Finding into death of Eileen Kaye McInnes

IN THE CORONERS COURT OF VICTORIA AT WANGARATTA Court Reference: COR 2010 004123

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, STELLA MARIA STUTHRIDGE, CORONER, having investigated the death of EILEEN KAYE

MCINNES

without holding an inquest: find that the identity of the deceased was EILEEN KAYE MCINNES born on 30 August 1951 and the death occurred 27 October 2010 at 12695 Murray Valley Highway, Towong Victoria 3707 from: la CHEST AND ABDOMINAL INJURIES

Pursuant to section 67(2) of the Coroners Act 2008 there is a public interest to be served in making findings with respect to the following circumstances:

Mrs Eileen Kaye McInnes was 59 years old. She lived and worked on farming property in Racecourse Road, Towong with her husband Ron and son, Aaron. The family also leased a farm in

Murray River Road, Towong.

On Wednesday 27" October 2012, Mrs McInnes was working on the Murray River Road property, Mr Aaron McInnes travelled over to the Murray River Road property to collect a forklift for use at

the family farm. When Aaron arrived, he found his mother in the shed area of the farm. The

Massey Ferguson 6265 Tractor was parked facing forward into the shedding and had a bulka bag of calf pellets on the forks on the tractor. Mrs McInnes asked Aaron to move the calf pellets to

another area before he took the tractor.

Aaron got into the tractor and raised the bulka bag approximately 50 centimetres off the ground using the forks and the front-end loader. Aaron stated he always carried the bags in this way. This method of carrying the bag is the recommended way to carry the bag on the Australian Standards

label 3668 attached to the bag. Lifting the bag this way restricts the driver’s forward vision.

Aaron backed the tractor around and commenced to drive towards the gateway leading to the paddock. Aaron states he was travelling at approximately 12-14 kilometres an hours. Information

received from the Major Collision Investigation Unit corroborates this speed.

Aaron states that as he got into the tractor he saw his mother walk off, away from the direction he was to drive the tractor. Aaron travelled approximately 50 meters towards the paddock when he noticed ‘a flicker of a red shirt, possibly highlighted against the white Bulka Bag’. Aaron states he immediately believed it was his mother in front of the tractor crouching between the bulka bag and the front wheel of the tractor, Aaron had not sighted his mother before this point. He immediately

applied the brakes,

When the tractor stopped, Aaron found his mother lying on the ground between the front and rear wheels of the tractor, with her head closest to the front wheels. Aaron immediately sought the assistance of his father and ambulance. Mrs Eileen Kaye Mclnnes died shortly after of injuries

sustained in the accident.

Sergeant Brady, Victoria Police and Mathew Read, Work Safe Investigator extensively investigated the accident. The evidence suggests Mrs McInnes has changed her direction of travel and moved into the area where the tractor was operating. It appears the right hand side of the bulka bag has struck Mrs McInnes and then either in the process of falling or getting up she has

been run over by the front whcel of the tractor.

I am satisfied Mr Aaron McInnes is an experienced tractor driver, and had used this tractor since

2002. Further, he was using the tractor in the manner described in the accepted Australian

Standards Label 3668.

In the interest of prevention of a similar death, | note that during the investigation, Mr Kevin Simmonds of Worksafe undertook an extensive review of the scene and provided a report to the Coroner. Mr Simmonds expresses the opinion that despite the Australian Standard, the safost system of operating the tractor with a bulka bag on board would have been to operate the tractor in

reverse, possible with the rear window open. I agree with this assessment.

RECOMMENDATIONS

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

I recommend that Worksafe review the contents of the ‘Safe use of Tractors with Attachments’

handbook to reflect the above recommendation,

In all the circumstances I am satisfied Eileen Kaye McInnes died as a result of injuries sustained in a

farming accident (tractor).

Signature:

A\ ag

STELLA MARI4STUTHRIDGE

CORONER Date: 6 August 2012