Coroner's Finding: Barwick, Ian John

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Ian John Barwick Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Ian John Barwick; b) Mr Barwick died accidentally when he was overrun by a tractor on his farm, in the circumstances set out in this finding; c) The cause of death was mechanical traumatic asphyxia; and d) Mr Barwick died on 9 June 2020 at Chudleigh, Tasmania.

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

• The Police Report of Death for the Coroner;

• An opinion of the forensic pathologist regarding cause of death;

• Affidavit of Jeremy Barwick, son of Mr Barwick;

• Affidavit of Patricia Barwick, wife of Mr Barwick;

• Affidavits of attending and investigating police officers;

• Affidavit of crash investigator, Constable Nigel Housego;

• Toxicology report of Forensic Science Service Tasmania;

• WorkSafe Tasmania investigation file;

• Vehicle inspection report;

• Medical records for Mr Barwick; and

• Forensic and photographic evidence.

Background Ian John Barwick was born in Tasmania on 8 March 1953. He was 67 years of age at the time of his death and is survived by his wife and three children. At the age of 14 years, Mr Barwick left school to work on his family’s dairy and sheep farm in Chudleigh. Mr Barwick

was a talented sportsman and played football at a high level. He chose not to pursue a professional football career in favour of remaining in Tasmania.

In 2000, Mr Barwick and his wife, Patricia Barwick, formed a business farming partnership.

The partnership did not employ any other persons at the time of Mr Barwick’s death. They farmed 640 acres of land at Mersey Hill Road, Chudleigh. The Barwick family had been farming the land for about 64 years. Approximately 12 months prior to the death of Mr Barwick, 480 acres of the property was leased by the Barwick partnership to another farmer for dairy production. The remainder of the land was owned and used by Mr and Mrs Barwick for beef cattle farming.

Mr Barwick had maintained and operated his own farm equipment for 50 years. The David Brown 780 tractor (referred to as “the tractor”) involved in the death of Mr Barwick was at least 50 years old. In 1977, the tractor had rolled onto Mr Barwick’s father, causing his death. Following this, Mr Barwick installed rollover protection on the tractor.

Mr and Mrs Barwick were both aware that the tractor had mechanical issues but continued to use it on the farm on several occasions per year. In her affidavit for the coronial investigation, Mrs Barwick said that 15 to 20 years before Mr Barwick died, she experienced an incident with the tractor. The tractor had been set to neutral gear and the handbrake was engaged whilst Mrs Barwick alighted to deal with a hay bale. However, the tractor started to roll forward and picked up speed on a bank before running into a hay bale.

Mr Barwick was diagnosed with Type 1 diabetes at 33 years of age and was insulin dependent. In 2006, Mr Barwick was diagnosed with first degree atrial ventricular heart block. Mr Barwick’s health was otherwise in good condition, and medical issues did not contribute to his death.

Incident causing death At about 3.45pm on 9 June 2020, Mr Barwick left the farmhouse on the tractor to winter feed the cattle on the property. Wintering cattle involves feeding the cattle in a sheltered area during cold months to keep the cattle warm and maintain productivity.

At 5.00pm Mrs Barwick became concerned that Mr Barwick had not yet returned home.

Mrs Barwick searched for Mr Barwick but was not able to find him. At 5.15pm, Mrs Barwick called their son, Jeremy Barwick (“Jeremy”) and he came to the property to help look for Mr Barwick. Both Mrs Barwick and Jeremy tried calling Mr Barwick but could not find him.

At approximately 5.40pm, Jeremy found Mr Barwick, deceased, on State Reserve land adjacent to the farm property. The back left hand wheel of the tractor was on top of Mr

Barwick’s torso. Mr Barwick’s legs were facing uphill and his head was facing the front of the tractor. The tractor engine was running but it was not in gear. The area where Mr Barwick was located was heavily forested, steep and rocky. At 5.46pm Jeremy called emergency services and, at 6.15pm, police officers arrived at the scene. According to the attending SES officer who arrived at the scene, the handbrake of the tractor was not engaged.

A scene analysis and a reconstruction of events was undertaken by experienced crash investigator, Constable Nigel Housego, to determine the sequence of events leading to Mr Barwick’s death. Constable Housego formed the view that the tractor had not rolled onto its side at any stage, but had moved forward and trapped Mr Barwick underneath. Constable Housego was of the view that Mr Barwick had left the tractor running in neutral without applying the handbrake, due to the area appearing flat. It appeared to Constable Housego that Mr Barwick had tripped or fallen into the path of the moving tractor. The fact that Mr Barwick was found with his hands up covering his chest and head reinforced his view.

An exact sequence of events leading to Mr Barwick’s death is difficult to determine. In his affidavit, Jeremy said that he believed that Mr Barwick drove the tractor down a steep slope and started unrolling the bale from the tractor to feed the cows. Jeremy surmised, based upon his own significant experience with tractors, that Mr Barwick alighted from the tractor, most likely to manually unroll the last 10% of the bale. The tractor then continued to move whilst Mr Barwick was attending to the remainder of the hay. Jeremy said that his father must then have noticed the tractor moving and tried to jump back on, but slipped or tripped and was caught under the back wheel. Constable Housego agreed that this sequence of events was likely. There were no witnesses to the incident and no evidence to suggest other persons were involved in the incident. There is no evidence to suggest that Mr Barwick was suicidal or that his actions were deliberate. I agree with this likely scenario. I add that Mr Barwick likely alighted from the tractor on a portion of the track that appeared flat when compared to the other sections but which in fact had a 5.8% gradient – thus causing the tractor, without the handbrake applied, to roll forward.

On 10 June 2020, an autopsy was performed by forensic pathologist, Dr Donald Ritchey. At autopsy, Dr Ritchey noted that Mr Barwick had multiple rib fractures and copious foamy pulmonary oedema fluid within the airways. Dr Ritchey determined that Mr Barwick died from traumatic mechanical asphyxia consistent with being run over by the tractor. I accept his opinion.

Condition of the tractor On 15 June 2020, the tractor was inspected by Mr Barry Spencer, a Transport Safety and Investigations Officer employed by the Department of State Growth. I am satisfied that he is

appropriately qualified to express the opinions contained in his affidavit for the coronial investigation. Mr Spencer found that the tractor was not safe for operational use, the main safety issues being as follows:

• The hand brake lever did not hold upwards when applied and instantly self-released by dropping downwards;

• The left and right brake pedals could no longer be locked together to operate as a one pedal assembly due to a bent locking lever;

• The left and right foot brake pedals applied the brakes at different heights with a 40mm difference in pedal height;

• The clutch safety start switch had been previously damaged, had been bypassed and was no longer operational;

• There was excessive circular free play in the steering wheel measuring 135 degrees, due to worn steering components;

• Engine oil seeped onto the engine exhaust manifold and caused fumes in the vicinity of the driver’s seat whilst the engine was running;

• The front wheel bearings were loose and had a considerable amount of excess play, requiring attention and adjustment;

• Diesel fuel was constantly dripping from the right side of the engine at the diesel lift pump; and

• The tractor had no grab handles and therefore the driver would have had to use the steering wheel to mount the tractor.

The most significant safety issue contributing to Mr Barwick’s death would appear to be the non-operational handbrake. Mr Barwick either applied the handbrake before he alighted from the tractor but it failed, or alternatively, he did not apply the handbrake at all knowing that it was ineffective.

Comments and recommendations Mr Barwick died at his ‘workplace’ of unnatural causes. As such, his death would ordinarily be required to be the subject of a public inquest pursuant to section 24 Coroners Act 1995.

However, I have received a representation from the senior next of kin, Mrs Patricia Barwick, under section 26A(2) of the Act, that she does not seek that an inquest be held. Additionally, I am satisfied that not holding an inquest, under section 26A(3) of the Act, is not contrary to the public interest. I have therefore decided not to do so.

For the investigation, I commissioned a report from the National Coronial Information System on tractor incident deaths in Australia between 2012 and 2022. 1 The report indicated that there were 131 deaths within the decade, being an average of 12.3 deaths per year. The vast majority of the deceased were male and 63.4% of deaths were persons aged over 61 years. The main causes of death were: rollovers (29%); unexpected tractor movement (15.3%); and defective braking systems (13%).

The death of Mr Barwick is the fifth tractor death in Tasmania since 2017. Four of the deaths involved very old tractors (three with defects) operated by males aged between 63 years and 87 years. One of the deaths occurred in circumstances almost identical to this case.

Constable Housego commented in his investigation report that not only do tractors deteriorate with age but the physical capacity of the operator to meet the demands of their operation diminishes over time. Most often, old tractors are used in smaller family operations and may not be properly maintained, whereas larger working farms use more modern, safer tractors. These factors in combination mean that there is a high risk of danger to the operator of an old tractor and that further deaths or injuries are likely to occur.

Constable Housego provided information that in 1982, roll-over structures were made mandatory for any tractor used in a workplace in Australia, and that any tractor introduced after this date had to comply with a higher safety standard.

Constable Housego was of the view that if a Safe Tractor Access Platform (STAP) had been fitted to the tractor, then Mr Barwick would likely not have died as he would not have fallen between the tyres. A STAP is a simple platform fitted to the step area of the tractor that prevents operators from standing (or landing) on the ground between the front and rear wheels. A STAP greatly reduces the chances of an operator being run over whilst mounting and dismounting the tractor.

Mr Barwick’s death highlights that the practice of operators mounting and dismounting tractors which are in motion, or are likely to move, places their life at risk. Operators should not engage in this practice.

Recommendations I recommend that tractors manufactured before 1982 be legislatively prohibited from use in commercial farming operations.

1 National Coronial Information System – Tractor incident deaths in Australia CR22-24

I recommend, alternatively to recommendation 1, that Safe Tractor Access Platforms (STAPs)2 be required by legislation to be retrofitted to tractors manufactured before 1982 and which are used in commercial farming operations.

I extend my appreciation to the investigating officer, Senior Constable Nigel Housego, for his thorough investigation.

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

Dated: 19 May 2023 at Hobart in the State of Tasmania.

Olivia McTaggart Coroner 2 Constructed to enable the operator to mount and dismount a tractor without stepping in front of the rear wheels.