Deceased
Todd Andrew Carver
Demographics
42y, male
Date of death
2014-07-13
Finding date
2021-07-02
Cause of death
Asphyxia due to traumatic compression of the chest and airway caused by roof collapse of the prime mover cabin after rollover
AI-generated summary
Todd Andrew Carver, a 42-year-old truck driver, died in a rollover of a prime mover and fish tanker on Esperance Coast Road, Tasmania on 13 July 2014. He died of asphyxia when trapped in the crushed cabin. The investigation found the primary cause was excessive speed through a curve—the vehicle exceeded the rollover threshold by approximately 1 km/h. A partially-laden trailer (75-85% full) with movable ice slurry and fish created dynamic load instability that contributed to the rollover. The coroner rejected an engineer's theory about suspension defects as unsupported and based on incorrect assumptions. Training deficiencies were identified: Mr Carver received insufficient, poorly documented training on handling dynamic loads and rollover prevention for this high-risk route. The coroner concluded that while additional training might not have prevented this specific rollover, better training in load dynamics and rollover awareness could have reinforced safer driving habits. Key recommendations included mandatory rollover awareness modules, specific safety guidelines for dynamic loads, probationary performance reviews, and regular refresher training.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
FINDINGS, COMMENTS AND RECOMMENDATIONS of Coroner Olivia McTaggart following the holding of an inquest under the Coroners Act 1995 into the death of:
Table of Contents
Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Todd Andrew Carver, with an inquest held at Hobart in Tasmania, make the following findings.
Hearing dates 16-18 December 2020 and 18 February 2021.
Appearances Counsel Assisting: S Nicholson Counsel for West Coast Transport Pty Ltd as trustee of the West Coast Transport Unit Trust trading as De Bruyn’s Transport (“De Bruyn’s”): K Read SC Counsel for Hendrickson (Asia Pacific Pty Ltd) Trucks (“Hendrickson”): S Knight Counsel for Fiona Carver: A Kendall Introduction
Todd Andrew Carver, aged 42 years, died in the course of his employment as a truck driver for De Bruyn’s Transport. On 13 July 2014 he was driving a prime mover and laden fish tanker (together called “the vehicle”) northbound on Esperance Coast Road when the vehicle suffered a rollover, leaving the road on the opposite side and travelling over a steep embankment.
The coronial investigation was finalised on 8 October 2015, when Coroner Stephen Carey handed down his findings without holding a public inquest. Coroner Carey’s finding is attached to this finding. Coroner Carey determined that the cause of the crash was the effect of the speed of the vehicle exceeding the rollover threshold for the stretch of road in question. He determined that Mr Carver died of asphyxia when he became trapped in the cabin of the prime mover after the rollover.
On 5 February 2018, more than two years after Coroner Carey’s finding, one Dr Arnold McLean, engineer, wrote to Coroner Carey (then retired) seeking the re-opening of the investigation. Dr McLean asserted in his letter that there was a safety issue with air suspension
systems of the type fitted to the prime mover driven by Mr Carver and this issue caused or contributed to the rollover and Mr Carver’s death.
Dr McLean described that, just before the rollover, Mr Carver had operated the vehicle in low gear and with high torque without braking, and in that state, the air suspension exhibited the phenomenon of “frame rise” which meant that the pressure in the air spring was “void” and therefore the suspension would have had minimal roll resistance. With reduced roll resistance, the vehicle entered into a rollover on the curve in question.
Upon receipt of Dr McLean’s correspondence, I obtained, as delegate of the Chief Magistrate under the Coroners Act 1995 (“the Act”), the completed investigation file.
Upon reviewing the evidence upon which Coroner Carey based his findings, it was apparent that Dr McLean had not provided evidence in the original investigation nor had the issue raised by him been considered. It was unclear to me at that time how Dr McLean came to be in possession of considerable investigative information about the circumstances of the rollover so as to form his opinion.
It was also apparent that Mr Carver died as a result of an accident or injury that occurred at his place of work and his death was not due to natural causes.1 In such a case, a public inquest is mandatory – except if the senior next of kin (as defined in the Act) requests the coroner not to hold an inquest and the coroner is satisfied that it would not be contrary to the public interest or the interest of justice if the inquest was not held.2
Mr Carver’s senior next of kin is his wife, Mrs Fiona Carver. Unfortunately, in the original investigation, Mrs Carver was not sent written notification as required by section 26A of the Act that a decision had been made to hold an inquest and the reasons for that decision. Having not received such notification, she did not appreciate that an inquest was mandatory. It is only upon receipt of such written notice by the senior next of kin that the coroner may dispense with the holding of a public inquest under that section. I am satisfied that Mrs Carver would not have provided written notice requesting the coroner not to hold an inquest.
Coroner Carey then finalised the investigation with an in-chambers finding, overlooking the requirement to hold an inquest or to write to Mrs Carver as required by the Act.
1 Sections 24(1)(ea) and 26A, Coroners Act 1995 (Tas).
2 Section 26A.
When Mrs Carver was advised of the receipt of Dr McLean’s request to re-open the investigation, Mrs Carver also indicated that she sought re-opening on the basis that she had concerns about Mr Carver’s experience in driving heavy combination vehicles with liquid loads as well as concerns about De Bruyn’s standard of vehicle maintenance.
On 1 October 2018, after hearing from the interested parties, I made an order as the Delegate of the Chief Magistrate under the Act that the investigation be re-opened and the findings be re-examined by myself on the basis that the investigation was compromised by procedural irregularity and also that facts or evidence affecting the findings had come to light.3
Given the requirements of section 26A, I determined that a public inquest should be held, with the following issues to be examined: a) The factual circumstances of the crash; b) Causation for the crash, including whether the issue postulated by Dr Arnold McLean (regarding the vehicle having minimal roll resistance at the time of the crash due to particular characteristics of its air suspension) is relevant to causation; and c) An examination of the adequacy of Mr Carver’s training in operating the vehicles provided in the course of his employment with De Bruyn’s.
For the following reasons I find, as did Coroner Carey, that the cause of the rollover was that the vehicle driven by Mr Carver exceeded the rollover speed for the road. I find that there was no defect, fault or safety issue associated with the air suspension system on the prime mover as postulated by Dr McLean that contributed to the rollover. For the following reasons, I find that there were aspects of the training of Mr Carver that required improvement, although I cannot find as a fact that these training issues contributed to his death.
Evidence considered in the re-opening and re-investigation
The evidence to which Coroner Carey had regard in the original investigation is attached to this finding.
Also attached is the exhibit list of the documentary evidence to which I have had regard in the re-opened investigation. The additional documentary exhibits (over and above the original documentary exhibits) comprised documents regarding the air suspension system on the prime 3 Section 58(1)(b) and (d).
mover; documents from De Bruyn’s regarding induction, training and safety procedures; documents authored by Dr McLean; affidavits of De Bruyn’s management personnel; reports from two crash analysis experts, John Ruller and Shane Richardson, regarding the rollover and suspension; driving records for Mr Carver; and an additional affidavit of Mrs Carver.
Mr Carver’s background
He spent his adolescent years in the Dover area. Mr Carver was married to Fiona Michelle Carver and they have two children. Mr Carver also has two children from a previous marriage.
Upon graduation, Mr Carver was posted to Hobart. He served at Maydena, Glenorchy, Eastern District Traffic, Kingston, Tasmania Police Academy, Queenstown and the Police Radio Room.
Whilst at the Police Academy, Mr Carver was an operational skills instructor in charge of driver training. This training included instruction for all vehicles driven by police officers in Tasmania Police. This training is centred on instruction in low-risk driving behaviour.
Mr Carver was a passionate motorcycle enthusiast and completed the Tasmania Police Motorcycle Course in March 2000. From that date onwards he was involved in riding police motorcycles in roles requiring high levels of skill.
Mr Carver resigned from Tasmania Police in August 2011 and in October 2011 he gained employment driving trucks for De Bruyn’s, working in suburban deliveries. Mr Carver drove for De Bruyn’s for almost 12 months at that time.
Mr Carver left De Bruyn’s and began working for Driver Safety Services as a driver trainer and assessor. During this time, Mr Carver trained De Bruyn’s drivers in the TruckSafe program.
While at Driver Safety Services, Mr Carver obtained his heavy combination licence, enabling him to drive a prime mover or truck towing a trailer.
Commencement of employment on the fish run
On or about 17 November 2013, Mr Carver returned to employment with De Bruyn’s to drive heavy combination vehicles on the ‘fish run’. This involved Mr Carver driving prime movers and laden fish trailers at night between Port Huon and the premises of Huon Aquaculture in Hideaway Bay. The route driven was along Esperance Coast Road, a distance of approximately 20 kilometres. Esperance Coast Road is a narrow road with a single lane in each direction and not constructed for heavy vehicular traffic.
As part of the fish run, Mr Carver was required to have ice slurry, a mixture of ice and salt water, loaded into the empty trailer at Port Huon before driving to Hideaway Bay where fish were added to the trailer. Once the fish had been loaded into the trailer at Hideaway Bay, Mr Carver drove the same route back to Port Huon where the trailer was filled with more ice slurry. The trailer load of fish and slurry is then delivered to the fish processing factory at Parramatta Creek in north west Tasmania. It was not Mr Carver’s job to drive to Parramatta Creek with the full tanker.
Circumstances of death
On Sunday, 13 July 2014 after sleeping in until approximately midday, Mr Carver had lunch with his family at their home and then spent time with his family, playing with his children at a local park. After returning home he had his evening meal at about 6.00pm, got ready to go to work, and after helping his wife prepare their children for bed he left for work.
He commenced work at 7.15pm at his employer's depot (De Bruyns Transport) at Gormanston Road, Moonah. He left the depot at 7.36pm driving a Mack Trident Prime Mover registration number C97JY which was towing a Tieman Fish Tanker registered number Z46PO. Mr Carver has driven this vehicle to Port Huon, arriving at approximately 8.30pm and the tanker was loaded with approximately 4,000 litres of ice slurry. He then left Port Huon and travelled to Hideaway Bay leaving at approximately 9.00pm. He arrived at Hideaway Bay at 9.24pm and positioned the Prime Mover and Tanker in order to allow it to be loaded with fish. He has then gone to the crib room to await the loading of his vehicle at which time he spoke to a fellow driver, Mr Leon Fewkes. Mr Fewkes reports that Mr Carver was relaxed and appeared to be in a good frame of mind and they discussed general family matters. Mr Fewkes asked Mr Carver what time he had to be back and his reply was "a couple of hours" which means he had plenty of time to perform his delivery task.
Mr Carver has left Hideaway Bay with his load at 11.08pm and began travelling back to Port Huon. The police investigation has determined that Mr Carver has driven a distance of approximately 4km north-bound along Esperance Coast Road at which point he was driving down a slight incline and has commenced to negotiate a closed left-hand curve. The trailer has started to move out to the right-hand side of the corner and has gone over an embankment on the eastern side of the road with the weight and rotation of the trailer causing the Prime Mover to flip onto the driver's side. The truck and trailer have slid down the embankment with the cabin striking an Aurora power pole and trees, roof first. The truck and trailer have come to rest in close proximity to one another approximately 15m down the embankment.
Phillip Holland, a fellow driver, had arrived at the Port Huon yard at around 11.00pm, hooked up a trailer and put ice slurry in and left the yard at approximately 11.07pm. In the course of his
journey towards Esperance Coast Road, he had attempted via his UHF radio to contact Mr Carver as, in normal course, he would pass his truck coming in the other direction on the Esperance Coast Road. Such contact was the normal course in order that both drivers could prepare to pass safely when they met on Esperance Coast Road. Mr Holland was unable to contact Mr Carver and proceeded along Esperance Coast Road with his speed reduced as he did not know where the other vehicle, being driven by Mr Carver was, on the roadway. As he rounded a right-hand corner before the accident scene, he could see truck lights but it was not until he arrived at the scene that he realised the truck had been involved in an accident and was located down the embankment. He immediately called the fish farm and informed them of this, requesting that ambulance, police and SES be notified. He thereafter went down to the damaged truck and called out for Mr Carver as he was unaware of whether he was in the vehicle or had been thrown clear. He then located Mr Carver, seated in the vehicle, but could not gain access to him nor could he get any response from him. A number of persons from the fish farm attended the scene and attempted to gain access to the vehicle to get Mr Carver out but without success.
Police officers arrived at the scene at about 11.55pm. I/C Constable Silk noted that the rear window of the Prime Mover had come out and he could see the left side of the driver in his seat, pinned by the roof of the truck. He attempted to find a pulse by checking the driver's neck and left wrist but could not find one. He then looked through the driver's window and observed that Mr Carver's eyes and mouth were open and there appeared to be no signs of life. He noted that Mr Carver was facing to the right as the roof was pressing down on the left side of his face and head and the roof had also compressed onto his chest area. A Tasmanian Fire Brigade unit arrived at the scene and fire officers and SES personnel took steps to disconnect the vehicle battery as it was noted fuel was leaking from the driver's side fuel tank. Ambulance personnel arrived at the scene at 12.10am and the attending ambulance officer confirmed that Mr Carver was deceased.
Attending police identified the extent of the crash scene and secured that area with Tasmanian Police Forensic Services and the Crash Investigation Service officers arriving later to commence a formal investigation of the accident.
The post-mortem identified that Mr Carver had marked congestion of the upper chest, face and head but only superficial injuries of the face and body. There was congestion of the eyes and scatter petechiae on the lower eyelids. Copious food debris was located within the airways. Fatal traumatic injuries were not identified externally or internally; however aspirated food was identified in the lungs. The conclusion from these findings were that Mr Carver had succumbed to traumatic/positional asphyxia that occurred when the roof of the cab of the truck was compressed
onto his upper body when it rolled down the embankment. The position of the head and airway prevented normal respirations leading to death by asphyxia.
When the roof cabin was removed to allow Mr Carver to be extricated from the vehicle he was sitting in his normal driving position with his seatbelt on. His right and left hands were positioned as if they had still been on the steering wheel when it came to rest. There was no indication that he had made any attempt at moving his position after the crash which indicates that he was unconscious after impact.
Coroner Carey’s further findings
There was no evidence to suggest that Mr Carver’s speed leaving Hideaway Bay was inappropriate or excessive and that Mr Carver would not have been aware of the critical curve speed or rollover speed. He noted that, in the case of liquid loads, drivers could not know in advance the exact rollover speed, due to the number of variables in play on each individual journey.
That airbag suspension, such as that fitted to the prime mover, was stable and more comfortable to drivers than conventional leaf style suspension. However, airbag suspension divorces the driver from the feel of the road.
That since the rollover, the shoulder of the road has been extended and six guide posts have been placed around the curve. Additionally, a 35 km/h advisory sign has been erected at that corner.
Coroner Carey recommended that there be compulsory training in rollover preventions for all persons licenced to drive heavy rigid vehicles who are exposed to such a risk.
Coroner Carey also recommended that there be consideration given to inserting some form of baffle, at least transversely, in order to minimise the slosh and surge effects of the load within a trailer with a single open chamber.
Causation for the crash
The original crash investigation by Senior Constable Kelly Cordwell and Sergeant Rodney Carrick was very thorough. In the re-investigation, I also had the benefit of the opinions of two further highly qualified experts who provided evidence regarding the rollover. They were Dr Shane Richardson, experienced mechanical engineer, and Mr John Ruller, experienced road crash investigator and collision analyst. Both experts provided very detailed reports reconstructing the crash circumstances after attending the collision location and reviewing the documentary evidence and Electronic Brake System (EBS) data from the trailer.
Both Dr Richardson and Mr Ruller provided logical and detailed analysis of the evidence and of the conclusions of the original crash investigators. Their conclusions concerning the essential factors causing the rollover were not challenged at inquest by any counsel.
From their evidence, I am able to find that the rollover occurred because Mr Carver was travelling through the curve at a speed that was too high for the radius through which it was turning and for the load which it was carrying. That is, if Mr Carver had travelled at a slower speed or driven a wider turn radius the rollover would not have occurred.
Like Coroner Carey, I am satisfied upon the evidence that Mr Carver was travelling at a speed only just over the rollover threshold speed.
EBS is a sophisticated system containing sensors that detect the stability of the trailer as measured by lateral acceleration. The system may assist in maintaining the stability of the trailer by the automatic application of brakes. It may predict, for example, that a rollover is about to happen and apply the brakes differently to particular wheels in order to prevent that occurrence.
On the basis of the expert evidence about the EBS data, I am able to find that the speed of the vehicle just before rollover was approximately 39 km/h. At the time of this speed being recorded the system showed that there was a “slow wheel recovery”, indicating that a wheel had slowed and then not sped up as the EBS would expect. At this time, the system was powered up, the warning light was on and there was no foot pedal brake applied. Within three seconds of the slow wheel recovery, the speed of the vehicle was shown at 0 km/h and the lateral acceleration signal was activated. It appears that, at this stage, the rollover was taking
place with the wheels stopped and/or in the air.4 Dr Richardson provided a particularly detailed and technical analysis of the EBS data in coming to his conclusions.
Issues associated with liquid or movable loads
It is well-recognised that liquid or movable loads carried in trailers or tankers can contribute to rollovers. The load carried by Mr Carver was not liquid but I am quite satisfied that it was movable or dynamic. When the tank is full, very little load movement is possible. However, when the tank is only partially full and experiencing a lateral acceleration by cornering, the load will shift sideways. This sideways movement or “slosh” also causes the centre of gravity of the vehicle to shift sideways which reduces its rollover stability. In general terms, the larger the air gap, known as “ullage”, the greater possibility for the dynamic load within the tank to slosh. If the trailer was full the driving issue caused by ullage is removed.5
The trailer driven by Mr Carver had a capacity of 30,000 litres. About 4,000 litres of ice slurry was loaded into it at Port Huon after which Mr Carver drove to Hideaway Bay. At Hideaway Bay there was 3,731 fish placed into it, being a mass of approximately 18,000 kilograms.
Therefore the load of the trailer equated to about 22 tonnes at the time of Mr Carver’s fateful journey from Hideaway Bay to Port Huon. This known mass does not allow an easy calculation of ullage. However, upon the evidence, it is most likely the case, upon the estimation of experienced witnesses, that the trailer was between 75% and 85% full, with 15% to 25% ullage.6 Both Mr Ruller and Dr Richardson were of the opinion that the ullage cannot be precisely known.
5 Transcript, page 33, Mr Ruller’s evidence.
6 For example, C 42 Affidavit of Jan De Bruyn, paragraph 90.
7 C 8, Affidavit of Phillip Holland.
Bruyn, it was not a large load of fish and the tanker could have held a lot more. He noted that Huon Aquaculture harvests to order, and therefore determines the quantity of the loads.8
I am satisfied that the degree of ullage in the trailer posed a risk of instability that contributed to the rollover. Dr Richardson accepted that there could have been some slosh proportional to the air gap in the tanker9 but doubted that the phenomenon of “surge” was in operation due to the likely lack of longitudinal movement of the load at the time of the rollover.
Finally, I accept the evidence of both experts that the tanker, being more unstable with a lower roll threshold than that of a prime mover, rolled first. The speed, the path travelled, slope of the roadway on the exit of the curve and the movement of the load all caused the tanker to roll, also dragging the prime mover containing Mr Carver into a rollover.
Mr Ruller observed that that the tyre marks from the prime mover ceased on the bitumen surface and no such marks were made in the soft ground of the embankment. Further, the fibreglass shavings embedded on the road surface also indicate that the prime mover rolled over onto its right side on the road surface, having been brought onto its side by the rolling trailer. He noted that a prime mover has a much higher roll threshold than that of a loaded trailer and that the learning shows that it is inevitably the trailer that commences to roll in such circumstances. He said that, as it does, the movement in the fifth wheel connection (between the prime mover and trailer) is taken up. Until that time a driver will most likely be unaware of what is about to occur. He stated that once the movement in the fifth wheel has been taken up, the rolling trailer will start to lift the prime mover and eventually take it over.
In the case of the prime mover driven by Mr Carver, its cabin came into contact with the power pole and trees as it was pulled over by the trailer and down the embankment. This resulted in the cabin being crushed and the death of Mr Carver.10 Other possible causes of the rollover
8 C 42, paragraph 90.
9 C 40, page 34.
10 C 37, paragraphs 192, 193 and 194.
Dr McLean’s opinion
In his letter to Coroner Carey of 5 February 2018, Dr McLean asserted that unsafe characteristics of the air suspension on the prime mover driven by Mr Carver contributed to the rollover. In forming his opinion, he relied particularly upon the fact that the prime mover was fitted with a Hendrickson HAS 400 floating “Z” link tandem drive air suspension, which model was instrumental in rollovers.
It is worth setting out the section of his letter that explains the essence of his opinion: Post passing the Huon Charm Waterfront Cottage at 572 Esperance Coast Rd, in the northerly direction, Mr Carver’s vehicle ascended a relatively steep windy section of the road of some 300 metre (sic) in extent. During the ascent the prime mover would have been operated in a relatively low gear to apply sufficient torque to the drive wheels to cause the vehicle combination to ascend the road grade. During this drive wheel high torque operation phase the tandem axle air suspension would have exhibited the phenomena of frame rise. Subject to frame rise the tandem axle air suspension air springs implode and post sufficient time become completely deficient in air pressure.
Hence when Mr Carver's prime mover reached the crest of the climb (at approximately the northern boundary of No. 564 / 537 Esperance Coast) the tandem drive air suspension air pressure was void. With the air pressure in the air springs void the prime mover's tandem drive suspension would have exhibited minimal roll resistance.
Post the ascent crest Mr Carver’s vehicle travelled at relatively slow speed along a relatively high quality surface for some 300m (3 off power pole spaces approximately). Mr Carver allowed his vehicle to operate passively along this section of road so much so that he did not need to apply brakes entering the subject accident left hand curve. Here it should be noted it is common practice for semi trailer drivers not to apply brakes to avoid the risk of the articulated vehicle jack knifing.
This brake application avoidance was particularly strong for yesteryear trained and experienced mechanical suspended prime mover drivers.
Unbeknown to Mr Carver the tandem drive air suspension frame rise was locked in. Furthermore it is blatantly evident the subject left hand curve was the first curve post a substantial sustained positive torque application (as occurred when the prime mover ascended the previous grade). This combination of variables so exposed the combination to high risk of loss of control according to air suspended heavy vehicle accident scenario # 3 previously reported by the undersigned. Most concerning prime movers installed with HAS suspensions, particularly HAS 400 suspensions, exhibit high accident risk in the stated accident scenario. (In comparison Volvo prime movers which incorporate significant torsion bars (or anti roll bars) to assist develop the suspension’s roll resistance exhibit high statistic in accident scenario # 2.) Since Mr Carver did not dab the prime mover brakes or briefly apply the trailer brakes the tandem drive axle group suspension frame rise remained locked in as he applied left hand lock to negotiate the left hand curve. (Had Mr Carver dabbed the prime mover brakes for a brief instant (sufficiently short to avoid the incidence of jack knifing the suspension frame rise state would have been cancelled. Had Mr Carver dabbed the prime mover's brakes just prior to entering the subject corner he would still be alive.)11
The impact caused the trailer to separate from the prime mover and to subsequently roll down the embankment.
Dr McLean ended his letter by expressing concern that should the true cause of Mr Carver’s death not be identified and reported, ongoing serious and fatal accidents would continue unabated in Tasmanian road haulage activities.
Dr McLean subsequently provided further evidence in the re-investigation, including a paper authored by him for the 2009 Australasian Transport Research Forum entitled “Suggested Heavy Vehicle Air Suspension Contribution to Fatal Accident Statistics and Signatures”.12 He also swore two affidavits providing his opinion as to the cause of the rollover. In the affidavits, he 11 Exhibit C 36.
12 Exhibits C 36A and C 36B.
maintained that the issue that he raised in his initial letter remained a cause of Mr Carver’s rollover.13
Additionally, three reports were tendered at inquest by counsel for De Bruyn’s that were previously authored by Dr McLean and provided to Wallace Wilkinson & Webster Lawyers in 2016 and 2017.14 It is apparent that that firm had previously retained Dr McLean on behalf of De Bruyn’s in the context of civil proceedings associated with Mr Carver’s death. Such civil proceedings are not the concern of this inquest. I note, however, that Dr McLean did not reveal in his initial correspondence to the Court that he had been retained by Mr Carver’s employer, that he had been provided with investigative information as part of that retainer and that he had authored these three reports. The fact of his prior involvement only became known to me during the re-investigation period, when De Bruyn’s solicitor provided that information to the Coronial Division.
Dr McLean’s first two reports prepared for Wallace Wilkinson & Webster appear to affirm his opinion regarding the contribution of the airbag suspension to Mr Carver’s death for the same reasons given in his initial letter to the Court. His third report deals solely with his opinion that the risk of a loss of control would have been significantly reduced had the prime mover been fitted with a standard HAS 460 air suspension system and not an HAS 400 suspension.
Difficulties with Dr McLean’s evidence
For the reasons set out below, I discount his opinion as being relevant to Mr Carver’s death.
Significant issues arise in respect of his qualifications and experience, the facts assumed by him, his impartiality and his credibility.
Lack of evidence of qualifications
14 Exhibits C 55-56.
documents tendered in evidence. In his initial letter, he did not provide details of his expertise and the only indication of his qualifications were letters following his signature, these being “PhD (UoW), BE Hons 1 (UNSW), CPE, FIEAust, MASME, MACRS”.
Incorrect assumed facts
Dr McLean did not undertake any comprehensive analysis of the scene evidence similar to that completed by Mr Ruller and Dr Richardson. Those experts set out fully and clearly their reasoning regarding the occurrence of the rollover, with both in substantial agreement as to how it happened. It is clear to me that as a matter of logic, sound expert opinion and evidence at the scene, that the partially laden trailer (with its lower roll threshold) rolled first and irretrievably and, as it did, it caused the prime mover to flip over on the road.
It is contrary to the scene evidence and expert crash analysis to find that the prime mover, by virtue of its state of frame rise, instigated the rollover. Yet Dr McLean maintained that this was the case, even in his oral evidence after presumably having considered the carefully reasoned and comprehensive reports of Mr Ruller and Dr Richardson, whose views were to the contrary. He stated in answer to a question from counsel assisting that if the prime mover had not been subject to frame rise, it would have remained upright and would have been able to contain the roll of the trailer.16
Dr Richardson, Mr Kramer and Mr Ruller all provided evidence that they were not familiar with the phenomenon postulated by Dr McLean.
Mr Kramer stated that he had been to many crashes and incidents and liaised with many industry personnel in a period of over 30 years in the industry. He said that he had not heard 15 C 38, page 1.
16 Transcript, page 95.
of frame rise in the context of Dr McLean’s theory and had not encountered any incidents where it was said to have caused such an issue.17
He said there had been none. This was subsequently confirmed in the affidavit filed on behalf of Hendrickson.
Although he was not familiar with Dr McLean’s theory, his analysis is helpful. He has an extensive educational and research background in traffic crash investigation and reconstruction, combined with over 36 years of practical experience involving reconstruction of over 1000 serious and fatal traffic collisions.
Mr Ruller stated that it would more likely be the case that once the vehicle reached the crest and the drive wheel torque reduced so too would the frame rise. Thus the ride height would once again drop back to normal and air returned to the suspension. He questioned how frame rise could be “locked in” once torque is no longer applied to the drive wheels, considering the vehicle travelled down a -2% gradient road slope – in this regard, he said that graphs indicate that as speed increases, frame rise decreases.
In relation to the circumstances of the rollover, Mr Ruller analysed inaccuracies in Dr McLean’s purported reconstruction. He made particular mention of Dr McLean’s incorrect belief that the tyre scuff marks leading into the curve were caused by the outside steer tyre of the prime mover. Mr Ruller stated, and I accept, that the scuff marks were those made by the outside tyres of the trailer. I accept Mr Ruller’s view that Dr McLean has formed his opinions on a research paper that is based on statistical data only and he has not critically evaluated the physical evidence left as a result of this crash.
It defies logic to find that when the trailer initiated the rollover, with its momentum taking the prime mover over with it, the suspension system on the prime mover could have made any difference to the tragic outcome.
Dr Richardson stated in evidence that he had previously heard of the theory propounded by Dr McLean and understood some of the issues involved. However, he said that Dr McLean had 17 Transcript 17.12.20, page 37.
provided no objective evidence to support his assertion that the tandem drive air suspension frame rise was “locked in”. He stated that “in the absence of any objective evidence to support his assertion, the Author accepts that Dr McLean’s premise is an unproven theory based on a belief that Dr McLean has. The Author disagrees with Mr (sic) McLean with respect to the cause of this rollover, especially given that Dr McLean appears to have failed to reconstruct the crash circumstances, attend the collision location and/or evaluate the EBS data.”18
What was the make and model of the suspension system fitted to the prime mover?
Importantly, Dr McLean asserted that it was a Hendrickson HAS 400 air suspension, fitted to Mr Carver’s prime mover, that contributed to the rollover and that this model suffered particularly from the safety issue he describes. By way of explanation, the HAS 460 possesses a vertical load capacity of 46,000 pounds, whilst an HAS 400 model suspension has a vertical load capacity of 40,000 pounds.
The tax invoice for the purchase of the Mack prime mover described the suspension fitted to the rear axle of that vehicle as “AL 460”.20 The AL460 suspension is made and designed by Mack. Mr Kramer gave evidence that the system appeared to be a "Hendrickson type", and Mr De Bruyn gave evidence that he was of the view that at least some Hendrickson components had been used in the suspension system. However, he seemed to accept the proposition that Mack had designed and engineered the system and fitted products from different manufacturers.21 There was no comprehensive documentary evidence of the details of the design and composition of the system’s components available at inquest.
Mr Richardo Martin, Vice-President of International Operations of Hendrickson, swore an affidavit after the completion of the oral evidence at inquest. He stated that it appeared that some Hendrickson components may have been used in the suspension system fitted to the prime mover, but it is not clear whether all of the components were Hendrickson. He stated that Hendrickson had no evidence to confirm that it designed and engineered the air 18 C 40, page 59.
19 Transcript, page 53.
20 Exhibit C 46.
21 Transcript 16.12.20, page 29, lines 20 – 25.
suspension system for this particular model of Mack prime mover. He said that it was likely that Mack, or some other company acting for Mack, had undertaken the design and engineering work for the air suspension system for the prime mover. Counsel for Hendrickson submitted that for it to be a Hendrickson air suspension system, it should not only comprise Hendrickson components, but be engineered and designed by Hendrickson for use in the particular truck to which it is fitted. He submitted that it does not follow that just because some Hendrickson components had been used, that it was a Hendrickson system designed and manufactured by it for use in that vehicle. Such submission has force. Dr McLean did not touch upon this issue.
Therefore, the evidence suggests that there may have been some Hendrickson components in the air suspension system fitted to the prime mover, but that it is quite feasible that not all were Hendrickson components. It is quite plausible on the evidence that the air suspension system was not designed and engineered by Hendrickson.
Although the exact composition of it is unclear, it is beyond doubt (as confirmed by the documentation) that the suspension was a 460 model. Mr De Bruyn, in evidence, was adamant that a 400 suspension was not fitted to the prime mover, stating that this model was unavailable and unsuitable for the Mack Trident prime mover in question.22
Dr McLean is therefore incorrect in his assertion that the suspension was a 400 model. He did not inspect the prime mover or the suspension system. He made an assumption that it was an HAS 400 model and based his opinion on that assumption. He asserted in written reports that the Hendrickson HAS 460 system should have been used instead. 23 Therefore, the 460 suspension system which he said should have been fitted to the Mack, was in fact fitted to it.
Further, Dr McLean swore two affidavits for this inquest in late 2020. He only sought to have the second one tendered in evidence. The affidavits are very similar but with one exceptionthe first affidavit refers to the prime mover being fitted with an HAS 400 system, whereas the second affidavit removed references to the model of the suspension system and maintained that there were general faults with air suspension systems.
Unconvincingly, Dr McLean also moved away from the importance of the distinction between the 400 and 460 models in his evidence in Court, stating that in the 460 model the problem would still occur24. When counsel assisting put to him that he had previously expressed an 22 Transcript, page 29.
23 C56 Report 31.3.17 24 Transcript, page 95.
opinion that a 460 system would be appropriate for the route in question, he was evasive, argumentative and stated that it was a question of the terminology used and that his words had been taken out of context.25
Counsel for De Bruyn’s and Hendrickson validly questioned whether Dr McLean had provided his various reports in accordance with the Expert Witness Code of Conduct and the Institute of Engineers Australia Code of Professional Ethics.
They also questioned whether he had some commercial motive for his assertions about faults in air suspension systems generally. In this regard, Dr McLean said in evidence: “I can transfer a HAS400, 460 or 461 into a safe suspension system which I have – there are over 850 vehicles on the road in Australia with safe air suspensions and I can convert a HAS to our [indistinct word(s)] and be adequate for our road conditions and especially the [indistinct word(s)] road conditions in Tasmania.”26
Thus, in relation to the make and model of the suspension, Dr McLean’s opinion is largely undermined by two important factors – firstly, the fact that the 460 model suspension actually fitted to the prime mover did not, on his own theory, possess the defects that he articulated.
Secondly, his opinion relied upon the system being a Hendrickson system, when there is good evidence to indicate that it was not designed and approved for the prime mover by Hendrickson but may have contained Hendrickson components.
Manner of giving evidence
He interrupted me and counsel constantly and I was required on several occasions to firmly request that he not interrupt and to respond in a concise and relevant manner.
26 Transcript 17.12.20, page 100.
27 Transcript, page 97.
first air suspended vehicle in 1998. He described Mr Kramer’s report as “grossly deficient” in particular respects and the police accident investigators as being “completely ignorant” in various respects. Such language is inappropriate for an expert and detracts from his credibility.
In Lowe v Mack Trucks Australia Pty Limited28, Justice Kenny of the Federal Court commented in detail upon the evidence of Dr McLean, who provided expert evidence in that case concerning defects in a Mack truck. In his analysis of the evidence, Her Honour dealt with some of the same difficulties exhibited by Dr McLean at this inquest.
Her Honour stated in separate passages of the judgment: “Dr McLean’s evidence did not differentiate between his assumed facts or assumptions and his ‘expert’ opinion. These assumed facts and assumptions were in most cases unproven and untested.
Much of his evidence was virtually incomprehensible, ill-ordered, illogical or manifestly erroneous.”29 …… These assumed facts and assumptions were never properly identified and proven. The inspections and data analysis were shown to be demonstrably unreliably or wrong; the relevant reasoning processes, questionable; and his account disorganised.30 …… A good deal of Dr McLean’s evidence, including both his written report and oral evidence at trial, was incomprehensible, inconsistent and illogical. He could not identify his reasoning, at least not readily, and sometimes not at all. When he did so, the difficulties with it were patent.”31
29 para 206.
30 para 207.
31 para 214.
Training issues relevant to Mr Carver’s death Mr Carver’s experience and competence as a driver on the fish run
I have already discussed Mr Carver’s extensive general experience as a driver and driving instructor. He was appropriately licenced to drive heavy combination vehicles for the fish run, although he had only held that licence for a short time before he started. Before his reemployment with De Bruyn’s he had no experience in driving heavy combination vehicles. It is also unlikely that he had experience driving movable loads.
Before his death, Mr Carver had been driving the fish run for a period of almost 8 months from the commencement of his employment on 17 November 2013. He was regarded as competent and safe. There were no issues of substance with his driving during this period. His driving was undertaken five nights per week with two runs per night. He had driven about 350 runs before his death.32 As discussed above, each “run” involved Mr Carver driving a prime mover and trailer, in various combinations, along Esperance Coast Road between Port Huon and Hideaway Bay.
Training of Mr Carver by De Bruyn’s
He stated that Mr Carver was “fully inducted as a driver” at that time. The records available to me regarding such induction and training in 2011 include an induction checklist signed by Mr Carver and computerised employee record. These indicate that Mr Carver was inducted into various standard procedures and work requirements.
Mr Carver was not required to undertake another driving assessment when he was employed again by De Bruyn’s in 2013 because of his former employment with Driver Safety Services as a truck trainer and assessor and his overall experience. Mr Kroon stated that this was in line with the fact that Mr Carver, himself, was providing training in Certificate 3 driving operations and that was the qualification to which De Bruyn’s training was directed.34
On the day of commencing his re-employment for De Bruyn’s driving the fish run, being 17 November 2013, Mr Carver’s driver log records that he drove the prime mover and trailer from the Hobart depot of De Bruyn’s to Port Huon, then from Port Huon to Hideaway Bay.
At 11.00pm he drove from Hideaway Bay to the Hobart depot.35 There is no indication in that document that he undertook this drive as part of a training run, although the corresponding entry for Mr Fewkes’ driver log on the same date states that Mr Carver drove the vehicle (with him) for about five hours between Hideaway Bay and Port Huon and finally back to the depot in Hobart.36 It is unclear whether Mr Carver was actually a passenger or driver from the wording on this sheet. It is also difficult to reconcile the times recorded on Mr Fewkes’ log with Mr Carver’s for the same day.
By way of explanation, De Bruyn’s had a “buddy system” in place whereby new drivers were allocated to experienced drivers as a passenger and also as a driver for training purposes. In the case of Mr Carver, he was buddied to Mr Fewkes. Mr Fewkes gave evidence that he had Mr Carver with him for three days and gave him advice about driving the fish run. He gave evidence that Mr Carver drove satisfactorily and Mr Fewkes reported this fact to one of the managers. This may be the case but there is no paperwork, apart from Mr Fewkes’ driver log for 17 November, regarding Mr Carver’s buddy training or a record of his assessed performance. There was no system of recording or analysing the results of the buddy training at that time.
The following day, 18 November, Mr Carver was involved in his formal induction process, which took three hours from 1.00pm to 4.00pm. Mr Carver signed the induction check list to say that he had been provided with copies of documentation and equipment. Mr Carver had been required to sign off on several SOPs, many being the same as in his first period of employment.
34 C 41, Affidavit of Ferdinand Kroon, paragraph 6-11.
35 Mr Carver's Driver log 0004457.
On this occasion, he was additionally provided with the SOP entitled Harvest Fish Tank and Bin Operations.37 This covers the operation of loading the tanker hauling the fish. This requires a driver, amongst other things, to monitor the trailer levels of ice, fish and water. It also requires a driver travelling on country roads to observe speed limits, drive to the conditions and approach blind corners cautiously and with reduced speed.
Mr Carver was not required to watch the VicRoads Heavy Vehicle Rollover DVD presentation, Fatigue Management DVD presentation or Forklift Safety Essentials DVD presentation as he was given “recognition for prior learning” in respect of those matters. The VicRoads DVD is a very helpful, and no doubt an effective resource which explains the particularly high risk nature of driving trailers with movable loads. It is difficult to see in the documentation that he did complete this training when he was first employed by De Bruyn’s. I assume the likelihood is that he did so, or even in his capacity as a trainer with Driver Safety Services. In general, I found it difficult to clearly ascertain how Mr Carver’s training took place, the way in which it was done and the documentary components applicable.
Mr Kroon also gave evidence that Mr Carver, during his employment on the fish run, had been subject to some random checks of his driving and no concerns were detected.
Comments on Mr Carver’s training
All of the evidence indicates that special training considerations should apply to those driving this high risk route with dynamic or movable loads.
Mr Ruller stated in his report: “Hauling a movable load is completely different to hauling standard freight.
A professional driver with many years’ experience hauling solid freight and (sic) then switches over to hauling a moveable load can very quickly run into difficulties if not provided with training specifically dealing with such a load.
With a liquid load, the amount of load being carried can change considerably the handling of the combination over the same stretch of road. On one day the load can feel controlled and comfortable while on another, given the amount of produce being carried, can very much unsettle a seasoned driver.
37 C 43A, Induction Checklist 18.11 2013.
A driver needs to know how much load they are carrying and how that load will handle over the roads to be travelled. Otherwise, the overall trip can become a guessing game.
The load can one minute feel stable but the next moment suddenly become very unstable due to some input by the driver. Most drivers will not be aware that there is a problem until such time as they have a wheel lift, by which time it is too late.”38
With respect, I accept the evidence of Mr Ruller, which accords with other cogent industry evidence about the need for strong and targeted training in such circumstances.39
Mr Carver was not driving carelessly or obviously inappropriately before the rollover, evidenced by his moderate speed at the time of the trailer’s wheel lift. It is likely that he did not realise that the trailer was in the process of rollover.
A detailed incident analysis report (“ICAM report”) was prepared by Mr Kroon that identified that the main causes of the rollover were personal to Mr Carver. Regularly throughout the report, Mr Kroon cited “judgment deficiency”, “complacency” and “over-confidence” on the part of Mr Carver.40 Mr Kroon did not consider training as an issue, concluding that it was adequate, particularly in light of his previous driving and driver instructor experience.
Whilst the ICAM report is comprehensive, it emphasises Mr Carver’s personal fault to an unhelpful extent instead of conveying that a rollover may easily occur in circumstances of small deviations in correct speed and driving line where the driver is operating diligently. The report did not expressly refer to or analyse the issue of the contribution of the unbaffled tanker being subject to dangerous lateral forces whilst cornering due to its movable load with significant ullage.
Mr Kroon did refer in the report to the fact that the fish run was a high risk route and noted how easily a rollover event could occur. He did not, however, go on to analyse why that was the case or consider in any depth the exposure of drivers to the particular risks inherent in it.
No doubt this is because of his view that the problem lay almost solely with Mr Carver’s erroneous driving.
39 C 64, Vic Roads Rollover awareness package.
lower speed for that corner but suffered a moment of inattention. However, there was no advisory speed sign at that stage to indicate an appropriate speed and, as Mr Ruller said, Mr Carver needed to judge this for himself on each trip, with the benefit of the “feel” of the load.
These include setting minimum times for driving the fish run, re-inducting employees into the VicRoads Rollover Awareness program and increasing the frequency of driving and stability checks using available systems.
There was, properly, some focus at inquest upon the fact that, despite Mr Carver’s many drives on the fish run, he drove less than five trips with the combination he was driving on the evening of the rollover. Upon all of the evidence, it is unclear whether this fact made a significant difference to his handling of the vehicle before the rollover.
As submitted by counsel for De Bruyn’s, the evidence of Mr Moss and Mr Holland who were experienced drivers, did not support the proposition. Mr De Bruyn said in evidence that a change in prime mover does not make any difference in handling ability, whereas the trailer did make a difference.41 Mr Holland indicated that the other trailer setups and sizes were effectively the same. Mr Moss emphasised that a driver required, in any event, to drive to the load, which was different every day. Mr Fewkes thought that a Volvo cab-over-engine prime mover was safer than a Mack but commented that the job involved driving different vehicles as a vehicle was not personally allocated. I cannot draw any conclusion in respect of whether any unfamiliarity with this combination on the part of Mr Carver contributed to the rollover.
Another issue arising is whether Mr Carver was aware of the level of the load in the trailer when he left Hideaway Bay. There is evidence from Mr Fewkes that Mr Carver was in the crib room whilst the fish was being loaded into the trailer.42 Mr Carver may not have checked the level, or weighed the load, which could have assisted him with stability considerations. There is no documentary evidence to assist on this question.
The evidence of Mr Ruller and Mr De Bruyn, together with De Bruyn’s documented requirements, demonstrate the importance of a driver visually inspecting the level of the load and knowing its mass to assist in determining how to drive safely with that load. Whilst I accept that the requirement of De Bruyn’s is to inspect the fish levels and to ensure that the 41 Transcript, page 80.
42 C 10, Affidavit of L Fewkes.
weight of the load is known (using on-board scales), it is unclear whether these requirements are being routinely complied with. There is no exact record of the mass of Mr Carver’s load as he left Hideaway Bay. There is also some uncertainty regarding the amount of slurry in the trailer, with estimates ranging from 4000 litres to 7000 litres.43
Mr Ruller was of the opinion that training was minimal for this route given the type of load that Mr Carver was expected to haul. He said that “more in depth training may well have given him cause to adjust his driving techniques on this occasion.” 44 This view accords with the affidavit evidence of Wayne Hughes, a retired De Bruyn’s driver, who questioned the adequacy of driver experience on unfamiliar roads with shifting loads. Mr Fewkes was of the opinion that the training for the fish run was too brief and inadequate. Other drivers providing evidence did not take issue with the training. Dr Richardson was of the view that it was satisfactory, given Mr Carver’s driving experience.
In my view, the training provided to Mr Carver was insufficient for the fish run. It was also insufficiently documented. As discussed above, I was not able to ascertain from the driver logs the extent of Mr Carver’s buddy training and what driving was undertaken as a driver or passenger. The interviews and/or assessments after the buddy training were informal and not recorded. The current policies and procedures are vastly improved and recognise that a driver may require extensive buddy driving and set out clear training guidelines and requirements for documentation.45
Further, Mr Carver drove the fish run and/or was a passenger on 17 November before undertaking the formal employment induction the following day. I cannot determine any good reason for commencing driving before the induction.
Upon the evidence, it appears that the induction takes place over several hours, with the new employee being provided with copious documentation concerning his/her employment conditions, as well as the TruckSafe Employee’s Handbook and relevant SOPs (numbering 15 in the case of Mr Carver). A site tour is also conducted and the three DVD presentations referred to above are also watched by the employee (but not in Mr Carver’s case). I could not determine how effectively a new driver might absorb such comprehensive documentation or how the SOPs were presented and explained to an employee. It was unclear whether there was any follow-up process with the employee to assess knowledge of the SOPs.
43 C 4. Mr De Bruyn suggests the quantity was likely 7000 litres.
44 C 37, page 36.
45 C 43C, De Bruyn's Safety and Procedures Manual – May 2019.
There was no SOP that dealt with the specific safety issues associated with heavy vehicle rollovers and movable loads specifically relating to the fish run. Mr De Bruyn gave evidence at inquest that, after discussions with Mr Kroon, the SOP would be updated to include consideration of these important issues.
According to the ICAM report, Mr Carver’s probationary report was not finalised as it should have been.46 No reason was given and the issue was not dealt with further at inquest. This may have been an opportunity at an earlier date to comprehensively review Mr Carver’s driving and reinforce safety issues in respect of the fish run.
In hindsight, there was an overreliance by De Bruyn’s upon Mr Carver’s previous driving experience in assessing his training requirements. Assuming Mr Carver had previously had some training in rollover awareness in 2011 or previously, that training was not undertaken when he was driving heavy combination vehicles. In relation to this critical safety issue, repetition of the important messages can only be of benefit.
Might additional training have prevented Mr Carver’s rollover?
Nevertheless, in the context of his lengthy previous driving career, he was relatively new to heavy combination vehicles.47 The driving risk was increased by the movable and loads which varied constantly in their quantities.
46 C 32, page 15.
47 C 32, ICAM report, page 16, noting Mr Carver's perceived lack of experience in heavy combination driving.
Baffling and trailer capacity
The inquest went some way towards exploring the issue of whether the trailers transporting the fish should be baffled so as to contain the slosh and surge, thus reducing the lateral and longitudinal acceleration of the vehicle and correspondingly reducing the risk of a rollover.
Coroner Carey noted in his finding that the rollover threshold is affected, upon cornering by the slosh and surge effect. Although he did not discuss the issue of baffling in great detail he stated “I recommend that some consideration be given to inserting some form of baffle, at least transversely, in order to minimise these effects”.
Mr De Bruyn stated in his affidavit and in evidence at inquest that, for hygiene and fish cooling reasons, as well as prevention of damage to the fish, baffles could not be inserted in the tanks.
He said that he does not know of any other aquaculture company that uses ball baffles. 48He said in evidence: “So we did investigate fitting baffles to the tanks in the initial design, but essentially – we talked about – one of the witnesses talked about public health, so hygiene is critical. The tanks have to be cleaned otherwise you end up listeria in the tank, listeria ends up on fish, people end up dying from food poisoning. So hygiene is very critical and it’s also the ability to discharge the tank. Essentially the tank arrives at the factory at Parramatta Creek, it plugs into the factory and the fish are sucked out of the tank. If there was baffles in the tank, we wouldn’t be able to discharge a tank.
There’s also temperature issues as well. If there were baffles in the tank you would end up with differentials in temperature and it would actually – the fish wouldn’t cool properly.”49
49 Transcript, page 105.
cornering and rollover behaviour. This is due to the partially filled tank. A tank that is filled to anything less than its full capacity allows the liquid to move from side to side and whilst doing so there is a lateral shift of the load which in turn reduces the vehicle’s performance in cornering and rollover.
Also, the dynamic motions of the load may occur out of phase with the vehicles lateral motions in such a way as to become exaggerated and thus further reduce the rollover threshold.”50
Dr Richardson was of the view that lateral baffling of the tanker was not particularly warranted given the analysis of lateral acceleration over the life of the tanker showed that for the vast majority of the time, it was exposed to lateral acceleration of less than 0.3 G. He said that the benefit of lateral baffling at lateral accelerations of 0.1 G, 0.2G and 0.3 G would need to be studied and tested to enable objective quantification.51 He stated that, as the phenomenon of surge was not involved, longitudinal baffles would not have altered the static rollover threshold of the tanker whereas lateral baffles may have, depending upon the degree of slosh. He stated that the effect cannot be quantified without testing a modified tanker with fish, water and ice slurry. He considered that it is not reasonably practicable to install lateral baffles in existing tankers and he thought that lateral and longitudinal baffles would damage the fish.52 Dr Richardson kept the issue of baffling open subject to consideration of further testing.
Although I make no formal recommendations, there is merit in De Bruyn’s continuing to give consideration to whether its fish tankers might feasibly be baffled in the interests of driver safety.
Similarly, I comment that De Bruyn’s should give ongoing consideration to whether the tankers used upon the fish run are of a size that reduces the risk of rollover to the extent possible.
Formal findings
51 C 40, page 74.
52 C 40, page 75.
d) Mr Carver died on 13 July 2014 at Hideaway Bay in Tasmania.
Recommendations
I recommend that De Bruyn’s develops a specific rollover awareness and training module, as an adjunct to the employee induction process, which is compulsory for drivers undertaking the fish run and similarly high risk routes involving heavy combination vehicles carrying dynamic loads; and that such module is developed in conjunction with the VicRoads Heavy Vehicle Rollover Prevention program and contains an emphasis upon the particular safety issues associated with the route and tasks to be undertaken by the employee.
I recommend that De Bruyn’s incorporates into its SOPs safety guidelines and procedures for rollover prevention, including guidelines and procedures specifically applicable to the preparation and driving of heavy combination vehicles, dynamic loads and unbaffled trailers.
I recommend that, upon reviewing an employee’s performance at the expiration of the probationary period, there be an assessment of the safety of the driver on the fish run and other high risk routes with particular emphasis on rollover prevention techniques.
I recommend that, in the three yearly employee refresher training, there be specific refresher training in rollover prevention.
Acknowledgements
I extend my appreciation to counsel assisting and the other counsel. I am also grateful for the work of the Coroner’s Associates and staff of the Coroner’s Office in this inquest.
I convey my sincere condolences to the family and loved ones of Todd Andrew Carver.
Dated: 2 July 2021 at Hobart in the State of Tasmania.
Olivia McTaggart Coroner
LIST OF EXHIBITS IN THE ORIGINAL INVESTIGATION Record of investigation into the death of Todd Andrew Carver No. TYPE OF EXHIBIT NAME OF WITNESS
C1 REPORT OF DEATH CONST M SILK C2 LIFE EXTINCT AFFIDAVIT DR G KAVABAR C3 AFFIDAVIT OF IDENTIFICATION MR A CORDWELL C4 MEDICAL NOTES AMBULANCE TASMANIA C5 POST MORTEM AFFIDAVIT DR D RITCHEY C6 FSST TOXICOLOGY REPORT MS M CONNOR C7 AFFIDAVIT MRS F CARVER C8 AFFIDAVIT MR P HOLLAND C9 AFFIDAVIT MR J BRETT C10 AFFIDAVIT MR L FEWKES C11 AFFIDAVIT MR G MOSS C12 AFFIDAVIT MR R STONE C13 AFFIDAVIT MR W HUGHES C14 AFFIDAVIT CONST M SILK C15 AFFIDAVIT CONST P EDWARDS C16 AFFIDAVIT S/CONST K CORDWELL C17 AFFIDAVIT SGT R CARRICK C18 AFFIDAVIT TRANSPORT INSPECTOR M KRAMER C19 AFFIDAVIT & DISC OF PHOTOS CONST T JAMES C20 TRAFFIC CRASH REPORT TASMANIA POLICE
C21 COPY OF DEBRUYN’S TRANSPORT VEHICLE INDUCTION FORMS C22 COPY OF DEBRUYN’S TRANSPORT STANDARD OPERATING PROCEDURES C23 COPY OF DEBRUYN’S TRANSPORT SIGNED BY MR T STANDARD OPERATING PROCEDURES CARVER REGISTER C24 DYNAFLEET REPORT C25 WORK ORDER HISTORY TANKER C26 WORK ORDER HISTORY MACK TRIDENT 6 X 4 PRIME MOVER C27 SURVEYS OF SCENE C28 SCENE DIAGRAM C29 ARTICLE ON STABILITY EFFECTS OF SLOSHING LIQUIDS AND HANGING MEATS C30 TANKER SPECIFICATIONS C31 AUSTRALIAN ROAD TRANSPORT SUPPLIERS ASSOCIATION ROLL OVER STUDY C32 DEBRUYN’S TRANSPORT INCIDENT FORM C33 WORK SCHEDULE FOR MR T CARVER C34 DRIVER LICENCE DETAILS FOR MR T CARVER C35 DVD- VIC ROADS ROLL OVER PREVENTION PROGRAM AND POWER POINT PRESENTATION C36 MISCELLANEOUS PAPERWORK LILIST O
LIST OF EXHIBITS IN THE RE-INVESTIGATION AND INQUEST Record of investigation into the death of Todd Andrew Carver No. TYPE OF EXHIBIT NAME OF WITNESS
C1 REPORT OF DEATH CONST M SILK C2 LIFE EXTINCT AFFIDAVIT DR G KAVABAR C3 AFFIDAVIT OF MR A CORDWELL IDENTIFICATION C4 MEDICAL NOTES AMBULANCE TASMANIA C5 POST MORTEM AFFIDAVIT DR D RITCHEY C6 FSST TOXICOLOGY REPORT MS M CONNOR C7 AFFIDAVIT MRS F CARVER C8 AFFIDAVIT MR P HOLLAND C9 AFFIDAVIT MR J BRETT C10 AFFIDAVIT MR L FEWKES C11 AFFIDAVIT MR G MOSS C12 AFFIDAVIT MR R STONE C13 AFFIDAVIT MR W HUGHES C14 AFFIDAVIT CONST M SILK C15 AFFIDAVIT CONST P EDWARDS C16 AFFIDAVIT S/CONST K CORDWELL C17 AFFIDAVIT SGT R CARRICK C18 AFFIDAVIT TRANSPORT INSPECTOR M KRAMER C19 AFFIDAVIT & DISC OF PHOTOS CONST T JAMES C20 TRAFFIC CRASH REPORT TASMANIA POLICE
C21 COPY OF DEBRUYN’S DE BRUYN’S TRANSPORT TRANSPORT VEHICLE INDUCTION FORMS C22 COPY OF DEBRUYN’S DE BRUYN’S TRANSPORT TRANSPORT STANDARD OPERATING PROCEDURES C23 COPY OF DEBRUYN’S DE BRUYN’S TRANSPORT TRANSPORT STANDARD OPERATING PROCEDURES REGISTER C24 DYNAFLEET REPORT C25 WORK ORDER HISTORY TANKER C26 WORK ORDER HISTORY MACK TRIDENT 6 X 4 PRIME MOVER C27 SURVEYS OF SCENE S/CONST K CORDWELL C28 SCENE DIAGRAM S/CONST K CORDWELL C29 ARTICLE ON STABILITY EFFECTS OF SLOSHING LIQUIDS AND HANGING MEATS C30 TANKER SPECIFICATIONS C31 AUSTRALIAN ROAD TRANSPORT SUPPLIERS ASSOCIATION ROLL OVER STUDY C32 DEBRUYN’S TRANSPORT DE BRUYN’S TRANSPORT INCIDENT FORM C33 WORK SCHEDULE FOR MR T CARVER C34 DRIVER LICENCE DETAILS FOR MR T CARVER C35 DVD- VIC ROADS ROLL OVER PREVENTION PROGRAM AND POWER POINT PRESENTATION
C36 LETTER FROM DOCTOR DR A MCLEAN MCLEAN C36A ARTICLE DR A MCLEAN C36B ARTICLE – SUGGESTED HEAVY DR A MCLEAN VEHICLE AIR SUSPENSION CONTRIBUTIONS TO FATAL ACCIDENTS C37 REPORT AND ANNEXURES MR J RULLER C38 AFFIDAVIT 25.09.2020 DR A MCLEAN C39 SUPPLEMENTARY AFFIDAVIT MRS F CARVER C40 REPORT DR S RICHARDSON C41 AFFIDAVIT MR F KROON C42 AFFIDAVIT MR J DE BRUYN C43A EMPLOYER DOCUMENTS – PRE DE BRUYN’S TRANSPORT ACCIDENT C43B EMPLOYER DOCUMENTS – DE BRUYN’S TRANSPORT POST ACCIDENT C43C EMPLOYER DOCUMENTS – DE BRUYN’S TRANSPORT SAFETY MANUALS C43D EMPLOYER DOCUMENTS – DEBRUYN’S TRANSPORT SAFETY OPERATING PROCEDURES C44 PHOTOS DE BRUYN’S TRANSPORT C45 THIRD PARTY DOCUMENTS DE BRUYN’S TRANSPORT C46 TAX INVOICE – MACK TRIDENT DE BRUYN’S TRANSPORT 6X4 PRIME MOVER TRUCK 02.07.2012
C47 EMAIL DATED 16.12.2020 MR M KRAMER C48 RECORD FROM STATE DEPT STATE GROWTH GROWTH C49 CERTIFIED ROAD–FRIENDLY DEPT INFARSTRUCTURE, SUSPENSIONS TRANSPORT, REGIONAL
DEVELOPMENT AND COMMUNICATIONS C50 ROAD–FRIENDLY SUSPENSION DEPT OF TRANSPORT AND CERTIFICATE NUMBER REGIONAL SERVICES C51 DIAGRAM DRAWN BY MR K READ C52 CUSTOMER QUOTE WEBSTER TRUCKS C53 ORDER CONFIRMATION WEBSTER TRUCKS C54 REPORT TO WALLACE, DR A MCLEAN WILKINSON AND WEBSTER DATED 11.11.2016 C55 REPORT TO WALLACE, DR A MCLEAN WILKINSON AND WEBSTER DATED 19.12.2016 C56 REPORT TO WALLACE, DR A MCLEAN WILKINSON AND WEBSTER DATED 31.03.2017 C57 HEAVY VEHICLE LICENCE UPGRADES – TESTING SPECIFICATIONS C58 STATIC ROLL THRESHOLD CALCULATION SUMMARY C59 TIMESHEET OF MR L FEWKES DE BRUYN’S TRANSPORT DATED 17.11.2013 C60 NHVR MASS AND DIMENSION NHVR LIMITS C61 MACK TRIDENT AXLE BACK MACK TRIDENT SPECIFICATIONS C62 TRUCK SAFE MASS & DE BRUYN’S TRANSPORT MAINTENANCE MANAGEMENT ACCREDITATION AWARENESS C63 AFFIDAVIT RICHARDO ANDREW MARTIN C64 ROLLOVER AWARENESS VIC ROADS C65 INDUCTION SHEET DE BRUYN’S
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