Finding into death of Anthony John Roach

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2007 0739

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1)

Section 67 of the Coroners Act 2008

Inquest into the Death of: ANTHONY JOHN ROACH

Delivered On:

Delivered At:

Hearing Dates:

Findings of:

Representation:

Police Coronial Support Unit

26 June 2013

Level 11, 222 Exhibition Street Melbourne 3000

11 February 2010 6—8 December 2010 4 March 2011

ies}

JANE HENDTLASS, CORONER

Mr Champion SC appeared on behalf of President of the Nunawading & District MX Club Inc.

Leading Senior Constable Greigory McFarlane assisting the Coroner

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I, JANE HENDTLASS, Coroner having investigated the death of ANTHONY JOHN ROACH

AND having held an inquest in relation to this death on 11 February 2010, 6 to 8 December 2010 and 4 March 2011

at MELBOURNE

find that the identity of the deceased was ANTHONY JOHN ROACH

born on 9 June 1965

and the death occurred on 24 February 2007

at Nunawading & District MX Club, Burwood Highway, Vermont South 3133

from: l(a) ACUTE INTERNAL BLOOD LOSS l(b) LACERATION OF THE AORTA IN TANDEM WITH SPINAL FRACTURE l(c) BLUNT FORCE TRAUMA TO THE BACK

in the following circumstances:

1. Anthony Roach was 41 years old when he died. He lived with and cared for his four year old daughter, Mia Hamilton Roach, at 9 Imperial Avenue in Bayswater. Mr Roach also had a continuing relationship with Mia's mother, Margaret Hamilton, and her two

other children. Ms Hamilton's son, Jesse Vine, lived part-time with Mr Roach.

2. Mr Roach had been a member of the Nunawading & District MX Club Incorporated (the "Club") for about eight years, In 2005, he was a general committee member of the club and a track hand appointed by the Committee. Mr Roach was also a member of other motocross clubs in Thomastown and Frankston and Motocross Victoria.

He and Jesse rode in motor cycle races most weekends.

3. At Christmas 2006, Mr Roach bought a new motorcycle. This motorcycle was assessed as in good mechanical and as new condition, However, Mr Roach had only ridden it a

couple of times before his death.

4. On 24 February 2007, Mr Roach and Jesse participated in the Club motorcycle race meeting at Nunawading, At about 10,00am, as he was completing the first lap of the B Grade Martini Racing race (the "Race'), Mr Roach’s motorcycle crashed towards the end of the

top of the big table top jump. He fell off on the down ramp.

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As Mr Roach began to get up from his fall, another motorcycle in the race ridden by James Snow came down the slippery ramp from the jump and was unable to avoid hitting Mr Roach as he tried to recover from his fall. Mr Roach was immediately

unconscious with no pulse and not breathing.

At 10.50am on 24 February 2007, Anthony Roach died.

The forensic pathologist who performed the autopsy formed the opinion that the cause of death was acute internal blood loss caused by laceration of the aorta in tandem with spinal fracture and blunt force trauma to the back. Further, histology showed

tobacco macrophages in the lung tissue indicating he was a smoker.

Toxicological analysis detected 15ng/ml delta-9-tetrahydrocannabinol in blood where levels greater than Sng/ml strongly suggest use of cannabis within the last two to four

hours.

Toxicological analysis also detected 1340ng/ml 11-nor-delta-9-tetrahydrocannabinol in urine. This concentration indicates that cannabis was also used over a longer period of time. Chronic use can account for up to about 2ng/ml of the delta-9-tetrahydrocannabinol in blood.

Accordingly, I find that Anthony Roach died from acute internal blood loss caused by laceration of the aorta in tandem with spinal fracture and blunt force trauma

to the back sustained during a motor cycle race.

This Finding will review in more detail the arrangements for Motocross racing at the Nunawading & District MX Club and the incident in which Mr Roach died. It will then comment and make recommendations intended to improve the safety of motocross

participants in Victoria.

Nunawading & District MX Club

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The Nunawading && District MX Club ran monthly motocross race meetings at the motocross venue at the Old Burwood Road Tip and Lots land 2 and part 3 Burwood Highway in Vermont South. The Club was also open every weekend for members to

practice.

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The Club held a lease from the City of Whitehorse to use the land and a planning

permit to conduct Motocross Club race meetings and ancillary activities on the land.

The planning permit expired on 20 November 2003 unless extended by the Manager-City

Development afier consultation with the Council's Operation Group.

As relevant the planning permit and lease required:

e Race meetings to be limited to between 9.30am and 4.30pm on Saturdays, Sundays and

public holidays; e Racing shall be supervised at all times by adult members of the Club;

• No motorcycle with an engine capacity over 250cc shall use the land;

e The layout of the track shall be to the satisfaction of the Council's Group Manager

Operations.

Within the conditions imposed by their lease, a volunteer Management Committee managed

the Club. In 2007, the Chair of the Management Committee was Claude Crugnale.

Mr Crugnale described the Club as a feeder club because members included motorcycle riders, family members and children who were learning to ride motorcycles. The Club actively encouraged family participation in and support for motorcycle riding and the family

membership fee included all children under 18 years old.

The monthly race meetings of the Club were administered according to the Nunawading

& District MX Club Inc. Policies and Procedures.

In particular, the Club Management Committee was responsible for determining and maintaining the track on which motocross races were run (the “Track”). They also provided scrutineers and marshalls on race days and allowed members to buy food and non-alcoholic

beverages from the canteen.

Further, all participants in Club race meetings had to be existing members of the Club.

St John First Aid personnel routinely attended each race day. All accidents must be written in

the incident book. This record should have included the place on the track where the accident

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occurred, The Management Committee Member on Duty was responsible for completing the

incident book.

Nunawading & District MX Club provided the Court with the original incident book. This book includes incidents from 15 July 2000. However, there was no record in the incident

book of any incidents after 23 July 2005.

The Club usually ran up to 20 races and more than 100 riders participated in these races on

each race day.

The track included capacity for 15 riders in each race: that is there were 15 start gates.

Each race was allocated to different levels of rider competence and first time riders were independently graded at Nunawading. However, the riders in a race were often of mixed

competencies.

Riders who intended to ride on a race day were required to advise the Club that they intended

to ride before the race day. Their names were then printed in the schedule.

The Policies and Procedures Manual indicated that entries closed on the Thursday prior to the race meeting and no late entries would be accepted. The Race Entry form indicated this

notification must occur on the previous Sunday.

The Motocross track comprised ‘a dirt track and a number of jumps of various levels of

complexity.

The table top jump was the third obstacle in a race and about half way round the track. It was about 2-3 metres above the ground and 15-20 metres long. There were ramps leading up

to it on cach end.

Riders approached the up ramp of the table top jump at a speed that depended on their capability. They needed to travel at about 50kph on the up ramp to achieve the height and distance needed in their motorcycle to jump over the flat part of the jump and land on the down ramp. However, it was not unusual for motorcycles to land on the ramp or, even, not

jump at all.

It was usual for the track to be damp and muddy. When there has been no rain, the track was

dampened down to minimise dust.

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Before participating in the motorcycle races at the monthly meetings of the Club, each rider was required to sign in on the daily sheet, have their bikes scrutinised by the scrutincers and have a briefing. All riders must have a representative for

Corner Duty.

The Nunawading & District MX Club "Guide to Assist Scrutineers" indicated that riders should wear a helmet in good condition with a chin strap that works, back protector or body armour, footwear with ankle protection, gloves and goggles

and long sleeved protective clothing.

Mr Snow told the Court that the scrutineer checked:

“Just stuff like spring loaded footpads, bearings, loose spokes and tyre pressures, chain

tension, wear and tear.”

Mr Snow also said that most bikes had been pretty well maintained so most of them passed or they could be fixed. If they could not be fixed, bikes with deficiencies were not allowed to

Trace,

In his statement, Mr Crugnale said that the club prohibited drug and alcohol use on the track. If someone was found drinking or using drugs they were removed from the race and they must attend a meeting to assess their future involvement in the Club. However, there was no routine individual assessment of riders undertaken prior

to racing.

Further, no witnesses said they had ever seen anyone using cannabis at a Club race

day and no one was aware that Mr Roach had used cannabis on 24 February 2007.

After walking the track, there was a briefing for riders every race day. In that briefing, the Club President told riders the order of events and emphasised that they were riding at their own risk. If any rider wanted to withdraw because of the state of the track their money could

be refunded.

Riders were also provided with the opportunity to undertake three practice laps on the track

before racing commenced for the day.

Motoreycle races run by the Club required riders to wait in a grid from which

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they were released one at the start of a race.

There were 12-15 marshals appointed each race day: two marshals to each corner of the track as well as the starting marshall, the gate marshall and two running marshalls. These marshals

were usually family members.

The marshalls’ job was.to stand close to the track and watch the race from when a bike passed them until it entered the vision of the next two marshals, Ifa marshal saw an accident, he or she was required to put up a yellow flag to inform the following riders. The marshal also

displayed a white flag with a red cross to call for first aid.

The Race on 24 February 2007

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On 24 February 2007, there were 18 races scheduled. It had been raining and the track was wet but it was not in poor condition. The track and the ramps for the jumps were

muddy and greasy. No one withdrew from riding because of the state of the track.

On 24 February 2007, Mr Crugnale was Assistant Chief Marshal. His role was to supervise the track during the races and deliver the riders’ briefing. To bis knowledge, no

one was using alcohol or drugs.

Philip Russell was a Committee member and in charge of scrutinecring the bikes on 24

February 2007. He and Brett Barber performed all the scrutineering on the day.

Mr Roach and Jesse arrived at the track at 7,.00am on 24 February 2007. Mr Roach was scheduled to participate in the first race of the day. However, he had signed his Race Entry Form on the day of the race, not on the previous Sunday or Thursday

variously specified as mandatory by Mr Crugnale and the Race Entry Form.

Mr Roach was in gate 14 of 15 gates allocated for the race.

At 9.00am on 24 February 2007, the practice rides commenced, Mr Roach undertook

three warm up laps to assess the track.

Then at 10.00am, Mr Roach participated in the race.

There were nine riders scheduled to participate in the Race including Mr Roach,

James Keskinen, Simon Lawther, Russell Whittam, Jason Harris and Owen Chadwick.

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Other riders who participated in the race, despite not being on the race schedule, included

James Snow and Matt Russell.

These race participants included both A and B Grade riders.

At about 7.00am on 24 February 2007, Mr Snow and his parents also arrived at the Club.

Mr Snow was 16 years old. He had been riding at motocross for about four years. Mr Snow had been upgraded from an A grade junior racer to B grade senior in November 2006.

Since then he had raced in about five or ten senior races. Mr Snow also raced at other motocross

venues including those affiliated with Motorcycle Victoria or Motorcycle Australia.

Mr Snow's motorcycle was assessed to be in good mechanical order and in near new

condition.

Mr Snow also undertook three practice laps of the race course and participated in the race in which Mr Roach died.

During the race, Mr Snow was about second last with Mr Roach two in front of him as they approached the table top jump. Mr Snow told the Court that it was early in the race and the riders were still bunched together over a distance of 15 to 20 metres from front to back of the race and two

or three metres wide.

Mr Snow told the Court that he was in the air approaching the down ramp for the table top jump when he saw Mr Roach’s bike tangled with another bike and the two bikes fall to the ground in

front of him. He also saw another rider swerve to miss Mr Roach,

When he hit the down ramp, Mr Snow was travelling at 50kph and about 1 % metres from the left hand side of the track. There was another rider on his right and Mr Roach was on the

ground about 10-15 metres in front of him.

Mr Snow applied his brakes heavily and skidded on the greasy track but he could not avoid colliding wilh Mr Roach. He thought he hit Mr Roach in the torso and hip area.

In their statements prepared for the Court, Matt Russell and Simon Lawther explained their observations of the factors that caused Mr Roach to lose control of his motorcycle as well as Mr

Roach’s movements after his motorcycle landed:

© Matt Russell was an A grade rider open division (power of bikc unlimited) with 10 years

experience. In his statement, Mr Russell says that Mr Roach was just in front of him, a

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couple of metres away, when they approached the 45 foot table top jump on the second

straight of the first lap.

As Mr Russell was beginning the jump, he saw Mr Roach's bike appear to slide out from under him before Mr Roach became airborne for the length of the jump. Mr Russell did not

see any contact between Mr Roach’s motorcycle and another motorcycle.

As he got to the other end of the jump, Mr Roach hit the ground and his motorcycle fell on to his lower body. Mr Roach continued to slide for another 15 feet down the ramp. Mr Russell was able to avoid hitting Mr Roach as he lay on the ground without moving.

He did not see Mr Roach's bike collide with another bike, He does not comment on

whether a second bike collided with Mr Roach while he was on the ground.

Mr Lawther says he was also next to Mr Roach on the grid but he was near the back of the riders when the race started. He was beside and a bit behind Mr Roach as they approached the table top jump. However, he did not have a good view of Mr Roach when he lost control of his bike. He did not collide with Mr Roach's bike.

61. Further, a number of other observers prepared statements for the Court outlining their

observations of the Race and the incident in which Mr Roach died.

Brett Barber was the Marshal on Corner Four during the Race. He had a clear view

of the riders as they came off the table top jump.

Mr Barber says that Mr Roach approached the table top jump at the correct speed.

His motorcycle was straight and there was no indication of it losing direction in the air.

As he was in the air, Mr Roach's left hand came off the handle bar.

This action could have been part of tearing off his goggle protector film but it was an unusual time to do it and his goggles were not fitted with tear-offs. When Mr Roach

landed on the down ramp, his left hand was still not on the handle bar.

In his statement, Mr Barber described his observation of Mr Roach’s behaviour this way:

"They are in the air. Anthony's left hand came off the handlebar, but when he's landed

he didn't have his hand back on the bar."

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Mr Roach lost control of his bike when the front wheel washed out and landed to the right side. Mr Barber says that Mr Roach and the bike slid down the down ramp and to the right

into the line of Mr Snow’s motorcycle.

At the bottom of the ramp, Mr Roach was trying to get up with his elbow on the ground to assist him. However, he lay down again at the same time as Mr Snow’s bike hit the centre of

Mr Roach's back.

e Maxwell Harris was a Flag Marshal at Corner Four back table top jump on 24 February 2007. However, his view was obscured by the jump and he could not see

what caused Mr Roach to lose control or subsequent events.

e Brett North was another motorcycle rider who was observing the race. He says that Mr Roach was about eight feet off the ground on the table top jump when another rider clipped his right hand. Mr Roach's right hand slipped off the handle bars and the bike washed out so that it slid down the off ramp with Mr Roach still on it.

Another rider came off the table top jump and landed on Mr Roach.

e Stephen Walker was also a motorcycle rider who was observing the race. He noticed Mr Roach was in fourth position as he approached the big table top jump. Mr Walker is unable to explain why he crashed his bike at the top of the jump. He saw Mr Roach fall off his bike on the down ramp and he saw him trying to get up or move

himself off the track, However, Mr Snow hit Mr Roach with his bike.

e Daniel Mott was a Junior B grade motorcycle rider who was videoing the race from a distance of about 80 metres. He was 15 years old and had five years expericnce racing motorcycles. However, it was his first day at the Nunawading track and he did not know Mr Roach or the other participants in the race. Mr Mott also saw Mr Roach stand up

after his bike crashed before another rider hit him.

The video shows that Mr Roach’s motorcycle was nose heavy while he was in the air compared with other riders’ motorcycles. Mr Mott told the Court that this indicated that he was already incorrectly placed in his jump. The sound on the video also indicates that Mr Roach not fully in control of his motorcycle at the time he became airborne over the

table top jump and tried to rectify this by accelerating harder.

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Mr Mott was unable to say what had caused Mr Roach to lose control of his motorcycle.

However, there is no indication on Mr Mott’s video that any other rider had contact with

Mr Roach while he was in the air over the table top jump.

Philip Russell was a committee member and in charge of scrutineering the bikes on 24 February 2007. He saw Mr Roach hit the table top jump very close to his son, Matthew, who was also in the first race. As Mr Roach hit the up ramp, the rear of his bike stepped out to his right. When he was in the air, Mr Roach’s bike positioned slightly sideways so that Mr Russell was aware that, if he did not correct it, Mr Roach would land sideways.

Mr Russell saw Mr Roach’s bike land sideways and Mr Roach was thrown off.

Chennell Rupenovic was one of the St John Ambulance volunteers who responded to the incident in which Mr Roach was injured. He had worked at the Club for about five months when Mr Roach died. Mr Rupenovic told the Court that it was common for

riders to fall off their motorcycles during races at the Club.

From about 8.45am on 24 February 2007, Mr Rupenovic was at the Club with other St Johns Ambulance voluntcers. He was stationed under an elevated tower in the middle of the track during the race that was used by the time keepers and about 10 metres

from the incident in which Mr Roach died.

Mr Rupenovic saw Mr Roach come over the ramp and crash on the left side of the track. Mr Rupenovie says that he also saw Mr Roach trying to get up when a

second rider hit him.

Mr Cragnale and the investigating policeman, Leading Senior Constable Mark Preston, inspected the scene immediately after the incident in which Mr Roach died. In their opinion, the skid marks they found. at the beginning of the table top jump came from Mr

Roach’s motorcycle.

All this evidence indicates to me that Mr Roach probably skidded on approach and was not travelling in a straight line when he entered the up ramp of the 45 foot table top jump on the second straight of the first lap of the Motocross track. Nevertheless, he was travelling at sufficient speed to take off and reach a height of about eight metres over the jump. At the same time, he increased the throttle which is the usual way to correct the direction in which

an airborne motorcycle is travelling.

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While in the air and with his left hand on the throttle, Mr Roach took his right hand off the handle bars and moved it in the direction of his face. It is significant in the context of Mr

Roach’s known cannabis use that Mr Barber told the Court:

“T've only ever done something similar to that once and that was because of my skill

level. Iwas very tired.“

Mr Roach did not replace his hand on the handle bars or fully correct the direction of his motorcycle before it hit the down ramp, washed out to the right and slid down the ramp. Mr

Roach went down with his motorcycle.

The evidence is inconsistent about whether or not Mr Roach’s motorcycle had contact with another motorcycle during the period it was out of control. On balance, it seems more likely that no other motorcycle was involved during the period when Mr Roach’s motorcycle was in the air over the 45 foot table top jump on the second straight of the first lap of the Motocross

track.

I also had the opportunity to inspect the Club motocross track. 1 was assured that, although there had been other changes to the track, the table top jump that I saw was essentially in the same format that it was at the time of the event. Further, I noted that the signs on the canteen said "No Aicohol", and that they were long standing. Since that time new signs have been

added that also say "No Drugs".

After he saw Mr Roach fall on the track on 24 February 2007, Mr Rupenovic could not enter the track until the marshals raised the white flag with a red cross on it to indicate it was safe. There was some delay in the marshals raising the flag but, when they did get to Mr Roach, he was not responding, they could find no pulse and he was

gasping with Agonal breathing.

Mr Roach was unable to be revived.

Dr Martin Dutch was the coordinator of St John volunteers as well as an emergency physician

at the Royal Melbourne Hospital. He told the Court that:

“even if this incident had occurred in the ambulance bay of our hospital, we would be

unable to do anything for this patient.”

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Therefore, in this case, ] have no reason to believe that the presence of emergency medical officers with more experience and training than the volunteer St John first responders at the

scene would have made any difference to the outcome.

The incident on 24 February 2007, when Mr Roach died, is not recorded in the incident book, Further, Mr Crugnale was unable to provide the Coroner with any other written documentation of the incident. However, another incident on 13 March 2004 involving Mr

Roach is recorded. On that occasion an ambulance was called.

Therefore, I find that no evidence that any one from the Nunawading & District MX Club

recorded the incident in which Mr Roach died in the incident record book.

Toxicological evidence indicates that Mr Roach was probably a frequent cannabis user.

Further, he had a level of delta-9-tetrahydrocannabinol in his blood consistent with have used the drug in the two hours before he died, that is after he arrived and signed on at the Club on 24 February 2007,

Although the investigating police membcr made some enquiries and Mr Roach’s cannabis use was not out of the ordinary for the people that he found Mr Roach was involved with Mr Barber had known Mr Roach for 30 years. He had never seen Mr Roach

using drugs other than alcohol. He had never seen drugs at the Club,

Mr Barber was very surprised when he was told that Mr Roach had a cannabis level which indicated he had been using the drug after he arrived at the track. However, he also told the Court that he had an apprentice who used cannabis and he was also completely unaware of

this until someone else told him:

“Ll had an apprentice that used to smoke a lot of dope and that and I was oblivious to

that too. I just always thought he was tired until one of’ my other workers complained.” Mr Davey also had no idea that Mr Roach used cannabis. If he had known:

“He would've been kicked out straight away. It's just - it's a non event, he would've

been gone, in his car and out the gate, see you later. It's an absolute zero tolerance...”.

Mr Crugnale, Matt Russell and Mr Lawther all spoke to Mr Roach before the race and he did not appear to be affected by drugs. Mr Russell told the Court:

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"T was waiting next to Roachie at gate 13 for about five minutes and during this time I had a short conversation with Roachie which probably went on for about a minute. We had a general conversation about the race just before and I told him, "Don't cut me off before the line and he had a little chuckle at this. When I spoke to Roachie he did not appear that he had been drinking or taking any drugs. I'd spoken to him many times before and he did not seem any different on this particular day. His speech was good

and he did not look tired or anything like that."

78, Therefore, 1 am unable to say when or where Mr Roach used cannabis in the two hours before

he died,

COMMENTS:

Pursuant to section 67(3) of the Coroners Act 2008, | make the following comments connected with the death (including any notification to the Director of Public Prosecutions under Section 69(2) of

that Act):

1. On 24 February 2007, Anthony Roach died when he was hit by a motorcycle ridden by James Snow as he tried to get up following a fall after he lost control of his motorcycle on the down ramp of the table top jump in the first lap of the first race at the Nunawading & District MX Club (the “Club”).

2. Mr Roach would not have died in the way he did if he had not fallen off his motorcycle or if Mr Snow had been able to avoid him after he fell off his motorcycle. The reason that Mr Snow could not avoid Mr Roach was that there was another rider on his left preventing him

taking evasive action.

3, Mr Snow told the Court the reasons he participated in the sport:

“Adrenalin is great, more it's a combination of so many things like, you know, the bike, you know, the family, going away to different tracks, you're racing, the adrenalin, and you're in control, Like you have bad luck and you know, something happens, but you're

“

in control of what happens.

4. A search of the National Coronial Information Service database indicates that there have been at least 24 deaths in Australia involving off road motorcycle racing incidents since the

year 2000.

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In a similar incident on 27 February 2005, Richard Cant died when was thrown from his motorcycle at Broadford Motorcycle Race Championships. The riders behind him were in a

tight bunch and two of them hit him while he was on the ground.

Therefore, design of the track and risk management early in a motocross race are important

for preventing further avoidable deaths during motocross races.

In Victoria, Motorcycling Victoria is recognised by the Department of Planning and Community Development as the peak body for motorcycle sports. The Chief Executive Officer of Motorcycling Victoria is Andrew Weiss. He had previously worked at

Motorcycling Australia. Motorcycling Victoria is a member of Motorcycling Australia.

The Chief Executive Officer of Motorcycling Australia is David White. He has 30 years experience in motorcycle administration and was the President of Motorcycling Victoria from 1986 to 1991,

Mr White told the Court that Motorcycling Australia is recognised as the peak motorcycle racing body by the Federal Government through the Australian Sports Commission. There

were about 440 motocross venues licensed with Motorcycling Australia in 2010, Mr Weiss and Mr White gave evidence in the Inquest into Anthony Roach’s death.

Motorcycling Victoria acknowledges that:

"Invariably accidents will happen which could cause serious injury or death."

Mr Weiss told the Court that Motorcycling Australia and Motorcycling Victoria address the risks associated with motocross racing by providing for accreditation of motocross clubs,

licensing of the motocross venues and permits for motocross meetings.

Further, participants in motorcycle racc mectings at an accredited motocross venue must hold a Motorcycle Sport Licence issued by Motorcycling Australia (a 'Motorcycle Sport

Licencc').

Therefore, I will comment in more detail about the reasons that Mr Roach fell from his

motorcycle on 24 February 2007.

I will then discuss the degree to which accreditation of motocross clubs, licensing of the

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motocross venues and permits for motocross meetings could assist with preventing following riders hitting and further complicating the injuries of riders who fall from their motorcycles

early in the race.

Mr Roach’s fall

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Mr Roach fell from his motorcycle on the down ramp of the table top jump in the first lap of the first motocross race at the Club on 24 February 2007.

When he entered the up ramp of the table top jump, Mr Roach was about 10" of 15 tidets in the race. Mr Roach's motorcycle appeared to slide out from under him before he became airborne for the length of the jump. However, he was travelling at sufficient speed to take off and

reach a height of about eight metres over the jump.

As he travelled over the table top jump, Mr Roach increased the throttle which is the usual way to correct the direction in which an airborne motorcycle is travelling. Therefore, he

knew that his motorcycle was not properly aligned to land safely.

Despite this knowledge, Mr Roach also took his right hand off the handle bars and moved it in the direction of his face while he was still in the air with his left hand on the throttle, He looked as if he was attempting to remove a film used by some motorcycle riders to protect

their goggles from mud. However, his goggles were not fitted with this protection.

Mr Roach did not replace his right hand on the handle bar or fully correct the direction of his motorcycle before his motorcycle hit the down ramp, washed out to the right and slid down

the ramp. Mr Roach went down with his motorcycle.

Mr Roach’s actions in taking his right hand off the handle bars of his motorcycle mid air and failing to replace it before he landed on the down ramp of the table top contributed to his

losing control of his motorcycle and placing himself in the path of Mr Snow’s motorcycle.

Mr Roach had a delta-9-tetrahydrocannabinol level consistent with use of cannabis in the two hours prior to his death. Therefore, I find that he used cannabis after he arrived at

the motocross track at 7am on 24 February 2007.

Mr Barber described Mr Roach’s actions as similar to his own behaviour when his skill levels

were impaired because he was tired. In an experienced motorcycle rider like Mr Roach, they

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also seem to me .to also reflect the influence of his known use of cannabis on his behaviour.

Accordingly, 1 find that Mr Roach’s use of cannabis probably contributed to the incident in which he died.

The Court heard evidence that usc of cannabis can be associated with reddening of the conjunctiva, in other words the eyes, increased heart rate, increased blood pressures, impaired cognitive skills, an initial sense of euphoria and with long term use, they can develop

paranoia. These symptoms may assist trained observers to suspect cannabis use.

Further, even though several members of the Club could recite some of these symptoms of cannabis use, no one suspected Mr Roach was using cannabis on 24 February 2007.

Therefore, more objective measures are required to prevent further deaths and scrious injuries

occurring as the result of cannabis use by motorcycle riders.

However, although no one at the Club suspected he was a regular cannabis user, Mr Roach’s urine analysis was consistent with persistent cannabis use. It is possible that Mr Roach had developed a tolerance to cannabis and was less affected than a naive user would have been at

the same level. Therefore, his cannabis use may not have been obvious to those around him.

As the peak body for motorcycle racing in Australia, Motorcycling Australia is required to cooperate with the Australian Sports Anti-Doping Authority Act 2006. Accordingly, Motorcycling Australia has referred responsibility for conducting anti-doping functions to the

Australian Sports Anti-Doping Authority.

However, Mr White told the Court that charges for the Australian Sports Anti-Doping Authority are about $750 a test and Motorcycling Australia must pay for a minimum of four tests. Therefore, Motorcycling Australia also told the Court it is now implementing routinc

saliva testing.

Further, Motorcycling Australia told the Court that saliva testing was less robust than the Australian Sports Anti-Doping Authority procedures but it was cheaper and they intended to avoid long-term disqualification with associated disciplinary hearings for riders who are

positive to saliva tests. Rather:

“it would be simply - "You've tested positive to this, go home, you can't ride today".

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If I am correct about the effect of Mr Roach’s recent cannabis use of his loss of control of his motorcycle and his fall on 24 February 2007, random testing for cannabis use would have

prevented Mr Roach losing control of his motorcycle.

Further, in the context of the age and gender of most participants in Club motocross race meetings, there is no reason to assume that Mr Roach was the only Club member who used cannabis on a regular basis. These motocross race participants also increase the risk of injury

to themselves and other riders.

Testing for cannabis would deter cannabis uscrs from participating in the Club race meetings and motocross riders from using cannabis. The outcome adopted by Motorcycling Australia

for riders with positive cannabis saliva tests also seems consistent with the Club ethos.

Accordingly, the Club Management Committee should implement a random and targeted saliva testing programme sufficient to deter cannabis users from participating in Club motocross races. Further, there may be an opportunity for the Club to discuss the risk

minimisation aspects of the program with their insurers. Recommendation 1

Accreditation of Motocross Clubs

Motorcycling Victoria accepts applications for accreditation from motocross clubs. This accreditation requires payment of a fee based on the number of individual members and

cooperation with Motorcycling Victoria licensing and permit arrangements.

However, the Club was not accredited by Motorcycling Victoria.

Mr Cugnale explained that the Club sees itself as a family or feeder and training Club for motocross riding and racing. It provides for family memberships which includes all children in a family under 18 years old. Tt makes provision for children to develop their motorcycle riding skills over a period of time and for them to graduate to bigger motorcycles and racing

motorcycles over time.

As Mr Snow explained his history with the Club: he had been going to the Club with his family since he was seven years old. He was ten years old when he became a member of the Club. At that time he started riding the PeeWee 80 motorcycles but he did not compete in motorcycle races.. When he was 12 years old, Mr Snow began competitive racing on a 125cc

motorcycle. When he was 16 years old, Mr Snow progressed to a 250cc bike.

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Therefore, accreditation with Motorcycling Australia would interfere with the family oriented

culture of the Club. Mr White from Motorcycling Australia admitted to the Court:

“they're obviously a club that basically operates ah, on their own within their own

charter. So um, yeah, there is, I guess, a limited range of what they offer them.”

Further, Mrs Cugnale told the Court that accreditation with Motorcycling Australia included insurance with their self-insurance scheme. The premiums for this were more expensive than the private insurance taken out by the Club but it included a greater compensation limit for

serious injury.

Therefore, there seems to be little organisational advantage to be gained from affiliation of

the Club with Motorcycling Victoria and, through them, Motorcycling Australia.

Accordingly, IT make no recommendation in relation to accrediting the Club with

Motorcycling Victoria.

Licensing of Motocross Venues

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Although there were 64 licensed motocross venues licensed with Motorcycling Victoria in

2010, the Club venue was not licensed with Motorcycling Victoria.

Motorcycling Victoria and Motorcycling Australia venue accreditation requires satisfactory compliance with Motorcycling Australia Venue Standards’ for sites used to

host motocross trace meetings.

Motorcycling Victoria and Motorcycling Australia Venue Standards cater for nine different motorcycle disciplines but the Venue Standards for Motocross seem the most likely

to apply to a venue like that run by the Club.

Motorcycling Australia Venue Standards are assessed by venue inspectors who are accredited through the Motorcycling Australia accreditation system and evidenced by issue of licences

for venues issued by Motorcycling Victoria.

The Venue Standards must be applied in their entirety when a new venue is constructed.

Further, in the case of existing venues, entire conformity is the goal. However, other factors

' Motorcycling Australia, Venue Standards, edition 1, 22 December 2006,

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must be taken into account after a targeted risk assessment has been undertaken by the venue

inspector.

At least six of the deaths associated with motorcycle racing in Australia since 2000 have been

attributed to issues relating to the track.

For example:

e On 10 February 2001, Andrew Miles died when he lost control of his motorcycle mid air on the table top jump at Wheelstanders Motocross Track in Ipswich.. His head hit the

handle bars of his motorcycle.

e On 17 April 2001, Michael Peter King died in New South Wales because he collided with

a tree root protruding on to the track.

e On 2 September 2001, Brendan Smith died when he successfully cleared a large jump at a

private property in Heywood but hit the next jump as he landed.

• On 14 April 2002, Stefan Praill died when his motorcycle failed to take a bend and left the track at Barbagallo Raceway in Wannaroo. Mr Praill sustained fatal injuries when he

crashed into a stack of large earth moving haul pack tyres used as a barrier.

e On 9 September 2003, Warren Pryor died when he landed incorrectly after jumping an

obstacle in private property at Bellingen and landed on his head and neck.

• On 8 May 2004, Dean Gayther died when he failed to take a corner at Broadmeadows Motorcycle Track. He was thrown from his motorcycle and hit a fence sustaining fatal

injuries.

e On 13 November 2005, Ashley Jones died when he went wide to the outside of the track

to get an advantage in a race at Myrtleford Speedway Track and hit a concrete barrier,

The standards imposed on licensed venues by Motorcycling Victoria and Motorcycling Australia were devcloped to make motorcycle competition as safe as possible while, at the same time, acknowledging it is a sport with a significant clement of

danger.

However, motocross venues licensed with Motorcycling Australia include obstacles that are

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very similar in number and character and to those provided by the Club. Mr Mott told the

Court that the obstacles were no different to those in affiliated tracks:

“Tf anything, they're smaller than the - the obstacles are smaller - much smaller than a

lot of tracks you ride on.”

In particular, Motorcycling Australia Venue Standards for motocross require the table top jemp to be an obstacle between three and 18 metres long. The Club Table Top jump involved in the incident in which Mr Roach died was about 13.7m long and therefore within

the specifications imposed by Motorcycling Australia Venue Standards for motocross

Mr Mott also said that the table top jump is among the safest jumps on any motocross course

in Victoria because:

“the fact you can hit it at any - any speed you'd like and not have anywhere else to go but on top. You land on anywhere at point in time, um, the down ramp isn't sharp or

anything. Nice and plain, so - yeah,” Mr Davey explained:

“We consider that to be one of the safest jumps on the track. So that's actually stayed

the same” Therefore, I make no recommendations with respect to the table top jump design.

However, Mr Mott has personally been involved in stacks on table top jumps about 10 times

during racing, On two to three of these incidents, he was hit by oncoming riders.

Motorcycling Australia Venue Standards for motocross must have a minimum track length of 800m, a maximum length of 3km and a width of six metres. Motorcycling Australia licensed

motocross venues routinely run races with 30 or 40 start gates.

The Club track at the ond of the table top ramp was four metres wide. There is no evidence before me about the length of the Club track but it is generally accepted to be no more than

800 metres and much shorter than Motorcycling Australia accredited venues,

This shorter narrower track means that the obstacles at the Club are closer together than those

at Motorcycling Victoria accredited tracks.

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It is possible that this shorter narrower track increases the risks that riders would otherwise face on a Motorcycling Victoria accredited track when they are still close together at the beginning of a race and when they lose control of their motorcycles and place other riders at

tisk.

The location of the Club venue has geographical features that make it impossible to

significantly widen or lengthen the track.

Therefore, it would be difficult for the Club to meet this standard for accreditation by

Motorcycling Victoria without a targeted risk assessment.

Motorcycling Australia Venue Standards for motocross also require the average track speed

to be 5Skph.

Mr Snow told the Court that his usual speed at the Club track was about S5kph. However, Mr Barber pointed out that the average speed at the Club is less than 55kph:

“You won't average that speed at Nunawading. It's a family orientated club and the percentage of members is 80 percent is juniors. So, it's really a mini bike club. So, if

they were to go with MV, F think the track would be more dangerous, “

Mr Snow also explained that differences between the Club venue and the accredited venues mean that the Club track was more technically complex than many of the accredited tracks so

that riders rode it slower than other tracks and it was not more dangerous than licensed tracks.

Therefore, it scems that, at least in Grade A & B races at the Club, the race speed is similar to that expected at Motorcycling Australia accredited venue. However, Motorcycling Australia Venue Standards are not designed to accommodate the slower speeds likely to occur in events

involving younger participants with smaller motorcycles.

Therefore, accreditation with Motorcycling Australia would interfere with the family

orientated culture of the Club.

Further, Mr Roach would not have died in the way he did if Mr Snow had been able to avoid

him after he fell off his motorcycle on to the track.

Mr Snow told the Court that it was early in the race and the riders were still bunched together over a

distance of 15 to 20 metres from front to back of the race. The reason that Mr Snow could not

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avoid Mr Roach was that there was another rider on his left preventing him taking evasive

action.

While a rider can lose control at any time in a race, incidents involving a second rider hitting them while they are on the ground are more likely to occur early in the race while the riders are more bunched up. In particular, motorcycle riders are most at risk of being hit by

following riders when they fall on the first lap.

The Motorcycle Australia requirement for venues to have a starting gate similar to that used in horse racing so that riders are allocated randomly to start gates and all the riders leave

together from a standing start.

Motoreyele Australia venue standards also include a long straight immediately after the

starting gates to assist in separating riders before they have to deal with the obstacles.

Further, the Court heard that, in Club races where riders are mixed grades and A Grade riders are more likely to ride faster than B Grade riders, the faster A riders can quickly out run the B riders. Mr Snow also said that registered motocross clubs also combine A and B grade races

on those tracks,

If this analysis of the speeds ridden by A and B grade riders is correct, mixed grade races

would assist in preventing the riders bunching in the early stages of the race.

However, there was also evidence before the Court that B grade riders are not always slower

then A grade riders. As Mr Barber told the Court:

“when you're racing you're out there to win. You're not out there to muck around.

You're doing your best to win. You want to be up front.”

Therefore, I make no recommendation in relation to mixed grades of riders in Motocross

races at the Club.

Other sports use different measures to separate race participants in time and space during the

eatly stages of a race.

For example, as | understand it, Formula One car races and some high’ performance motorcycle races start from a grid position determined by their speeds in the qualifying

rounds, Others start from a rolling start rather than a standing start. Sprint bicycle races

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have two or four participants and their times are used to determine the winner. In some

races, lanes are used to physically separate the competitors from each other.

lam not advocating any particular change in the way in which motocross races are started.

However, Mr Roach would not have died if the riders behind him in the race on 24 February

2007 had not been bunched up in a way that prevented Mr Snow avoiding him.

Accordingly, the Club and motocross clubs accredited with Motorcycling Victoria should reconsider the way in which motocross races are started to improve the time and/or space separation of race participants early in the race and reduce the risk of serious incidents

involving following riders. Recommendation 2

Permit for meeting

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Motoreycling Victoria also issues permits to conduct Competition Motocross Meetings

or Non Competitive Motocross Practice Days at their licensed venues.

However, the race meeting at the Club on 24 February 2007 did not have a permit issued by Motorcycling Victoria.

Permits for Competition Motocross Meetings or Non Competitive Motocross Practice Days are only issued if there is no conflicting meeting in the region. There is no provision for

members to ride their motorcycles at accredited venues on days other than permitted days.

Clubs who are members of Motorcycling Victoria must pay a permit fee and cooperate with scheduling of these Competition Motocross Meetings or Non Competitive Motocross

Practice Days.

On the other hand, the Club allows members to participate in training and practice rides at the venue every weekend when racing is not scheduled there. Committee members attend every

weekend to supervise and provide assistance.

Therefore, complying with the requirement for a permit imposed by Motorcycling Victoria

would interfere with the family orientated culture of the Club.

However, from a safety perspective, each application to Motorcycling Victoria for a Permit to Conduct a Competition Meeting or Non Competitive Practice Day

requires the organiscrs to nominate their First Aid provider and adequate scrutincers

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and marshalls.

The Court heard that St Johns always provides voluntary first aid services to the Club on race days. Dr Martin Dutch told the Court that this level of first aid was appropriate for the risks involved in motocross racing. Further, Mr Roach did not die because of failure to have more

highly trained emergency responders on site.

Therefore, the emergency response at the Club is not compromised by its not obtaining a

permit from Motorcycling Victoria for its race days.

Brett Barber has been an official with Motorcycling Victoria and a member of the Club, The Club procedures for registering participants and scrutineering bikes on race day are consistent with those Mr Barber describes as applying to all clubs registered with Motorcycling

Victoria.

Clubs who are members of Motorcycling Victoria must send reports of Adverse Events to Motorcycling Victoria within two wecks of the event. This provides Motorcycling Victoria with a database that assists them in determining important safety issues related to

their accreditation of venues.

In contrast, I note that the incident in which Mr Roach died was not recorded in the incident record book maintained by the Club and would not have otherwise have informed the design

standards for Club venues and race arrangements.

The current Chairman of the Club told the Court that they have improved their reporting of incidents on the track and these are discussed at each monthly meeting of the Club. In this way, the Committee is now able to allocate risk assessments to each part of the track and

revise any obstacles that are causing problems.

However, in the absence of accreditation with Motorcycling Victoria, this information is not

disseminated to the wider motocross community.

The Department of Planning and Community Development, in cooperation with Sports Medicine Australia, has established a Sportsinjurytracker sports injury surveillance system

for community sport in Victoria.”

? http://www.sportsinjurytracker.com.au

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This provides an opportunity for everyone to access information about motorcycle sports injuries. Therefore, I encourage the Club and Motorcycling Victoria to explore the possibility of cooperating with the Sportsinjurytracker sports injury surveillance system.

Recommendation 3

Motorcycle Sport Licences

97, Participants in most motorcycle race meetings in Victoria hold a Motorcycle Sport Licence issued by Motorcycling Victoria (the ‘Licence’), As relevant, the Licence Application Form requires riders to belong to an Ambulance Fund and to notify the organisers if they take prescribed substances.

98. Technically, this licence provides membership of both Motorcycling Australia and Motorcycling Victoria for the purposes of participating in motocross racing. It also includes insurance which is self-funded by Motorcycling Australia.

99, The Club is not affiliated with or registered as a Motocross Club with Motorcycling Victoria or Motorcycling Australia. However, most participants in Grade A and B motorcycle races at the Club hold a Motorcycle Sport Licence and also race at accredited motocross venues.

100, Further, the Club defers to the Motorcycling Victoria Manual on issues where the Club Manual is silent,

101, Therefore, I make no recommendation in relation to motocross race participants in Club races,

102, However, for consistency, the Club should ensure that the Club Application Form requires riders to belong to an Ambulance Fund and requires applicants to notify the organisers if they take prescribed substances. Recommendation 4.

RECOMMENDATIONS

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

connected with the death:

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Trecommend that:

1, The Nunawading & District MX Club implement a random and targeted cannabis saliva

testing programme for race participants on race days.

2, The Nunawading & District MX Club and Motorcycling Victoria re-consider the way in which motocross races are started to improve the time and/or space separation of race participants early in the race and reduce the risk of serious incidents involving following

riders.

3. The Nunawading & District MX Club and Motorcycling Victoria explore the possibility of

cooperating with the Sportsinjurytracker sports injury surveillance system,

4. The Nunawading & District MX Club ensure that the Club Application Form requires riders to belong to an Ambulance Fund and requires applicants to notify the

organisers if they take prescribed substances.

I direct that a copy of this finding be provided to the following:

Tnterested parties President, Nunawading & District MX Club

Chief Executive Officer Motorcycling Victoria

Chief Executive Officer Motorcycling Australia

Signature:

a a

DR JANE HENDTLASS CORONER Date: 26 June 2013

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