continued into the grassy scrubland where it vaulted off a mound of dirt and became airborne before hitting a tree causing it to roll and land on its roof. The vehicle came to rest in bushland approximately 15-20 metres from the Arnhem Highway.
The family in the Ford Ranger stopped to render assistance and called 000 at 1.55pm.
Other passers-by also stopped and together they attempted to gain access to the van, but it caught alight and became engulfed in flames. Due to the intensity of the fire they could not render any assistance to the two men who were trapped and killed in the vehicle.
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A nurse passing by also stopped and assisted the surviving passenger who had managed to get out through the damaged back door. He suffered non-life threatening fractures and injuries consistent with a motor vehicle crash.
First police on the scene arrived at 2.46pm and a crime scene was established.
Road Features and Conditions: The crash occurred approximately 92 kms west of Jabiru.
At that point, the Arnhem Highway was a straight sealed dual lane carriageway, divided by a single broken white line, with a single lane for traffic in each direction. The posted speed limit was 130kp/h.
The road was lined on either side by a gravel/grassy verge that leads to foliage and trees.
There was no noted road surface damage at the crash location, though multiple witnesses described the Arnhem Highway to be in generally poor condition with numerous sections of potholes that required evasive action. The surviving passenger described the road as “fucked”. He said that the HiAce hit potholes after passing through the roadworks and they could not be avoided because of oncoming traffic.
It was day time, the road surface was dry and the sun's position was not likely to be a factor in the crash.
Vehicle Inspection: The vehicle was unable to be inspected due to being destroyed by fire. However, reports obtained from the vehicle owner confirmed the following:
• The vehicle had four tyres fitted on 24 October 2022. Tyres fitted to the vehicle were 195R15 106/1045 8PRLT MAXPRO GT RADIAL. The speed index on these tyres is 180kp/h. A further tyre of the same specification was fitted to a loose rim on 16 February 2024.
• On 24 October 2022 the odometer on the vehicle was 236,093kms.
• The vehicle had been serviced on 21 September 2023 at 251,461kms. Noted during the service was an oil leak around the filter housing.
• On 25 March 2024, the driver commenced the vehicle weekly checklist and noted the odometer reading to be 262,347kms. He completed the checklist until Wednesday 27 March 2024. Nil issues were noted with the vehicle's tyres during these checks.
Tests and/or Calculations Conducted: Due to the vehicle being destroyed by fire, investigators were unable to access and image the Event Data Recorder. A desk top analysis of the rear left tyre friction mark left at the scene confirmed that the vehicle was travelling at a speed of approximately 164km/h at the time it entered a clockwise yaw.
Opinion as to the Cause of Crash: Based on scene evidence, witness statements and Police investigations the crash investigator concluded:
• The driver had consumed a quantity of alcohol whilst driving, however, was not over the legal limit.
• The van was travelling at approximately 164km/hr at the time it entered a clockwise yaw,
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before leaving the road.
• For an unknown reason the van has left the road at speed. The surviving passenger reported a possible tyre blow out, however, there was no scene evidence to support this theory. No tyre fragments were located relevant to the crash and no scuff marks or gouges were identified on the road surface.
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Selected photographs courtesy Major Crash investigations The tragic deaths of these two men took the Northern Territory’s shocking road toll to 17 in 2024 as compared to 3 road deaths at the same time in 2023.
The driver is survived and mourned by his fiancé, his step-child, his parents and two siblings and his extended family, friends and colleagues.
The front seat passenger is survived and mourned by his defacto partner and child, his former partner and their child, his parents and four siblings and his extended family, friends and colleagues.
Decision not to hold an inquest: Under section 16(1) of the Coroners Act 1993 (“the Act”) I decided not to hold an inquest because the investigations into the death disclosed the time, place and cause of death and the relevant circumstances concerning the death. I do not consider that holding of an inquest would elicit any information additional to that disclosed in the investigation to date and the circumstances do not require a mandatory inquest because:
• The deceased persons were not, immediately before death, persons held in care or custody; and
• The deaths were not caused or contributed to by injuries sustained while the deceased persons were held in custody; and
• The identity of the deceased persons is known.
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