Finding into death of Kalon Tippett

FORM 38 Rule 60(2)

FINDING INTO DEATH WITHOUT INQUEST Section 67 of the Coroners Act 2008 Court Reference: 1137/2009 In the Coroners Court of Victoria at Ballarat

IM. Kay Robertson, Coroner having investigated the death of.

Details of deceased:

Sumame: ‘Tippett First name: Kalon Address: 120 Sawmill Rd Newlyn Vic 3364

without holding an inquest: find that the identity of the deceased was Kalon Tippett and death occurred on 21st February 2009 at 120 Sawmill Rd Newlyn from

1a) Massive head injury _

*Pursuant to Section 67(2) of the Coroners Act 2008, an inquest into the death was not held and the deceased was not immediately before the person died, a person placed in custody or care; but there is a public interest to be served in making findings regarding the

following circumstances:

Kalon Robert Tippett was born on 15 March 2007. He lived with his parents, Rose and Brockwell (Brock) Tippett at “Braeside”, part of a family farming enterprise situated at Newlyn. Brock’s parents, Kenneth and Anne Tippett, together with Brock, ran the enterprise known as “Tippetts

Glengyron”.

1... THE CIRCUMSTANCES.

The incident in which Kalon died happened on a paddock at “Braeside”. In 2008 the paddock was cropped and prickle chained. Brock then organised to clear the paddock of rocks in preparation for the next crop. This involved people walking through the paddock picking up rocks and putting

them in the bucket on a tractor.

On 21 February 2009, Brock drove the tractor, a 6420 John Deere fitted with an enclosed cabin, to the paddock, Kalon was on the passenger seat

with a seat belt on.

At about 9.45am, Brock arrived at the paddock and started picking up rocks, Shortly afterwards, Kenneth Tippett and 2 other adults attived to assist. Kalon sat in the tractor cabin with Kenneth Tippett as he drove very slowly behind the others who were picking up rocks. After about 20 minutes Kalon was getting restless in the cabin and he was taken out of the

cabin and walked beside Brock,

Brock reportéd he was conscious of the risk to Kalon of being near the moving tractor and sat him in the bucket as he thought it would be safer, He was sitting on the left hand side of the bucket looking forward. Mr Kenneth Tippett had seen Brock put Kalon in the bucket but could not see Kalon from where he was, He believed him to be safe as the bucket was low to the ground.

Brock continued to keep an eye on Kalon as he picked up rocks and the tractor crawled forward, He reported Kalon remained seated and seemed happy. After they had travelled about. 100 metres, Brock turned away from the tractor and walked 10 — 20 metres to pick up rocks, When he tumed again he saw Kalon had gone under the wheels of the tractor. No-one saw him leave the bucket. Brock yelled and his father stopped the tractor, It was too late;Kalon had died instantaneously of massive head injuries.

POLICE INVESTIGATION,

Police attended and conducted a thorough investigation.

They reported ,

. the ground was flat and loose;

» the weather was clear; ;

« the tractor was well maintained and in good operating condition, + drugs or alcohol were not factors involved; ’ no criminal charges were being laid,

TRACTOR SAFETY.

‘The John Deere operators manual for the tractor has a chapter on safety. It is clearly set out and states in a large bold font “Keep Riders Off Machine” and “Only allow the operator on the machine... Riders on machine are subject to injury such as being struck by foreign objects and being thrown off the machine”,

Similarly, the operator’s manual for the loader has a chapter on safety.

Under the heading “Protect People and Animals” which is in large bold font it states “Do not lift or carry anyone on loader or in bucket or attachment”, Both manuals were in the tractor cabin,

There are many publications about farm safety including managing risks of children and tractors. There are also initiatives such as National Farm Safety Week which aim to improve farm safety, including reducing risks to children on farms,

SUPERVISION.

Brock and Kenneth Tippett are experienced farmers who havo grown up and worked on family farms all their lives. This has included working with equipment and machinery as part of every day operations. .

Brock and Kenneth Tippett were aware of safety warnings in relation to the tractor and both regarded children’s safety on the farm as common sense,

Brock Tippett in his statement said “This was the first time (1 had put Kalon in the bucket), When I was a kid, my dad used to sit me and Alistair in the bucket all the time. It was an accepted thing to do. It probably still is the area that this will stop as it has shocked the whole community and made people realize just how dangerous it can be.”

CONCLUSION,

Tractors are inherently dangerous. Risk can be minimised through ensuring they are well maintained, operators are sufficiently skilled and systems are

used which reduce the risk.

Young children behave erratically and do not understand risk or danger in the way adults do, Young children and tractors are a potent combination, a momentary lapse in supervision can easily resulting in tragic consequences, as in Kalon’s case.

Ideally children should not be in the vicinity of working farm machinery.

Where this is unavoidable, they need to be supervised very closely,

RECOMMENDATIONS:

Pursuant to Section 72(2) of the Coroners Act 2008, I make the following recommendation(s) connected with the death:

1 Agencies such as Workcover and farmers’ organisations should continue with safety campaigns to increase farmer awareness of safety, and need to | implement strategies to avoid tragic and preventable deaths.

Signature:

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Date: 10 August 2010

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