Coroner's Finding: AZ, CY and DX de-identified

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the name of the deceased, family, friends, and others by direction of the Coroner pursuant to s57(1)(c) of the Coroners Act 1995) I, Simon Cooper, Coroner, having investigated the death of AZ, CY and DX.

Find, pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is AZ; b) AZ died in the circumstances set out further in this finding; c) The cause of AZ’s death was multiple injuries sustained as a driver in a motor vehicle collision; and d) AZ died on the Midlands Highway, south of Ross in Tasmania, on 2 October 2020.

Find, pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is CY; b) CY died in the circumstances set out further in this finding; c) The cause of CYs’ death was multiple injuries sustained as a passenger in a motor vehicle collision; and d) CY died on the Midlands Highway, south of Ross, on 2 October 2020.

Find, pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is DX; b) DX died in the circumstances set out further in this finding; c) The cause of DX’s death was multiple injuries sustained as a passenger in a motor vehicle collision; and

d) DX died on the Midlands Highway, south of Ross, on 2 October 2020.

Introduction

1. In making the above findings, I have had regard to the evidence gained in the comprehensive investigation into AZ, CY and DX’s deaths. The evidence includes:  The Police Report of Death for the Coroner in each case;  Reports - Dr Donald Ritchey, the Forensic Pathologist who conducted each post mortem examination;  The results of toxicological analysis of samples taken from the body of each deceased;  Affidavits confirming identification and life extinct;  Video Recorded Interview – IS – 29 October 2020;  Affidavits - Family and Friends;  Affidavit - Transport Inspector Casey Perkins;  Affidavit - Crash Investigator Senior Constable Michal Rybka, with scene sketch plan;  Affidavits of other attending and investigating police officers;  Dashcam footage;  Records - Ambulance Tasmania;  Medical Records - West Tamar Health;  Manufacturer’s instructions – solar panel brackets; and  Forensic and photographic evidence.

2. In addition, this finding was informed by my attendance at the scene of the fatality on the day it occurred.

Circumstances of death

3. On Friday, 2 October 2020, AZ left Launceston to drive to Hobart via the Midlands Highway. CY, his 15-year-old daughter was a front seat passenger in the red Toyota Celica coupe he was driving. His rear seat passengers were his aunt DX and his seven-

year-old son GT. The family group were intending to visit Hobart for a shopping trip so that CY could spend recently received birthday money.

4. At the same time, IS was driving a blue Ford Ranger four wheel drive utility towing a Jayco Expanda caravan in a general northerly direction on the Midlands Highway.

Following IS in a line of traffic was a Holden Commodore driven by OQ. OQ had two passengers with her, ZB (her boyfriend) and her six-year-old niece EV.

5. Just south of Ross, a solar panel on the roof of IS’s caravan came loose and blew in the general direction of the southbound lane in which AZ was travelling. AZ seems to have reacted to the solar panel, swerved into his lane’s gravel verge, lost control, crossed into the northbound lane and collided with the Commodore driven by OQ.

6. All this can be clearly seen in the dashcam footage obtained as part of the investigation from nearby vehicles. It is also supported by accounts of a number of eyewitnesses.

Relevantly, that dashcam footage showed the solar panel flying high in the air well over the southbound lane in which AZ was travelling. The panel was not heading towards his car but rather flying over his vehicle.

7. AZ, CY and DX all were killed instantly. GT suffered a broken elbow and leg. OQ and her passengers all suffered injuries.

8. A number of members of the public stopped and rendered assistance. Police and emergency services were quickly on the scene but nothing could be done for AZ, CY and DX.

9. The Midlands Highway was closed for many hours while the scene was made safe, injured people transported to hospital and the three bodies removed from the Celica.

10. IS did not realise that the solar panel had come loose from his caravan until he was contacted by police further up the highway. He stopped and waited for police at Epping Forest.

Investigation

11. Each body was removed from the scene of the crash and transported by mortuary ambulance to the Royal Hobart Hospital. On Monday 5 October 2020, identification of AZ, CY and DX was completed by FR, FR was AZs’ mother, CYs’ grandmother and DX’s sister.

12. The Tasmanian State Forensic Pathologist Dr Donald Ritchey conducted post mortem examinations of each body the same day. Following those examinations, he expressed the opinion that the cause of death in each case was multiple blunt traumatic injuries sustained in a motor vehicle crash. I accept Dr Ritchey’s opinion.

13. Of particular significance, so far as forensic pathology evidence is concerned, was that AZ was found to have 35 µg/L of THC, the active constituent of the illegal drug cannabis in his body. THC has its greatest effect on the central nervous and cardiovascular systems. Relevantly, it impairs cognitive functioning, perceptual coordination, reaction times and judgement. I will return to the significance of this finding a little later.

14. I am satisfied that the cause of death in each case was multiple blunt traumatic injuries sustained either as a driver or passenger, as the case may be, in a motor vehicle crash.

15. IS and OQ both underwent standard alcohol and drug testing immediately after the crash. That testing showed that neither had alcohol nor any illicit drugs in their body at the time the crash happened.

16. AZ, OQ and IS were all identified as having valid driver’s licences at the time the crash occurred.

17. Police expert crash investigators commenced an investigation at the scene.

Investigators identified that AZ, CY and GT were all wearing seat belts at the time the crash occurred. DX was not wearing the seatbelt which was available to her.

18. The solar panel which came loose from IS’s caravan was located and seized for subsequent inspection and examination. The scene itself was measured, photographed and carefully examined.

19. Both the Commodore and AZ’ Celica were searched. In the boot of the Celica a bag was found. In the bag, police found a smoking device and 8.4 grammes of chopped cannabis. In light of the fact that it was identified that AZ had a substantial level of cannabis in his body at the time the crash occurred (and no other person in the vehicle did), it is reasonable to conclude, and I do, that the cannabis was his.

20. Nothing about the road surface or the behaviour of any other drivers was found by investigators to have caused or contributed to the happening of the crash.

21. The Celica and Commodore were both examined by a Transport Inspector. That inspector provided a report in which they expressed the opinion, which I accept, that neither vehicle had any mechanical deficiency which either caused or contributed to the happening of the crash.

22. The caravan and the vehicle towing it were both also inspected. No mechanical deficiency was identified, other than the fact that the solar panel had been able to come loose from the roof of the caravan. I will return to this issue shortly.

23. On the basis of observations and measurements taken at the scene, Senior Constable Michal Rybka, an experienced Crash Investigation Services officer calculated the relative speeds of the Commodore and the Celica before the two vehicles collided in the northbound lane (the correct lane for OQ’s Commodore). Senior Constable Rybka said that the Celica was travelling at between 91 and 94 km/h and the Commodore between 58 and 60 km/h immediately before the crash. The fact that the Commodore was travelling at a significantly lower speed than both the posted speed limit (110 km/h), and the Celica, is consistent with OQ braking heavily before the crash. Indeed, this is precisely what she told investigators she did when she realised the Celica was travelling towards her. Her passenger, ZB, confirmed this account. In his sworn affidavit he said that he felt OQ “hit the brakes before the crash and he [knew they] slowed down a lot, to like 60 km an hour or even less before” the crash.

24. I accept that Senior Constable Rybka is qualified to express the opinion he did in relation to speed and I accept his opinion as to the relative speeds of the vehicles immediately prior to the crash.

25. I am satisfied that excessive speed did not play any role in the happening of the crash.

26. IS was interviewed by police a few days after the crash. He confirmed that he had bought the caravan in good condition a few years before the crash. He said that the caravan was not fitted with solar panels when he bought it and that they were an “aftermarket” addition that he arranged. IS identified the circumstances in which the solar panel was fitted to the caravan. He told police the solar panel was installed by a qualified electrician. Police spoke to, and obtained an affidavit from, that electrician.

The electrician said that he had installed solar panels on caravans in a similar way in the past and that he did so on this occasion (and the others) in accordance with the solar panel bracket manufacturer’s instructions. I accept that this was so. The evidence satisfies me that the panels were bonded to the roof with Sikaflex 252 adhesive. It was this adhesive which failed and allowed the solar panel to blow free.

27. I note that the evidence was that at about the time the crash occurred, and in the lead up to it, the general area of the Midlands Highway had been windy. The strong winds no doubt contributed to the panel being dislodged.

Conclusion

28. The evidence viewed as a whole satisfies me that AZ overreacted to the situation he faced on the Midlands Highway on 2 October 2020. As I have already noted I am quite satisfied that the solar panel was actually flying over AZ’s vehicle, some distance above it. No doubt, AZ’s perception of what was occurring was different. However, I am also satisfied that both his perception and reaction time were very likely to have been affected by the THC found in his body at autopsy.

29. His response to the circumstances which confronted him is to be contrasted with that of OQ. OQ was able to perceive the presence of the Celica in her lane and apply her brakes heavily to reduce the speed of her vehicle and thus lessen the impact of the collision. Of course, OQ did not have THC in her body (nor anything else which adversely impacted upon her perception and reactions).

30. AZ should not have been driving. His inability to react appropriately to the solar panel because of the THC in his body was the principal reason, in my view, he, his 15-yearold daughter and aunt died.

31. DX was not wearing a seatbelt. Had she been, then like the other rear seat passenger, GT, she may not have died in the crash.

32. That having been said, a significant factor which contributed to the happening of the crash was the fact that the solar panel on IS’s caravan came loose at speed. I note there are no specific regulations governing how solar panels or similar are to be affixed to, or mounted, on caravans or similar in this state. In my respectful view there should be.

Comments and Recommendations

33. As part of the investigation in relation to these three deaths, I have been advised by the Department of State Growth that it has undertaken a review of current standards, performance measures, legislation and published guidelines regarding the proper fitment of aftermarket equipment and accessories. That review included consultation with other jurisdictions and the Caravan Industry Association of Australia (the peak national body for the caravanning industry).

34. The Department’s review highlighted that there is no Australian Design Rule or any legislation that addresses the matter. The Department of State Growth indicated that as a result of the review and consultation, the State Registrar of Motor Vehicles has issued a Special Information Bulletin (Security of Attachments) to ensure that checks of the security of external equipment and accessories are undertaken as part of preregistration inspections.

35. In addition, further advice been published in relation to the fitment of aftermarket solar panels.

36. Moreover, I am advised by the Department that a National approach is being pursued in relation to the Australian Light Vehicle Standards Rules for the insertion of a new rule addressing ongoing security of aftermarket accessories fitted to any vehicle.

37. I commend the Department’s approach and thank it for its assistance in relation to this matter. Having regard to the Department’s advice, I therefore consider in the circumstances of AZ, CY and DX’s deaths there is no need for me to make a formal recommendation in this regard.

38. I convey my sincere condolences to the family and loved ones of AZ, CY and DX.

Dated: 10 March 2022 at Hobart in the State of Tasmania.

Simon Cooper Coroner