Coroner's Finding: Selby, Robert Norman

MAGISTRATES COURT of TASMANIA

MAGISTRATES COURT

Taste CORONIAL DIVISION

Record of Investigation into Death (Without Inquest)

Coroners Act 1995 Coroners Rules 2006 Rule HH

|, Andrew McKee, Coroner, having investigated the death of Robert Norman Selby Find, pursuant to Section 28(1) of the Coroners Act 1995, that

a) The identity of the deceased is Robert Norman Selby;

b) Mr Selby died as a result of crush injuries to his chest and pelvis sustained when a tractor overran him;

c) Mr Selby's cause of death was crush injuries of his chest and pelvis; and

d) Mr Selby died on 3 August 2018 at Glengarry, Tasmania.

In making the above findings | have had regard to the evidence gained in the comprehensive investigation into Mr Selby’s death. The evidence includes:

a) An opinion of the forensic pathologist who conducted the autopsy;

b) The police report of death;

c) Accrash report and affidavit sworn by First Class Constable N Housego an experienced crash scene investigator;

d) An affidavit of Mr W Rice, a Transport Inspector, employed by the Department of State Growth;

e) Toxicology report prepared by Forensic Science Services Tasmania;

f) Relevant police family and witness affidavits; and

g) Forensic evidence.

Mr Selby was born on 24 September 1942 and was 75 years of age at the date of his death. Mr Selby grew up on rural properties in the Meander Valley and West Tamar. He married Judith in approximately 1975 (they had been married for 43 years and [0 months at the date of his death.) The marriage produced five children.

Mr and Mrs Selby have resided on their property at 271 Loop Road Glengarry since their marriage.

Throughout his working life Mr Selby was employed as the dispatch manager at the Blue Ribbon meatworks at Launceston. The meatworks closed in 2004 leaving Mr Selby without employment. After six months of sitting on a picket line Mr Selby started to receive a pension.

From that point onwards he enjoyed working on his farm and holidaying with Mrs Selby.

Mrs Selby has sworn an affidavit as part of the Coronial Investigation. In that affidavit she outlines in detail Mr Selby’s experience in using tractors on his property and the property

owned by their neighbours, the Comries. Mr Selby had driven a Massey Ferguson tractor (owned by him) for in excess of 43 years without incident. Mrs Selby outlined that Mr Selby was taught to drive tractors at an early age and had over 50 years’ experience in driving tractors on farms, in various conditions and terrains.

Mrs Selby made the following comment about her husband use of tractors:

“I knew Bob to be a very cautious tractor driver. Even when he drove our car he was very attentive, He wouldn’t move unless everybody had their seatbelts on. If a tractor was faulty, he would never get on it if he knew about it. He wasn’t a person that would take risks.”

Mrs J Comrie, who was with Mr Selby when he was overrun by the tractor, has sworn an affidavit as part of the Coronial Investigation. In that affidavit she made similar comments about Mr Selby’s use of tractors. Mrs Comrie indicated that Mr Selby had used the Ford 4000 tractor in the preceeding [0 years. In her affidavit she stated that Mr Selby was competent in the use of the Ford 4000 tractor.

Based on the affidavits of Mrs Selby and Mrs Comrie, | am satisfied that Mr Selby was experienced in the use of tractors and had been driving tractors on farms for at least 50 years.

Circumstances Surrounding Mr Selby’s Death

On 3 August 2018, Mr Selby attended his neighbour's property to assist in feeding cattle. He utilised a Ford 4000 tractor to feed the cattle. Mr Selby spiked a round bale of hay onto the back of the tractor. He then proceeded to a paddock.

Once at the paddock Mr Selby drove the tractor to near where Mrs Comrie was standing. He lowered the spike with the hay bale. He drove the tractor forward but the bale did not dislodge from the spike. Mrs Comrie approached the rear of the tractor and attempted to remove the bale of hay. She was unable to remove the bale from the spike.

Mr Selby stopped the tractor, dismounted from it and with the assistance of Mrs Comrie tried to remove the bale of hay. The bale did not dislodge.

Mr Selby returned to the left hand side of the tractor. The tractor remained running but was stationary. At this point Mrs Comrie was looking at the cattle. She did not observe Mr Selby get on the tractor or touch the controls.

When she turned back from looking at the cattle she observed the left back wheel of the tractor running over the top of Mr Selby.

Mrs Comrie immediately provided assistance to Mr Selby. He indicated to her that he would be alright.

Mrs Comrie chased the tractor. She mounted it and noted that it was in gear. Mrs Comrie then pulled the engine stop button and turned the key off. She then returned to Mr Selby. As neither her or Mr Selby had their mobiles phones, Mrs Comrie ran back to her house and her husband contacted emergency services.

Mrs Selby was advised of the incident and she attended the paddock. Mr Combrie was also in attendance at the paddock at this stage,

Emergency services attended the Comrie property. Paramedics provided treatment to Mr Selby but he was pronounced dead at the scene.

Condition of the Ford 4000 Tractor

The Ford 4000 tractor was inspected by Mr W Rice a Transport Safety and Investigations Officer employed by the Deapartment of State Growth. | am satisfied he is appropriately qualified to express the opinions contained in the affidavit he swore in the coronial investigation.

Mr Rice identified the following safety issues with the tractor:

a) The neutral switch fitted to the vehicle, which when operational stops the tractor’s

starter motor engaging when a gear is selected has been disabled on this vehicle. When tested in a low gear and the clutch pedal disengaged, the tractor started and moved away at idle speed. It is my opnion that this could be achieved when standing beside the vehicle.

The foot brake consists of two adjacent foot levers which can operate the rear brakes independently or when locked together engages both the right and left hand side. The locking pin which links both pedals was not present. This pin allows the operator to lock both pedals together and operate both rear brakes simulataneoulsy. If this function cannot be achieved it may not be possible to safely operate both pedals together which can affect the braking stability of the vehicle,

Mr Rice was specifically asked two questions in his affidavit by First Class Constable N Housego regarding the tractor and | am of the view it is appropriate to detail the questions and anwers

in full:

“Can the vehicle’s gear box be engaged whilst standing beside the vehicle on the left hand side?

Whistt standing beside the tractor on the left hand side | was able to depress the clutch with my left hand and engage a gear with my right hand.l was able to force the gear box into a low gear with the engine running and without depressing the clutch.This resulted in the vehicle moving and continuing to move forward whilst at idle speed.

Is it possible to engage a gear low enough to get off and back on while running that may have caused the crash?

Several tests were conducted with the tractor at idle speed.These tests revealed that when the first six of the eight gears were engaged and the tractor propelled forward it moved at less than half walking pace up to a slow walking pace.The last two higher gears were engaged and the tractor was propelled at a fast walking pace.

it is my opinion after witnessing these tests that it is possible to mount or dismount the tractor at any of these tested speeds, but | consider it to be a serious safety risk to

attempt this maneuver and the risks would only increase if higher engine revolutions were used in each of these gears.”

| accept the opinions expressed by Mr Rice in his affidavit sworn 27 September 2018.

Investigation by First Class Constable Housego.

A thorough investigation of the incident was conducted by First Class Constable Nigel Housego. First Class Constable Housego completed a comprehensive report and swore an affidavit on the 24 October 2018.

As to the cause of the incident, First Class Constable Housego provided the following opinion in his affidavit:

“Opinion As To Cause

It is my opinion that this fatal collision has been caused by the actions of Mr Selby, with no other person contributing to it

The police officer who initially responded to the collision, Senior Constable Dean Purdy, has

provided a detailed and helpful affidavit. SIC Purdy provides evidence of his experience. This

includes over 10 years of owning farms and tractors. He included his opinion of the crash cause.

Senior Constable Purdy stated:

‘In my opinion | believe the three point linkage and bale of hay was in the fully down position whilst stopped in an almost flat part of the paddock. | believe the deceased was either getting on or off the tractor, putting him in a position in front of the rear wheel facing backwards. | believe that this motion has caused the tractor to move slighily forward, which has possibly been assisted in movement of the water in the wheels. Once the tractor has moved slightly, the front of the tractor has moved into an area slightly lower than where it was, thereby reducing the downward pressure the bale had on the ground (and was effectively acting like handbrake). | believe that the tractor has gained momentum whilst there was less pressure on the ground from the bale of hay and has caught the deceased offguard, running over him.

The tractor has then continued rolling downhill and once it has entered the soft ground, where it has also levelled out, and the tractor has slowed allowing Mrs Comrie to get on it and bring it to a stop.

| don’t believe the tractor was in gear at the time, | don’t believe that the difficulty in steering the tractor contributed to the accident in any way.’

Transport Inspector Rice also offered an opinion:

‘From my experience and knowledge it is common practice to set a tractor in motion and distribute hay from an implement at the rear. Doing this the operator does not have to stop the tractor, feed out a certain amount of hay and move the tractor to another location. The operator will need to dismount the tractor whilst it is in motion and also mount the tractor whilst in motion.

When the tractor was inspected the left-hand side foot step did not have any anti-slip material fitted (not required or ever fitted) and with the age of the tractor the edge of the step has become shiny and smooth. Also when inspected the engine was leaking diesel. If the diesel has contaminated the footwear of the operator, together with the smooth surface of the step and with the tractor in motion this may have caused the operator to slip and fall under the drive wheel.

It is also possible that the driver has forced or used the clutch to engage a gear whilst standing beside the tractor,with the engine running. To do this the driver would need to be standing directly in front of the left hand drive wheel and may not have been able to move out of the path of the vehicle once it has started to move.”

Having regard to these helpful comments from S/C Purdy and Inspector Rice, observations of the scene and Mrs Comrie’s affidavit, | have formed the opinion into the most likely cause of this unfortunate fatal collision:

| believe that the tractor has been stationary with the engine running while Mr Selby was on the ground at the rear of the tractor, unsuccessfully assisting Mrs Crombie to pull the hay from the spike. Mr Selby has then walked around to the left side of the tractor and stoad in front of the rear wheel. Mr Selby has then engaged the gears, as suggested possible by Inspector Rice, causing the tractor to move forward in an attempt to force the hay off the lowered spike,

It is likely that Mr Selby has done this because he has had the intention of returning to the rear of the tractor to continue to pull the hay from the spike, with the tractor moving forwards.

(Inspector Rice stated that this is a common practice). Mr Selby has been caught out by the speed tractor has moved forward, due to it being in a higher gear than expected, and the rear left wheel has run over him. (The tractor gears are located in the driver footwell and are easily reached from a standing position).

Senior Constable Purdy offers the opinion that Mr Selby has been attempting to get on or off the tractor and slipped, causing the tractor to move forward while not in gear. Inspector Rice also states that Mr Selby may have slipped but with the tractor in motion.

| believe that the very slight slope and damp heavy ground would not allow the tractor to gain a forward momentum that would cause the rear wheel to run over Mr Selby’s body, without him having time to take evasive action.

Mrs Comrie also stated that when she caught up with the tractor after the collision, it was in gear. Mrs Comrie owns the tractor and is very familiar with it. | believe it is unlikely she would be mistaken regarding this fact.”

I note that a number of opinions have been expressed as to the possible mechanism of the incident. | am satisfied on the balance of probabilities that the opinion of First Class Constable Housego as to the mechanism of the incident is the most likely scenario, based on the evidence, and | accept his opinion.

Post Mortem Examination

A post mortem examination was conducted by Forensic pathologist Dr D Ritchey. Dr Ritchey opined that Mr Selby’s cause of death was crush injuries of the chest and pelvis sustained when he was overrun by a tractor.

| accept Dr Ritchey’s opinion as to Mr Selby’s cause of death.

Tractor Safety

As part of the Coronial Investigation | have had regard to the following documents regarding the safe use of tractors and tractor fatalities:

a) Farming Safely in Tasmania, Safe Farming Tasmania Program, produced by Worksafe

Tasmania;

b) Fatalities Due to Working with Tractors, Australia 2003-04 to 2007-07, produced by Safe Work Australia; and

c) Worlrelated Injuries And Fatalities On Australian Farms March 2013, produced by Safe Work Australia.

The document prepared by Worksafe Tasmania provides the following advice to general members of the public regarding the safe use of tractors:

“Tractors

Tractors are heavy and powerful machines that can lead to a serious injury or death through only a minor mistake.

Consider each type of tractor hazard and associated risk. Control measures should be chosen, implemented and readily reviewed to ensure the health and safety of tractor operators.

Guards should protect the operator or any other person from parts of the tractor which are potentially hazardous, either when the tractor is normal operation or undergoing routine maintenance.

Safe Use

Never dismount from a moving tractor or adjust or work on implements while they are in motion.

Always use three points of contact when getting on and off the tractor.

Look up for overhead and look down for underground clearances of powerlines.

Do not use or attach implements unless the power take off (PTO) shaft is guarded.

Always start a tractor from the driver’s seat, not from the ground.

Make sure the park break is engaged in operating effectively before leaving the driver’s seat.

Do not park a tractor on a steep slope.

Remove the key when the tractor is not in use.

Make sure all operators are trained and competent to safely use tractors.

Wear a seatbelt where fitted.”

The 2011 report prepared by Safe Work Australia indicate that runovers accounted for 38% of all tractor fatalities in the period covered by the report. The report also indicated that of all tractor fatalies during the period covered by the report persons aged 65 and over accounted for 40% of the fatalities.

The 2013 report prepared by Safe Work Australia indicated that the number of fatalities under the category ‘being hit by tractor’ (which included runovers) had increased from 40% to 52% for persons aged over 65.

Both reports from Safe Work Australia indicated that the number of rollover deaths could be prevented by the installation of a Safe Tractor Acces Platform. Regarding these platforms the report noted:

“The safe access tractor platform (STAP) was designed so that a person could no longer stand between the front and back wheels of a tractor. This makes it much less likely that the operastor will slip and fall under the tractor wheel if the tractor moves unexpectedly. It is currently a voluntary safety device. Worksafe Victoria and FarmSafe Australia support the use of STAP’s on the basis of relatively cheap installation costs and proven effectiveness in reducing run over incidents. The analysis in this report suggests that 8 of the deaths that occurred in the four years of this study could have been prevented if all tractors were fitted with a STAP.”

The above quotation should be read in the context that Safe Work Australia is not endorsing the practice of mounting or dismounting an operational or moving tractor.

In his comprehensive report to the Coroner, First Class Constable Housego opined that a STAP would have prevented Mr Selby’s death. | accept his opinion.

| referred the opinion of First Class Constable Housego to Worksafe Tasmania. | also sought the opinion of Worksafe Tasmania as to the retrofitting of STAP devices to tractors.

Worksafe Tasmania has indicated that supporting the retrofitting of STAP devices to tractors is problematic. It is the position of Worksafe Tasmania that the only safe way to mount or dismount from a tractor is when the tractor is not in operation and the park break is engaged.

Whilst Worksafe acknowledged that in some circumstances STAP devices assit in reducing the risk of being run over, their concern is that recommending the retrofitting of STAP devices to tractors could send a message that it is appropriate to acess or egress a tractor whilst it is in operation. Worksafe Tasmania does not wish in any way to endorse or encourage that type of behaviour.

| accept the views expressed by Worksafe Tasmania.

1 note and have considered the comments made by the family of Mr Selby on this issue. In particular, their support for the retrofitting of STAP devices. In their view blanket prohibitions do not take into account the complexities of working life.

| have given careful consideration to the matter. | am of the opinion that the views expressed by Worksafe Tasmania are the correct views and that Department’s recommendations regarding the safe use of tractors should be reinforced.

Comments and Recommendations

| extend my appreciation to investigating officer First Class Constable Nigel Housego for his investigation and report.

| make the following recommendation pursuant to Section 28 of the Coroners Act 1995:

|) That all operators of tractors comply with the recommendations of Worksafe Tasmania as to the safe use of tractors.

| wish to comment that owners of tractors should consider the retrofitting of STAP devices to their tractor. The retrofiitng of a STAP device should only be done to provide an added safety feature. The retrofitting of a STAP device does not alleviate the requirement of a tractor operator to follow the recommendations of Worksafe Tasmania in the safe use of tractors.

| wish to reiterate the instructions provided by Worksafe Tasmania as to the safe use of tractors should be followed at all times.

| convey my sincere condolences to the family and loved ones of Mr Selby.

Dated: 27 J why 2021 at Hobart Coroners Court in the State of Tasmania.

Andrew Mc Corone