Coroner's Finding: TR

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) (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) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of TR Find, pursuant to Section 28(1) of the Coroners Act 1995, that

(a) The identity of the deceased is TR;

(b) TR died as a result of injuries sustained in a single vehicle motor vehicle crash;

(c) TR’s cause of death was multiple traumatic injuries; and

(d) TR died on 31 January 2020 at Quoiba in Tasmania; Introduction In making these findings I have had regard to the evidence gained in the comprehensive investigation into TR’s death. The evidence includes:  The Police Report of Death for the Coroner ;  Affidavits establishing identity1 and life extinct;  Affidavit of Dr Donald Ritchey Forensic Pathologist;  Affidavit of Mr Neil McLachlan-Troup, forensic scientist, of Forensic Science Service Tasmania – toxicological and analytical report;  Ambulance Tasmania electronic patient care record;  Affidavit of Mr Alan Fitzpatrick, transport inspector, who inspected the vehicle involved in this crash;  Affidavit of Mr Q, the father of TR; 1 This includes a forensic odonatological examination by the consultant forensic odonatologist Dr Pacza.

 Affidavit of Ms Stacey Smith;  Affidavit of Mr M;  Affidavit of Ms C;  Affidavit of Ms Richelle Davies;  Affidavit of Mr Laszlo Faludi;  Affidavit of Constable Amy Boultbee;  Affidavit of Senior Constable Sven Mason;  Affidavit of First-Class Constable Dean Wotherspoon;  Affidavit of Senior Constable Caroline McGregor;  Medical records of TR; and  Forensic and photographic evidence.

This investigation concerns a fatal single vehicle crash that occurred on Durkins Road Quoiba approximately 420 metres west of its intersection with Racecourse Road on 31 January 2020 at approximately 23:40 hours. At that time TR was the driver and sole occupant of a Toyota Landcruiser flat tray utility which was proceeding in a general easterly direction towards Stony Rise Road. That vehicle was owned by her father. It was raining at the time of the crash and the road was wet. The speed limit on Durkins Road is 60km/h.

Background TR was born in Burnie, Tasmania on the 1 October 2002. She was 17 years of age, single and had not married or had any children and lived with her parents, Mr and Mrs Q, at the time of her death.

TR also had casual employment TR grew up in the Devonport area and completed year 10 at Reece High School. She was due to commence Year 12 at Don College. TR played soccer and had also played Australian Rules Football.

She was in good health.

The Circumstances Leading to TR’s Death In the evening of 31 January 2020 TR drove the vehicle to the home, in Wrenswood Drive at Quoiba, of her friend Mr M and his girlfriend who were holding “a bit of a get together.” Mr M says TR arrived between 21:00 and 21:30 hours. TR stayed for couple of hours before she left with Ms C and Ms B. Ms C was driving Ms B’s brother’s, to a party in Port Sorell. On their return Ms C and TR left again and drove to a nearby bottle shop in Devonport where Ms C purchased a 6 pack of

alcohol for a friend before they returned to Mr M’s home. TR remained at Mr M’s home for a short time before both she and Ms C left in their respective vehicles.

The Circumstances of the Crash and its Aftermath Ms C says she left Mr M’s home first driving her mother’s Mitsubishi wagon. At that time it was drizzling and she had her windscreen wipers on the middle setting. As she drove further down the road the rain got heavier. She had her lights on high beam. There was no other traffic about.

Ms C observed TR’s vehicle following her. She also had her headlights on and they were on low beam. Ms C says both headlights of the vehicle were operating. Ms C estimates TR was about 100 m behind her. TR did not bridge the gap between the 2 vehicles. Ms C observed TR pullover “for a couple of seconds in Wrenswood Drive but then could see her move off again”.

Ms C turned right into Durkins Road and headed down the hill in an easterly direction. By this time she says it was raining quite heavily. She did not experience any slipping or sliding in her vehicle and she made it safely home. She says she did not see TR’s headlights once she turned into Durkins Road.

Ms Smith was, at approximately 23:45 hours, travelling west on Durkins Road to her home on Wrenswood Drive. She says she was travelling uphill at about 40 to 55 km/h quite slowly because she is aware of wildlife in the area. She had her headlights on high beam. The road was wet but it was not raining at the time. As she came up the hill she saw lights and an indicator flashing and a vehicle which was facing on an angle into bushland. She stopped her vehicle just past the vehicle she had observed and then she walked down to the vehicle. It was difficult to see because there was no natural light or street lights in the area. Ms Smith says the stereo in the dashboard was flashing and music was playing which was not overly loud. She thought the vehicle may have been stolen because she could not see anyone in it and she thought the occupants “might have done a runner.” Ms Smith called out but nobody answered. She rang emergency services and then found TR who was outside the vehicle on the ground and who appeared to be deceased.

Tasmania police first received a call about this crash at 23:47 hours. Officers from the Devonport police station were tasked to attend the crash at 23:50 hours and were at the scene 6 minutes later.

Both the vehicle and TR were located. An officer from forensic services of Tasmania police was tasked to attend at midnight and First-Class Constable Wotherspoon arrived at 00:09 hours. On his journey to the scene First-Class Constable Wotherspoon noted the road was wet and rain was falling. The most recent rainfall prior to 31 January 2020 was on 23 January 2020 when 23 mm of rain fell at Devonport. When driving to the scene he noted the roads were slippery and the road surface at the scene was “notably so.” An officer from crash investigation services was notified at

00:06 hours and Senior Constable Mason arrived at 00:46 hours. On his arrival he observed that Durkins road had been closed to all traffic at both ends. He says when he arrived it was raining lightly. Visibility was clear and there was no fog or bushfire smoke in the vicinity of the crash.

Paramedics had already left whereas police from Devonport along with First Class Constable Wotherspoon were in attendance. Local fire and SES personnel were also present and they provided lighting.

The scene was inspected, marked and photographed. It was observed Durkins Road runs in an east/west direction from Devonport Road, across Stony Rise Road and it terminates at the top of Kelcey Tier at the Green Belt Lookout. The road is narrow and comprised of a single carriageway in each direction separated by a continuous white centreline. The westbound or uphill lane measured approximately 2.85 m wide and the eastbound lane was 2.95 m wide. The total sealed width was 5.85 m. The road edges were rough and uneven.

The crash occurred on a straight section of road which was on a steep gradient. At the top of the straight there is a right curve leading out onto the downhill straight. From the top of the straight to where the vehicle was located the gradient of the road decreased marginally. The road was wet and steeped and coefficient of friction testing determined the road was very slippery. When carrying out these tests Senior Constable Mason found no evidence of any fluids or contaminants such as fuel or oil on the roadway. To the left side of the road when exiting the curve are a line of guideposts.

There is also an embankment on the left and a dirt shoulder on the right covered by leaves and foliage. Forest lined both sides of the road. There was no street lighting and no moonlight.

Post-Mortem Examination Dr Ritchey conducted a post-mortem examination on 4 February 2020. Samples were also taken for histology and toxicology testing. As a result of his examination and after considering the test results Dr Ritchey determined TR’s cause of death was multiple traumatic injuries sustained in this crash. Those injuries included blunt trauma to the head and neck, blunt trauma of the chest and blunt trauma of the right arm. The toxicology results were negative for alcohol and illicit drugs.

Crash Investigation On the night of Senior Constable Mason’s attendance he determined the vehicle had crossed to the right hand side of the road. It veered diagonally for 11 m before the front right collided with a tree stump. Over the following 14.2 m there were no marks other than some broken tree branches until the vehicle struck a tree. That tree was 2.7 m from the road edge. Damage extended up the tree and it had been debarked. Behind this tree was a second tree approximately 1.95 m away which also

displayed some debarking. The vehicle came to rest between those 2 trees. There was a large tree stump in front of the vehicle which stopped it moving further forward. The vehicle was on its left side between these 2 trees. The roof had been peeled off and was crumpled in a mass at the rear.

The whole interior of the vehicle was open and exposed. The vehicle was in 4th gear. There was a mobile phone charger plugged into the dashboard and TR’s phone was located in the passenger foot well. Mobile phone records indicate TR was not using her phone at the time of the crash.

The windscreen wipers were in the on position. The vehicle was found to only have its park lights switched on which is contrary to the evidence of Ms C. The headlights were activated by twisting the end of a lever on the right side of the steering wheel. Constable Wotherspoon did 3 drivethroughs from Wrenswood Drive to past where the vehicle came to rest with the headlights on different settings. This was done on 5 March 2020 at 20:20 hours. Road conditions were dry. The first drive-through was with the headlights on high beam with driving lights also illuminated. Visibility was clear with no issues. The second drive-through was with low beam lights on only. Again visibility was good however in the wet Senior Constable Mason thought it was possible to lose your position on the roadway leading into the right curve where he believes the collision commenced. The third drive-through was with park lights on only and it was impossible to see clearly even in dry conditions. To turn the headlights on, it was one click forward into park and 2 clicks into low beam.

High beam would not work if only the park lights were on, unless the lever was physically held in by the driver. He thought it was impossible to twist the headlight lever backwards one click from low beam to park during the crash and he is therefore unable to positively say whether the lights were on low beam or whether just the park lights were illuminated.

Later that day Senior Constable Mason was advised by First-Class Constable Wotherspoon who was at the scene taking photographs in the daylight that he had found tyre marks on the left side of the road just down from the exit of the right curve. Senior Constable Mason attended and observed the left side tyre mark started travelling off the road 20.4 m downhill from the last guidepost. The mark measured 32.3 m in length to the point it tracked back onto the road. The mark went 2.3 m up an embankment which was approximately 1.6 m from the edge of the road. From the end of the tyre mark to the first tree stump on the opposite side of the road measured 33 m.

The driver’s seat belt was observed to be lying loosely across the interior of the vehicle. Closer inspection found that it had been torn from its mounting down by the right side of the driver’s seat.

The buckle was still clipped into the receiver and it appeared that the seatbelt had been worn.

On 4 February 2020 Senior Constable Mason returned to Durkins Road and surveyed the scene of the collision. He returned to the office and down loaded the survey into a computer program and from that program he produced a plan depicting the scene and the accident circumstances. In addition he calculated the minimum speed of the vehicle to be 56 km/h.

Senior Constable Mason obtained crash history data for this road dating back to 2013 from State Growth. There were 4 previous single vehicle crashes on this stretch of roadway. They involve a loss of control in wet conditions with excessive speed for the conditions, a loss of control in wet conditions where the driver was inexperienced, a loss of control in wet conditions with excessive braking involving an inexperienced driver and a loss of control in wet conditions involving an inexperienced driver. In 3 of the 4 accidents the vehicle collided with a tree and in the fourth there was a collision with an embankment.

Ms Smith says in her affidavit she has lived in Wrenswood Drive for almost 6 years. She is aware the corner just above the straight where this crash occurred can be very slippery. She is aware of a number of more minor crashes on this road in the vicinity of where this crash occurred.

TR was the holder of a first-year provisional driver licence and she was first licensed 12 days prior to this crash. She commenced learning to drive in her mother’s automatic vehicle in order to get used to steering, cornering and braking. Mr Q says his daughter wanted to learn to drive in a manual vehicle so she commenced to drive the vehicle. She completed 50 hours of driving in that vehicle however Mr Q says she was probably closer to having completed 80 hours in the vehicle before undergoing her provisional driver licence test.

Ms Davies who is a licensed driving instructor says she took TR for 2 lessons prior to her driving test. The first lesson was a couple of weeks before the test and the second one was, if not immediately before the test, a couple of days prior to it. She found TR drove the vehicle well and she says TR’s gear changes were smooth, she did not ride the clutch and she says TR’s general driving was very good.

Mr Faludi conducted TR’s provisional driving test on 20 January 2020. He has been a driving instructor for 15 years and an authorised assessor since 30 September 2019. The test consisted of 6 exercises of which 5 must be passed. TR passed 5 of the exercises. These exercises included driving a specific test route, a turnaround and parking exercise, another route exercise, a parallel parking exercise, a highway merger and another driving exercise. In addition there are 7 criteria which need to be passed and TR passed all of them. These criteria include looking, signalling, flowing with the traffic, movement and motion, her path on the roadway; that is not wandering across or around her lane, hazard response and vehicle management. TR was marked down on a few minor matters such as failing to scan, failing to check her mirrors enough, giving an incorrect signal out of a three-point turn, driving too slowly at 1 point and taking too long to move forward on a green light. She also at one point rested her wrist and hands on the steering wheel instead of holding the wheel. Mr Faludi says in his opinion TR was a safe and competent driver. To him she appeared confident, cautious and he was surprised how easily she drove the vehicle. He says on average he tests 4 students a day 5

days a week and would fail approximately 50%2 mainly for speeding, failing to give way, driving over the kerb; all things which TR did not do.

Mr Faludi says this is a very high failure rate by any training standard and he says although applicants are required to resit their driving assessment he believes they only learn how to pass a driving assessment instead of how to become a safer driver. He makes some suggestions as to how this could be corrected. These worthwhile suggestions are not relevant to this investigation given his opinion that TR was a competent driver however it would be prudent for officers from State Growth to discuss these suggestions with him. I recommend they do so.

Inspection of the Vehicle Mr Fitzpatrick is a transport inspector with the Department of State Growth. He is a qualified diesel mechanic with 14 years experience in the motor trade. He inspected the vehicle involved in this crash on 11 February 2020. That vehicle is a Toyota Landcruiser Turbo V8, single cab flat tray utility which was manufactured in June 2007. It had 3 seats and a manual 5 speed transmission. As a result of his inspection Mr Fitzpatrick says the vehicle was mechanically sound and roadworthy prior to and at the time of this crash. I accept his opinion.

Mr Fitzpatrick’s opinion corroborates that of the owner of the vehicle Mr Q. He also believed his vehicle was in a good roadworthy condition. He says there were no issues with the steering, the brakes or the clutch. It always went into gear. Mr Q says if the vehicle is driven sensibly then it behaves itself and does not slide out in the wet but if it gets to about 2500 to 3000 rpm the back end can slide out.

Accident Cause The consumption of alcohol and/or illicit drugs did not cause this accident. Neither was excessive speed per se a cause. From my assessment of the evidence I am satisfied to the requisite standard this crash was caused by a combination of inexperience and driving at night on a wet and slippery road. TR’s inexperience was both inexperience as a driver generally but also she was inexperienced in driving on Durkins Road. In this regard her father says she was aware of the road and how bad it could be in the wet but she had only been on Durkins Road before as a passenger.

Although Senior Constable Mason has determined TR’s minimum speed was not in excess of the speed limit he says she only had to be a couple of kilometres faster than the conditions allowed for the rear of the vehicle to slip out on the downhill curve and for her then to lose control. Once TR 2 Mr Faludi says discussions he has had with other assessors revealed they failed between 45 and 50% of P1 licence applicants.

lost control he says there would have been little hope of regaining control and remaining on the road. I agree with that assessment. Although the vehicle was found, after the crash, to only have its park lights switched on I am satisfied, given the evidence of Ms C and TR’s competence as a driver, the vehicle’s lights were on low beam at the time of the crash. The impact of the collision itself may well have been responsible for knocking the lever which controlled the lights from low beam back into park.

Comments and Recommendations Senior Constable Mason has suggested Durkins Road be resealed with nonslip asphalt that is being used on the north-west coast at roundabouts. He understands it has been used on the Bass Highway at Heybridge with a marked decrease in crashes. He recommends resealing be done in this manner from the junction of Durkins Road with Wrenswood Road for a distance of 350 m. He also recommends extending the Armco barrier on the southern side of the road to the gravel road running off to the southern side of Durkins Road which he says will prevent vehicles running off the road and colliding with trees which line that side of the road. I recommend these suggestions, having considered this matter carefully, be implemented particularly given the circumstances of this crash and the previous 4 crashes the details of which are set out above.

It appears some of this work has been completed given information provided by the Infrastructure and Works Manager of the Devonport City Council, who is responsible for this road, in July 2020.

That Council advised my office Durkins Road immediately west of the crash site was resealed.

Further work was to be done on the road surface in the following 6 months because the reseal was carried out in difficult conditions and has not “been totally effective. Some rework is required to ensure the effectiveness and longevity of this treatment.” At that time the Council was yet to decide if an extension of the roadside barrier from the west to past the crash site would proceed. No budget allocation for that work had been made in 2021 and Council’s plans in relation to this work “will be informed by the Coroner’s report.” Given Senior Constable Mason’s experience and his very thorough report his suggestions should be implemented if tragic accidents like this one involving TR are to be avoided in the future. I have recommended that his suggestions be implemented. To the extent they have not been implemented by the Devonport City Council then they should be. I also repeat the recommendation made on page 7.

The circumstances of TR’s death are not such as to require me to make any further comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of TR.

Dated 29 November 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner