Coroner's Finding: Tribolet, John Wesley

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the death of John Wesley Tribolet Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is John Wesley Tribolet; b) Mr Tribolet died as a result of a single vehicle crash on private property; c) The cause of Mr Tribolet’s cause of death was mechanical asphyxia; and d) Mr Tribolet died, aged 82 years, on 19 November 2019 at 1110 Swanston Road, Swanston, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Tribolet’s death. The evidence includes:  Police Report of Death for the Coroner;  Affidavits establishing identity and life extinct;  Report – Dr Donald Ritchey, Forensic Pathologist;  Report – Forensic Science Service Tasmania;  Records – Ambulance Tasmania;  Medical Records – Mr Tribolet;  Report – Tasmania Police Crash Investigation Services;  Report – WorkSafe Tasmania;  Vehicle Owner’s Manual – Polaris Ranger 4x4 500 EFI;  Affidavit – Mrs Elizabeth Tribolet, sworn 19 April 2020;  Affidavit – Mr Daniel Tribolet, sworn 19 April 2020;  Affidavit – Mr John Rowlands, sworn 30 December 2019;  Affidavit – Mr Peter Carnes, sworn 29 December 2019;  Affidavit – Constable Shane Leek, sworn 19 June 2020;  Affidavit – Constable Suzanne Jaenke, sworn 30 January 2020;

 Affidavit – Constable Jared Gowen sworn 26 December 2019;  Report – Mr Paul Wells, Transport Inspector; and  Affidavit – Constable Nicholas Monk, sworn 6 February 2020 (and photographs).

Introduction

1. Mr Tribolet was, at the time of his death, a semi-retired farmer. He had farmed all his life. He lived with his wife of more than 50 years, Elizabeth, on a property in the Swanston area, east of Oatlands.

2. The farm was owned and managed by his son Daniel1. The property was a sheep farm.

3. Mr Tribolet was, considering his age, in good health and led an active lifestyle. He was troubled by osteoarthritis and had recently undergone surgery to repair an inguinal hernia. He was also diagnosed as suffering from diabetes in years leading up to his death. Standard cardiac testing indicated he suffered no cardiac issues. Also Mr Tribolet required glasses. But otherwise, as I have said, particularly in view of his age, his health was good.

Circumstances of death

4. On 19 November 2019 Mr Tribolet was assisting Daniel and two other men, Mr John Rowlands and Mr Peter Carnes, with lamb marking. Mr Tribolet’s role was to move flocks of sheep from the covered lamb marking area to a nearby rear paddock.

To do so he drove a Polaris all-terrain vehicle, a vehicle with which he was familiar and which the evidence suggests he had used it if not daily then extremely often in his duties around the farm.

5. The Polaris ATV was a so-called side-by-side vehicle. It is designed expressly for off road use. It has four wheels, independent suspension and disc brakes and weighs 476 kg. The ATV is steered by a steering wheel in the left-hand drive configuration.

The transmission is operated or controlled by a single gear-lever with five gears – high, low, neutral, reverse and park. The vehicle is capable of carrying a passenger in addition to the driver. The passenger sits in the seat next to the driver. The ATV was fitted with a roll cage. It was fitted with several safety warnings highlighting that a seatbelt and helmet must be worn.

6. The evidence is that Mr Tribolet drove the ATV very slowly.

1 Strictly speaking the farm was owned and operated by Daniel in partnership with his wife, Rebecca.

7. The vehicle had been purchased second hand (it was in very good condition) and no cabin safety nets were within it when purchased.

8. At approximately 1:15 pm Daniel, Mr Rowlands and Mr Carnes completed marking one particular mob of sheep. Daniel asked his father to open up the gate and drift the ewes into the rear paddock. Mr Tribolet was seated alone in the ATV, not wearing the seatbelt fitted to the Polaris, not wearing a helmet and only wearing a pair of ‘crocs’2 and socks (he was reluctant, apparently, to wear proper work or safety boots).

9. At approximately 3:05 pm after Daniel, Mr Rowlands and Mr Carnes went to the main farm residence to have afternoon tea. Mr Tribolet’s absence from afternoon tea was noted but not considered unusual for he would reportedly often move about the farm on his own and not return for several hours.

10. Mrs Tribolet walked outside to move some hoses within the garden area at the rear of the Homestead. As she walked towards the rear of the garden she saw the ATV upside down in a nearby paddock. She walked a short way towards the ATV and saw that her husband was under it. She went back to the house to tell Daniel.

11. Daniel, Mr Rowlands and Mr Carnes all rushed to the ATV and lifted it back onto its wheels. It was apparent that Mr Tribolet was gravely injured. No pulse was able to be detected. Those present formed the view, correctly, that Mr Tribolet had passed away.

12. Police and ambulance were called and arrived in a timely fashion. Ambulance paramedics confirmed Mr Tribolet was deceased.

Investigation

13. The fact of Mr Tribolet’s death was reported to Coroner McKee in accordance with the requirements of the Coroners Act 1995. His body was photographed and formally identified at the scene and then transported by mortuary ambulance to the Royal Hobart Hospital.

14. Meanwhile, an investigation in relation to the circumstances surrounding Mr Tribolet’s death was commenced at the scene. A specialist officer from Tasmania Police Forensic Services attended and photographed and examined the scene. An officer from Tasmania Police Crash Investigation Services also attended and carried out 2 A foam plastic clog.

investigations. Investigators from WorkSafe Tasmania also intended and carried out investigations.

15. Nothing suspicious was identified at the scene. The terrain where the crash occurred was noted to be flat and dry.

16. The ATV was inspected at the scene. At the time of inspection the transmission was in high. Tyre marks, suggesting a loss of traction, were found in the soil behind the ATV. Near the tyre marks was a dead lamb with blood around its mouth which must have been struck by it. Next to the dead lamb was a steel gate and at 625 mm from the ground investigators found a fresh black paint transfer and that the steel gate was bent inwards at a shallow angle, indicating that the gate had been struck by the ATV.

17. Near the gate two fence posts showed signs of having also been struck by the ATV.

18. The ATV’s tyres were noted to be fully inflated and in good order. After examination at the scene it was seized and transported to the police garage in Hobart for subsequent investigation by a Transport Inspector.

19. The following day, 20 November 2019, Dr Donald Ritchey performed an autopsy.

Following that autopsy Dr Ritchey provided the report in which he expressed the opinion that the cause of Mr Tribolet’s death was mechanical asphyxia. The evidence in relation to asphyxia was the fact that Mr Tribolet’s body had been found pinned on the ground beneath an overturned ATV and had marked facial congestion with facial petechiae and florid conjunctival petechiae – both very clear signs of asphyxia. I accept Dr Ritchey’s opinion.

20. Samples taken from Mr Tribolet’s body were subsequently analysed at the laboratory of Forensic Science Service Tasmania. No alcohol or drugs were detected as being present in those samples.

21. The ATV was examined by Mr Paul Wells, an experienced Transport Inspector. Mr Wells found that the vehicle was fitted with lap sash retractable seat belts, capable of being coupled and uncoupled as required. The seat belts were securely mounted, damage and defect free and fully operational. Mr Wells did not find any mechanical defects in the ATV which could have caused or contributed to the happening of the crash.

22. All of this material has informed these findings.

Conclusion

23. I am quite satisfied that alcohol and drugs did not play any role in the crash which claimed Mr Tribolet’s life. I am also satisfied that the vehicle he was using was free from defect. There is no evidence to suggest that Mr Tribolet was operating the ATV at an excessive speed. Nor is there any evidence to suggest the involvement of any other person in his death. Weather conditions and the terrain did not cause or contribute to the happening of the crash either.

24. I am also satisfied that speed did not play any particular role in the happening of the fatal crash. The evidence at the scene satisfies me to the requisite legal standard that Mr Tribolet lost control of the ATV (just why I cannot determine) and collided with the lamb and an open gate. After collision with the gate the ATV continued to travel forward before mounting the wire fence, and climbing the fence post, which lifted the front wheels from the ground. Once the wheels lifted from the ground the ATV rolled laterally to the left. As it rolled, Mr Tribolet was ejected from the cabin and then rolled on by the ATV.

25. The single most important fact which caused this death was the failure of Mr Tribolet to wear a seatbelt. If he had worn a seatbelt Mr Tribolet would not have been ejected from the vehicle but would have remained within the roll cage and protected by it.

26. Similarly, had cage nets (something expressly recommended for use in the operator’s manual of the ATV) been in place Mr Tribolet would not have been thrown from the cabin and therefore not crushed to death.

Comments and Recommendations

27. The circumstances of Mr Tribolet’s death require me to recommend pursuant to Section 28 of the Coroners Act 1995 that ATVs only be operated in accordance with the operator’s manual, particularly in regard to the wearing of seat belts and the use of cage nets.

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

Dated: 17 February 2023 at Hobart the State of Tasmania.

Magistrate Simon Cooper Coroner