Inquest into the Death of Darren Ross TWINE

[2023] WACOR 17 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : PHILIP JOHN URQUHART, CORONER HEARD : 8 - 9 MARCH 2023 DELIVERED : 31 AUGUST 2023 FILE NO/S : CORC 28 of 2020

DECEASED : TWINE, DARREN ROSS Catchwords: Nil Legislation: Nil Counsel Appearing: S Markham assisted the coroner R Hartley (State Solicitors Office) appeared on behalf of the Western Australia Police Force P Meyer (Thames Legal) appeared on behalf of Cody Robinson Case(s) referred to in decision(s): Nil

[2023] WACOR 17 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Philip John Urquhart, Coroner, having investigated the death of Darren Ross TWINE with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, PERTH, on 8 to 9 March 2023, find that the identity of the deceased person was Darren Ross TWINE and that death occurred on 8 July 2020 at 945 Great Northern Highway, Port Hedland, from multiple injuries in the following circumstances: Table of Contents

[2023] WACOR 17 INTRODUCTION “A crisis is the sum of intuition and blind spots, a blend of facts noted and facts ignored.” Michael Crichton – author The deceased (Mr Twine) died on 8 July 2020 in a truck parking area in front of the Caltex Roadhouse, Great Northern Highway in Port Hedland (the Roadhouse).

He died from multiple injuries after he was struck by a prime mover.

Mr Twine’s death was a reportable death as it was unexpected within the meaning of section 3 of the Coroners Act 1996 (WA) (the Act). However, an inquest into his death was not mandatory as it did not fall within any of the circumstances set out in section 22(1) of the Act.

Nevertheless, pursuant to section 24(1) of the Act, Kerrilee Scrivener (Mr Twine’s partner) asked that an inquest be held into his death by letter dated 25 May 2021 to the Court.1 On 4 November 2022, the State Coroner determined that an inquest into Mr Twine’s death was desirable within the meaning of section 22(2) of the Act so that a coroner could hear evidence to assist in determining the circumstances of the death.

I held an inquest into Mr Twine’s death at Perth on 8-9 March 2023. The following witnesses gave oral evidence: Detective Sergeant Kevin Wisbey (investigating officer from Major Crash (i) Investigation Section at WAPF2); Glen Burrows (witness to some aspects of the incident); (ii) Paul Gregory (truck driver who saw Cody Robinson’s prime mover shortly (iii) after the incident); First Class Constable Hannah Dunnet3 (one of the police officers from South (iv) Hedland Police Station who attended the scene of the incident); Senior Constable Michael Feldmann (forensic collision investigator from (v) Major Crash Investigation Section at WAPF); Senior Constable Rita Cobanov (investigating officer from Major Crash (vi) Investigation Section at WAPF); and Cody Robinson (driver of the prime mover that struck Mr Twine).

(vii) 1 Exhibit 1, Tab 7, Letter from Kerrilee Scrivener dated 25/5/2021 2 Western Australian Police Force 3 This witness had the surname “Powell” at the inquest; however, I will refer to her by her surname as at the time of the incident

[2023] WACOR 17 At the conclusion of the oral evidence at the inquest, Ms Scrivener read out a statement that she had prepared on behalf of Mr Twine’s family.

The documentary evidence at the inquest comprised of one volume that was tendered as exhibit 1 at the commencement of the inquest.

My primary function has been to investigate the death of Mr Twine. It is a fact finding function. Pursuant to section 25(1)(b) and (c) of the Act, I must find, if possible, how Mr Twine’s death occurred and the cause of his death. Given the known circumstances in this matter, those findings can be made without difficulty.

Pursuant to section 25(2) of the Act, I may comment on any matter connected to Mr Twine’s death, including public health or safety or the administration of justice. This is an ancillary function of a coroner.

Section 25(5) of the Act prohibits me from framing a finding or comment in such a way as to appear to determine any civil liability or suggest a person is guilty of an offence arising from the death being investigated. It is not my role to assess the evidence for civil or criminal liability and I am not bound by the rules of evidence.

In making findings, I must be mindful of the standard of proof set out in Briginshaw v Briginshaw (1938) 60 CLR 336, 361-362 (Dixon J) which requires a consideration of the nature and gravity of the conduct when deciding whether a finding adverse in nature has been proven on the balance of probabilities (the Briginshaw principle).

I am also mindful not to insert any hindsight bias into my assessment of the actions taken by Mr Cody Robinson (Mr Robinson) as he began to drive his prime mover from the truck parking area at the Roadhouse. Hindsight bias is the tendency, after an event, to assume the event was more predictable or foreseeable than it actually was at the time.4

MR TWINE 5 Mr Twine was born on 8 May 1968 in Narembeen, Western Australia. He was 52 years old at the time of his death.

Mr Twine and Ms Scrivener were partners for 33 years. They had three children together, two sons and a daughter. Mr Twine and Ms Scrivener raised their children in Kalgoorlie, Southern Cross and Leinster until their eldest child started high school when the decision was made to move to Perth to enhance the children’s education.

4 Dillon H and Hadley M, The Australasian Coroner’s Manual (2015) 10 5 Exhibit 1, Tab 1, P100 – WAPF Report of Death; Exhibit 1, Volume 1, Tab 7, Letter from Kerrilee Scrivener dated 25/5/2021; Family statement by Kerrilee Scrivener

[2023] WACOR 17 Mr Twine was employed in the mining and trucking industries for over 30 years.

He worked as a shot-firer in open cut mines in the Goldfields and as an operator delivering explosives to open cut and underground mines throughout Western Australia. In the last 12 years of his working life, Mr Twine was a long-haul truck driver predominately servicing the mining industry. In 2020, Mr Twine was working as a truck driver for Norwest Crane Hire.

Mr Twine had a very strong work ethic and was highly regarded amongst his work colleagues. He enjoyed music, reading, playing golf and spending time with his family and friends.

EVENTS LEADING TO MR TWINE’S DEATH 6 Mr Robinson and Mr Twine knew each other through their employment as truck drivers with Norwest Crane Hire.

On 8 July 2020, Mr Robinson and Mr Twine had been working together in the Pilbara region with each driving their own prime mover. Mr Twine had more experience as a truck driver than Mr Robinson, who was only 25 years old at the time.

At the end of their work day, they parked their trailers in the company yard at Hematite Drive, Port Hedland and drove their prime movers to the Last Chance Tavern at South Hedland (the tavern). CCTV footage from the tavern showed the two men arriving at 5.47 pm and leaving at 6.30 pm. CCTV footage depicted both men consuming alcohol at the tavern, and after leaving, they walked to the tavern’s bottle shop where they purchased take-away beers.

The Roadhouse Mr Robinson and Mr Twine then drove their prime movers to the Roadhouse.

Their plan was to use the shower facilities at the Roadhouse, buy some take-away dinner and then drive to the Port Hedland Road Train Assembly area (the RTA area) situated about 1½ km north of the Roadhouse.

The Roadhouse has three main parking areas. One area is south of and adjacent to the Roadhouse and is equipped with fuel bowsers. The second area is in front of the Roadhouse and adjacent to Great Northern Highway. It is dedicated for larger vehicles such as prime movers to park (the truck parking area). The exit from this area onto Great Northern Highway is controlled by a “Give Way” sign.

6 Exhibit 1, Tab 2, Major Crash Investigation Report by Detective Sergeant Kevin Wisbey dated 6/8/21; Exhibit 1, Tab 8.1, Statement of Glen Burrows dated 8/7/20; Exhibit 1, Tab 9.1, Statement of Richard McCarthy dated 8/7/20; Exhibit 1, Tab 15, Statement of First Class Constable Hannah Dunnet dated 7 August 2020; Exhibit 1, Tab 16, Statement of Constable Mia Fiocco-Walton dated 19 July 2020; Exhibit 1, Tab 11.2, Statement of Carla Robinson dated 6 August 2020; Exhibit 1, Tab 20.1, Vehicle Activity Report for Mr Robinson’s prime mover dated 8 July 2020

[2023] WACOR 17 The third parking area is directly in front of the Roadhouse for passenger vehicles.

The truck parking area and this carpark are separated by a limestone retaining wall that is 70 cm in height (the wall). Alongside the wall on the side of the truck parking area is curbing.

Mr Robinson arrived at the Roadhouse shortly before Mr Twine. He parked his prime mover in the truck parking area. Two prime movers were already parked there, one behind the other and adjacent to the wall facing south. Mr Robinson parked his prime mover alongside the front prime mover. Mr Twine arrived several minutes later and parked directly behind Mr Robinson’s prime mover.

Their prime movers were also facing south. Mr Robinson locked his prime mover and left the motor running. Mr Twine turned his prime mover’s engine off.

CCTV footage from the Roadhouse showed Mr Robinson entering the premises at 7.02 pm7 and ordering his meal. He then entered the shower area. Mr Twine entered the Roadhouse at 7.06 pm and also ordered a meal before entering the shower area.

Mr Robinson and Mr Twine leave the Roadhouse Relevant to the inquest, CCTV footage showed Mr Robinson and Mr Twine leaving the Roadhouse entrance together at 7.20.03 pm. Although Mr Robinson had collected his meal, Mr Twine’s meal was not yet ready. They walked out of camera range in the direction of where their prime movers are parked approximately 40 metres away. There were no CCTV cameras depicting the truck parking area.

At about this time, Glen Burrows (Mr Burrows) was another long-haul truck driver who had parked his truck in the area where the fuel bowsers are located. As he walked towards the Roadhouse he saw a prime mover start to drive off from the truck parking area. This prime mover was being driven by Mr Robinson. As the prime mover began to move, Mr Burrows heard a noise which he described as sounding like the prime mover had driven over wooden pallets that had snapped.8 Mr Burrows did not see what had caused the noise as there were bollards blocking his view. He described the speed of the truck as “moving off in a normal motion” and there was no excessive speed.9 As Mr Burrows walked, he saw the prime mover continue to move normally and turn right onto Great Northern Highway. Mr Robinson drove his prime mover north on Great Northern Highway towards the RTA area. At no time did he stop his prime mover after it began moving from the truck parking area. CCTV footage showed Mr Burrows entering the Roadhouse at 7.21.50 pm.

7 Unless it is relevant, I have not specified the seconds on the digital time depicted on the CCTV footage 8 ts 8.3.23 (Mr Burrows), p.46 9 ts 8.3.23 (Mr Burrows), p.47

[2023] WACOR 17 Richard McCarthy (Mr McCarthy) was the driver of the prime mover that Mr Robinson had earlier parked alongside. CCTV footage showed Mr McCarthy leaving the Roadhouse at 7.33.50 pm. When Mr McCarthy got to his prime mover he saw Mr Twine lying on the ground near the prime mover. It was clear to Mr McCarthy that Mr Twine had died. CCTV footage then showed Mr McCarthy running back into the Roadhouse at 7.34.55 pm where he alerted Roadhouse staff of what he had seen. He then made a triple zero call. Mr McCarthy was the first person to have seen Mr Twine on the ground and who raised the alarm.

Actions by Mr Robinson after his prime mover had struck Mr Twine After Mr Robinson had arrived at the RTA area he called his mother in New Zealand. Telephone records indicated that this call was made at 7.34 pm.

Mr Robinson’s mother described her son as sounding “really frantic” and “really panic struck”. The first thing he said was he thought he might have killed somebody. When his mother said that it must have been an animal, Mr Robinson said that it was not because he was not on the highway and that he thought he had hit the curb but he felt like it was something else. Mr Robinson’s mother told him that he needed to go back.

Mr Robinson took his mother’s advice and drove back to the Roadhouse and parked his prime mover. The Vehicle Activity Report for Mr Robinson’s prime mover indicated that it was stationary at the RTA area for at least nine minutes before he drove back to the Roadhouse.

Mr Robinson called his mother again at 7.42 pm. CCTV footage from the Roadhouse showed Mr Robinson’s prime mover returning at 7.46 pm. Police and ambulance officers arrived at the Roadhouse a short time later.

A paramedic at the scene certified that Mr Twine was life extinct at 7.56 pm on 8 July 2020.10 What Mr Robinson said after returning to the Roadhouse Mr Burrows was the first person to recognise Mr Robinson’s prime mover after it had returned. He went and spoke to Mr Robinson whilst the latter was still sitting in the prime mover. Mr Burrows asked Mr Robinson whether it was him who had run over something earlier and Mr Robinson replied, “Yeah, I thought I hit a curb”. When Mr Burrows said that he had actually run over someone, Mr Robinson replied, “I am only 25, I am going to jail”. Mr Burrows then noticed Mr Robinson appearing to panic.

The first police officers who attended the scene were First Class Constable Hannah Dunnet (First Class Constable Dunnet) and Constable Mia Fiocco-Walton 10 Exhibit 1, Tab 3.3, Life Extinct Certification

[2023] WACOR 17 (Constable Fiocco-Walton) from South Hedland Police Station. These two police officers spoke to Mr Robinson who told them he had hit the person and that he did not know what had happened and thought the bump he felt was a curb. Mr Robinson was in a clearly distressed state when he spoke to these officers. One of the police officers arranged for the paramedics at the scene to attend to Mr Robinson due to his severe state of shock.

When talking to the paramedics, Mr Robinson said that as he moved off to pull out onto the main road he heard a crunch and thought it was a traffic cone. He then later thought he had better turn around.

In his conversation with police Mr Robinson also said that he had checked that no36 one was there before he took off and when he heard a noise he thought it was maybe a curb but after going to the RTA area he, “had a funny feeling it wasn’t a curb so I came back”.

Constable Fiocco-Walton took a preliminary sample of breath for blood alcohol content from Mr Robinson at the scene which recorded a reading of 0.027%.

Subsequent blood testing found that Mr Robinson had an alcohol level of 0.031%.11

CAUSE AND MANNER OF DEATH Cause of death 12 Dr Jodi White (Dr White), a forensic pathologist, conducted an external post mortem examination and CT scan on Mr Twine’s body on 13 July 2020.

The external examination found that Mr Twine had sustained multiple soft tissue and bony injuries to his head, trunk and limbs. The CT scan showed extensive disruption to Mr Twine’s skull, facial bones and cervical spine. There were multiple rib and pelvic fractures, and fracturing of the upper thoracic spine. There had been rupturing and displacement of the chest structures. These injuries were consistent with Mr Twine having been run over by the prime mover.

Toxicological analysis detected a blood alcohol reading of 0.035%, with no common illicit drugs detected.

Dr White also noted that Mr Twine was 170 cm in height.

11 Exhibit 1, Tab 6.5, Certificate of Drugs Analyst dated 10 August 2020 12 Exhibit 1, Volume 1, Tabs 5.1-5.4, Interim Post Mortem Report, Statement of Dr Jodi White, dated 20/10/2020, Supplementary Post Mortem Report, Full Post Mortem Report; Exhibit 1, Volume 1, Tab 6.1, Final Toxicology Report dated 24/7/2020

[2023] WACOR 17 At the conclusion of her investigations, Dr White expressed the opinion that the cause of death was multiple injuries.

I accept and adopt the conclusion expressed by Dr White as to the cause of Mr Twine’s death.

Manner of death I am satisfied that Mr Twine died at about 7.21 pm on 8 July 2020 when he was struck by the passenger-side front of a prime mover driven by Mr Robinson.

Notwithstanding the low speed of the prime mover, Mr Twine suffered catastrophic injuries from this impact when he was subsequently run over by the prime mover.

For the reasons set out later in this finding, I am satisfied that Mr Robinson did not see Mr Twine in front of the prime mover before the impact.

Accordingly, I find that Mr Twine’s death occurred by way of accident.

INVESTIGATIONS BY POLICE In July 2020, Senior Constable Rita Cobanov (Senior Constable Cobanov) was a crash investigator with the WAPF at Major Crash Investigation Section in Midland. She was allocated the investigation into Mr Twine’s death and flew to Port Hedland with Constable Neil Clarke (Constable Clarke), another crash investigator, on the morning of 9 July 2020.

On that same morning Senior Constable Cobanov had a brief conversation with Mr Robinson at the Hedland Health Campus in South Hedland. During that conversation Senior Constable Cobanov advised Mr Robinson that the identity of the deceased person was Mr Twine. Mr Robinson said that he had left the Roadhouse by himself the previous evening while Mr Twine waited inside for his dinner.13 That was not consistent with the CCTV footage from the Roadhouse entrance. Senior Constable Cobanov made arrangements to interview Mr Robinson later that day.

Senior Constable Cobanov then attended the Roadhouse. Markers at the scene indicated that Mr Twine’s body was found about 14 metres prior to the truck parking area’s “Give Way” line and 4½ metres from the wall.14 Senior Constable Cobanov noted that the truck parking area was flat and in good condition with no bumps in existence.15 13 Exhibit 1, Volume 1, Tab 25, Statement of Senior Constable Rita Cobanov, dated 2/3/2023, p.2 14 Exhibit 1, Tab 17.2, Initial Collision Assessment Report by Senior Constable Michael Feldmann dated 16 July 2020, p.1 15 Exhibit 1, Volume 1, Tab 25, Statement of Senior Constable Rita Cobanov, dated 2/3/2023, pp.4-5

[2023] WACOR 17 An examination of Mr Robinson’s prime mover identified hand marks on the front light bar affixed to the bull bar. On the passenger side of the bull bar were further hand marks and dirt smears at different heights. This examination also found the following :16 Black scuffs were found on the front left steering linkage. The front left steerer’s mudflap was torn slightly on the inside corner. Blood splatter was found on a cross member and cylinder to the rear of the mudflap with fresh wear marks identified on a tap and piping adjacent to this.

Hairs were located on a cross member slightly further rearwards and large blood staining was found on a longitudinally running chassis rail and hose on the passenger side, immediately in front of the first left side drive wheel.

Further hairs were found further rearwards and slightly towards the centre. Blood staining was also found on the left rear most mudflap.

Senior Constable Cobanov and Constable Clarke conducted a recorded interview with Mr Robinson that commenced at 5.17 pm on 9 July 2020 at South Hedland Police Station. During that interview, Mr Robinson repeated that he had left the Roadhouse by himself. When he was asked what happened as he pulled away from the truck parking area, Mr Robinson said, “I sort of felt like I hit a curb and I was, that’s alright, must have just hit a curb. Went to the RTA and then stopped”.17 He then said after having his dinner and some beer at the RTA area he had, “a bad feeling and I rung my mother” and said to her, “I don’t think it was a curb, I don’t know what to do”.18 During the interview, Mr Robinson said that he had placed a modified foil window shade to the bottom of the windscreen of his prime mover some months earlier. He said that he did that to keep the temperature down in the cabin during summer.19 Mr Robinson’s prime mover was examined by Senior Constable Darren Harston (Senior Constable Harston), a senior vehicle investigator with the Vehicle Investigation Unit at WAPF. He also examined the window shade that had been fitted to the bottom of the windscreen by Mr Robinson and made the following observations:20 The vehicle had a reflective foil window shade, cut to fit and when placed upright between the dash and the windscreen, blocks the visibility through the windscreen from the lower edge of the windscreen by 300 mm.

… 16 Exhibit 1, Tab 17.2, Initial Collision Assessment Report by Senior Constable Michael Feldmann dated 16 July 2020, p.2 17 Exhibit 1, Volume 1, Tab 21.1, Audio visual record of interview of Cody Robinson, dated 9/7/2020, p.16 18 Exhibit 1, Volume 1, Tab 21.1, Audio visual record of interview of Cody Robinson, dated 9/7/2020, p.17 19 Exhibit 1, Volume 1, Tab 21.1, Audio visual record of interview of Cody Robinson, dated 9/7/2020, p.9 20 Exhibit 1, Volume 1, Tab 18.2, Vehicle Examination Report of Senior Constable Darren Harston dated 15/7/2020, p.3

[2023] WACOR 17 With the foil window shade lowered onto the dash, the top of a 178 cm tall object was not visible in front of the vehicle by a 185 cm tall, seated driver until the object was approximately 1.3 metres ahead of the vehicle.

With the foil window shade fitted upright between the dash and the windscreen, the top of a 178 cm tall object was not visible in front of the vehicle by a 185 cm tall, seated driver until the object was approximately 3.5 metres ahead of the vehicle.

On 14 September 2020, Mr Robinson was interviewed for a second time by Senior Constable Cobanov. On this occasion the interview took place at the offices of Major Crash Investigation Section at Midland. In this interview, Mr Robinson confirmed that he had stood up from his seat and pulled down that part of the window shade that was in front of the steering wheel to check that there was nothing in front of the prime mover before he drove away.21 Mr Robinson said when he did that he saw nothing in front of the prime mover on the driver’s side or the passenger side.22 (However, I note it was night time and I also note Senior Constable’s evidence at the inquest: “I know Mr Robinson says he stands up and looks over the driver’s side but Mr Twine is on the far left and it’s even harder to see that corner if he doesn’t look and from where he is looking he can’t see that corner.”)23 During this interview, Mr Robinson was shown the CCTV footage of him and Mr Twine leaving the Roadhouse together at 7.20 pm. When he was asked for an explanation as to why he had said he left the Roadhouse by himself, Mr Robinson answered, “I don’t know”.24 Towards the end of the interview, Mr Robinson was directly asked that he had a look under the prime mover at the RTA area. He replied that he had and that he had seen nothing. When asked what he was looking for he replied, “I don’t know”.25 Throughout the interview, Mr Robinson denied looking at the truck parking area after he turned north onto Great Northern Highway.26 However, at the end of the interview, it was put to Mr Robinson that he did look back as he drove away from the truck parking area and that he did see a body. Mr Robinson answered “yes” to that proposition but maintained he did not recognise it was Mr Twine.27 He nevertheless denied he was checking for evidence when he looked under the prime mover at the RTA area, and that he was only looking for damage.28 21 Exhibit 1, Volume 1, Tab 18.2, Audio visual record of interview of Cody Robinson, dated 14/9/2020, p.21 22 Exhibit 1, Volume 1, Tab 18.2, Audio visual record of interview of Cody Robinson, dated 14/9/2020, p.24 23 ts 8.3.23 (Senior Constable Cobanov), p.108 24 Exhibit 1, Volume 1, Tab 18.2, Audio visual record of interview of Cody Robinson, dated 14/9/2020, p.35 25 Exhibit 1, Volume 1, 18.2, Audio visual record of interview of Cody Robinson, dated 14/9/2020, p.45 26 Exhibit 1, Volume 1, Tab 18.2, Audio visual record of interview of Cody Robinson, dated 14/9/2020, p.39 27 Exhibit 1, Volume 1, Tab 18.2, Audio visual record of interview of Cody Robinson, dated 14/9/2020, p.50 28 Exhibit 1, Volume 1, Tab 18.2, Audio visual record of interview of Cody Robinson, dated 14/9/2020, p.50

[2023] WACOR 17 Outcome of the police investigation After the interview on 14 September 2020, several indictable charges were considered by Senior Constable Cobanov, including dangerous driving occasioning death, failing to stop and failing to report an incident occasioning death.29 As is commonly done by the WAPF, advice was sought from the Office of the Director of Public Prosecutions (the DPP) for its opinion as to the viability of these charges.

After careful consideration by a Senior State Prosecutor at the DPP it was determined that a charge of dangerous driving occasioning death could not be proven to the requisite standard of proof beyond reasonable doubt. Factors considered in that determination included the inability of the driver of the prime mover to see a person in front of it even with the window shade removed. Other factors included that it was night time and there was no direct lighting in the area.30 The Senior State Prosecutor was also of the view that the part of the interview on 14 September 2020 where Mr Robinson admitted he had seen a body in the truck parking area after he drove away would potentially be ruled inadmissible due to the nature of the questioning by the interviewing police officers. In those circumstances, it was decided there would be insufficient evidence to prove to the required standard of beyond reasonable doubt the charges of failing to stop and failing to report after an incident occasioning death.31 Charges laid against Mr Robinson As a result of the advice from the DPP, Mr Robinson was charged with two summary offences; driving a specified vehicle type when exceeding 0.02 g alcohol per 100 ml blood pursuant to s 64A(4) of the Road Traffic Act 1974 (WA) and driving while not having a full and uninterrupted view pursuant to Reg 263(1)(b) of the Road Traffic Code 2000 (WA).

On 3 May 2021, Mr Robinson appeared in the South Hedland Magistrates Court.

He pleaded guilty to both charges and received a three month driver’s licence disqualification and a $150 fine for the exceeding the blood alcohol level charge, and a $100 fine for driving while not having a full and uninterrupted view.

29 Exhibit 1, Volume 1, Tab 25, Statement of Senior Constable Rita Cobanov, dated 2/3/2023, p.18 30 Exhibit 1, Volume 1, Tab 2.1, Major Crash Investigation Report by Detective Sergeant Kevin Wisbey, dated 6/8/2021, p.16 31 Exhibit 1, Volume 1, Tab 2.1, Major Crash Investigation Report by Detective Sergeant Kevin Wisbey, dated 6/8/2021, pp.16-17

[2023] WACOR 17 The account given by an uncooperative witness who was at the Roadhouse During her examination of the CCTV footage from the Roadhouse, Senior Constable Cobanov identified a man who was a possible witness to the incident.

This man was standing and smoking a cigarette in the parking area immediately in front of the Roadhouse. After the incident, the footage showed the man getting into a work vehicle and driving away. After examining other CCTV footage, Senior Constable Cobanov was able to obtain a photograph of his face which she sent to Roadhouse staff who were able to identify him by name as he was a regular customer who worked locally.32 On 1 September 2020, Senior Constable Cobanov telephoned the man and asked him what he could remember. He told her that he saw what he thought was a towel on a roo bar, and a man bending over in front of a truck. He also said he remembered seeing two men leave the Roadhouse and walk past him. Senior Constable Cobanov formed the view that the man did not want to talk over the telephone so she advised him arrangements would be made for a local police officer to meet with him.33 The man subsequently attended a local police station and provided a very brief statement which he did not sign. The statement provided no details that had been requested. Senior Constable Cobanov contacted the man again and advised him further clarification and details were required.34 Her request to travel to Port Hedland so that she could personally attend a follow up meeting with the man was denied.

As Senior Constable Cobanov explained at the inquest, it took many months before local police spoke to the man and, “by then, he didn’t tell them anything about the man bending over or anything of that.”35 Senior Constable Cobanov also agreed that the man was someone that was reluctant to cooperate with police, adding, “he wasn’t interested in helping us”.36 Despite Senior Constable Cobanov’s commendable efforts in first identifying a potentially critical witness and then trying to obtain a detailed statement from him, I am left with a brief description given over the telephone by this man relating to an unidentified male bending over an unidentified truck in an unidentified parking area at the Roadhouse. I also note that no item matching the description of a towel the man said was on the roo bar of the truck was found or mentioned by anyone else. In addition, I must have regard to the fact that if this man actually saw something that would assist the police investigation of a serious incident involving 32 I have determined it is not necessary to identify this man 33 Exhibit 1, Volume 1, Tab 25, Statement of Senior Constable Rita Cobanov, dated 2/3/2023, p.14 34 Exhibit 1, Volume 1, Tab 25, Statement of Senior Constable Rita Cobanov, dated 2/3/2023, p.15 35 ts 8.3.23 (Senior Constable Cobanov), p.100 36 ts 8.3.23 (Senior Constable Cobanov), p.100

[2023] WACOR 17 a fatality, he was extremely unhelpful in providing that assistance. That attitude casts doubt on his credibility.

Applying the Briginshaw principle, I am not satisfied I can make any findings that rely on the brief account given by this man to Senior Constable Cobanov in their telephone conversation on 1 September 2020.

ISSUES RAISED BY THE EVIDENCE Why was Mr Twine at the front of Mr Robinson’s prime mover?

This question cannot be easily answered. Police investigators were not able to determine exactly why an experienced truck driver would position himself in front of a prime mover that had its engine running and was about to drive off.37 An examination of Mr Twine’s prime mover found that it was unlocked with the engine turned off and his shower bag on the front seat.38 The CCTV footage from the Roadhouse entrance at 7.20.03 pm showed Mr Twine carrying this shower bag as he walked out of the Roadhouse.39 I agree with the conclusion drawn by the police investigators that Mr Twine clearly went to his prime mover, unlocked it and placed his shower bag on the front seat.40 He then needed to return to the Roadhouse to collect his meal, which Mr Robinson knew.41 However, there were other and more safe ways for Mr Twine to return to the Roadhouse that did not involve placing himself directly in front of Mr Robinson’s prime mover.

The WAPF Vehicle Investigation Unit conducted a thorough examination of Mr Robinson’s prime mover. Two electrical faults were detected with the left hand front indicators:42 The left bull bar upright mounted LED (light emitting diode) indicator does not illuminate due to the wiring severed at the LED light fixture.

… The left guard mounted factory LED (light emitting diode) indicator light does not illuminate due to the connector retaining clip broken allowing disconnection.

… The left front bull bar mounted indicator and left front guard mounted indicator not illuminating, when required would reduce indication of the intention to turn provided to 37 Exhibit 1, Volume 1, Tab 2, Major Crash Investigation Report by Detective Sergeant Kevin Wiseby, dated 6/8/2021, p.17 38 ts 8.3.23 (Senior Constable Cobanov), p.90 39 Exhibit 1, Volume 1, Tab 25, Statement of Senior Constable Rita Cobanov, dated 2/3/2023, p.5 40 Exhibit 1, Volume 1, Tab 2, Major Crash Investigation Report by Detective Sergeant Kevin Wisbey, dated 6/8/2021, p.17 41 ts 9.3.23 (Mr Robinson), p.188 42 Exhibit 1, Volume 1, Tab 18.2, Vehicle Examination Report of Senior Constable Darren Harston, dated 15/7/2020, pp.2 & 4

[2023] WACOR 17 other road users approaching from the front. The left front headlight housing indicator remains serviceable.

One explanation as to why Mr Twine would be positioned in front of Mr Robinson’s prime mover on the passenger side was that he was looking at the faulty left hand indicators. However, there is no credible direct or circumstantial evidence before me that this is why Mr Twine was there. I also note there were no discernible hand or palm prints on or about either of these indicators.43 In his evidence at the inquest, Mr Robinson said that he was aware of the faulty indicators.44 As to his plans to fix these indicators, Mr Robinson said a mechanic had told him before the incident that the indicator on the bull bar had to have the whole fixture taken out and replaced. This was to be a job for a mechanic as the part had to be ordered.45 With respect to the other indicator, as Mr Robinson believed it was just a faulty bulb, it was something he and/or the other drivers could have done on the weekend46 if there were bulbs in the company yard.47 As to the repair of this indicator, counsel assisting asked Mr Robinson the following questions:48 Is that something you could do yourself?---The – I’m not sure. I hadn’t done an indicator one myself, but I would have looked at – looked at it on the weekend.

Yes?---But the one on the bulbar would have been a mechanic’s job.

And basically if you had to get some assistance, you could have asked Darren Twine about that?---Yes.

Yes?---Could have asked him and any of the other drivers, the mechanic in the yard.

Yes. Okay. Did you discuss it with Darren?---What, the indicator? No, I - - - Did he bring it up with you? Did he notice - - -?---Not that I was aware of.

• • • and bring it up with you?---No. Not that – not on – yes.

Offer to fix it for you?---No.

I then asked Mr Robinson :49 Might have he done that?---Might have, but yes, it wasn’t – yes, it was – if – if we were going to do it, it would have been probably when we were loading, waiting to be loaded, probably when we were standing around. It wouldn’t have been probably at night time because my - - - 43 ts 9.3.2023, Senior Constable Feldmann, p.151 44 ts 9.3.2023, Mr Robinson, p.190 45 ts 9.3.2023, Mr Robinson, p.190 46 That is, the weekend of 11 and 12 July 2020 47 ts 9.3.2023, Mr Robinson, p.190 48 ts 9.3.2023, Mr Robinson, p.191 49 Ts 9.3.2023, Mr Robinson, p.191

[2023] WACOR 17 Because, you see, you say you can’t remember walking out of the roadhouse with Mr Twine?---Yes.

So I gather therefore you’ve got no memory whether you spoke to each other or not as you made your way to your prime movers?---Yes. Yes.

Would that be right to say?---Yes.

At the inquest, Mr Robinson still maintained that he had no recollection walking out of the Roadhouse with Mr Twine at 7.20 pm. He denied his explanation to police that he was by himself was in order to distance himself from Mr Twine.50 When he was asked whether he could think of any other explanation, Mr Robinson answered:51 No. I – that’s still how I remember. I still – even though I’ve seen the – the footage, it’s still in my head, I talked to the – my therapist lady about trying to do some things to try and – but all I can remember is seeing him standing near the bain-marie and me saying, “All right. I will see you at the RTA.” I don’t remember us walking out together. That’s all I can remember as which – yes. I don’t know. Yes.

Understandably Mr Robinson was closely questioned as to this aspect. After the above questions were asked, counsel assisting and I asked Mr Robinson the following :52 So you’ve heard all the evidence and it appears – well, it is the case that Darren Twine went back to his truck because his gear is inside the truck from when he had a shower?

• • • Yes.

He put his backpack inside. And then he has approached your truck for some reason?

--- Yes.

Very quickly?---Yes.

It had to be very quick because you were only in your truck for a minute and you took off?

---Mmm.

Okay. And he had his keys with him?---Mmm.

So you’re saying he didn’t come or offer to look at your lights for you?---I don’t recall. I don’t think he – I don’t think he did, no, because he - - - Well, you don’t think he did, but is it possible?---But – but I wouldn’t have had my indicators on where we were parked, so if they weren’t on, then you wouldn’t know they weren’t working.

Yes. Had you had any discussion with him prior to that though about them?---No.

Okay. And just think carefully. Was there any other discussion or arrangement with Mr Twine just before you came out of the Caltex about him looking at your lights or any other arrangement for him to come and speak to you at that moment about anything?

50 ts 9.3.2023, Mr Robinson, p.192 51 ts 9.3.2023, Mr Robinson, p.192 52 ts 9.3.2023, Mr Robinson, pp. 192-193

[2023] WACOR 17 Because what we’re trying to get at here is why was he standing there?---Yes. Yes. No, I can’t think of any reason why he would have to be – why he was where he was.

CORONER: Because you’re really the only person that can help us with that - - -?---And even then I - - -

• • • because you were the last person that he was with?---Yes. I ask myself that every day why he was there.

Although it seems to be a very plausible explanation that Mr Twine was in front of Mr Robinson’s prime mover because he was looking at the faulty indicators, the highest point the evidence supporting this scenario reached was in this exchange between myself and Mr Robinson:53 So is it just a coincidence that you had two faults with your indicators on that side? --- Yes.

It’s – yes.

Okay. Is that your explanation for it? --- Just – yes. Yes.

Because we’re trying to think of some reasons why he would be in that position? --- Yes.

Yes, for sure.

And the faulty indicators seems to be a possible explanation for it? --- Yes, but – yes, I don’t think the indicator was on at the time.

No, but he might well have known already? --- Yes, maybe. I’m not sure.

But you don’t remember discussing it with him? --- Yes, 100 percent.

Applying the Briginshaw principle, I cannot be satisfied to the required standard that this was the reason why Mr Twine was in that position.

Unfortunately, inquests are replete with examples of actions taken by people that cannot be explained. The reason for Mr Twine being at the front left hand side of Mr Robinson’s prime mover must now be added to that lengthy list.

Was Mr Robinson aware he had run over a person as he left the Roadhouse?

With two exceptions, the known conversations Mr Robinson had with other people from 8 July 2020 to 14 September 2020 were consistent with the account that he thought he had hit a curb as he began to drive from the truck parking area.

Those two exceptions were when he rang his mother at 7.34 pm on 8 July 2020 and said, “I think I might have killed somebody”54 and his admission under rigorous questioning by police towards the end of his interview on 14 September 2020 that he had seen a body in the truck parking area as he drove away.

Mr Robinson’s claim that he thought he had hit a curb must be met with some scepticism. The only curb in the vicinity was adjacent to the wall separating the 53 ts 9.3.2023, Mr Robinson, p.194 54 Exhibit 1, Volume 1, Tab 11.2, Statement of Carla Robinson, dated 6/8/2020, p.2

[2023] WACOR 17 two parking areas in front of the Roadhouse. In between that curb and Mr Robinson’s prime mover was the prime mover that had been driven and parked earlier by Mr Burrows. Mr Robinson was familiar with the surrounds of the Roadhouse as he had been there previously. I am therefore not surprised investigating police officers did not accept this explanation from Mr Robinson.

Given the findings I am required to make under the Act, the questioning of Mr Robinson as to what he thought and what he observed during and immediately after his prime mover struck Mr Twine was relevant.

At an inquest, a witness may decline to answer any question put to them on the ground that their answer “will criminate or intend to criminate him or her”.55 Where a coroner considers it is expedient for the ends of justice for the witness to be compelled to answer the question, the coroner may tell the witness that if they answer the question (and any other questions that may be put to them), the coroner will grant the witness a Certificate pursuant to section 47(1) of the Act.

A witness to whom a Certificate is granted is no longer entitled to refuse to answer questions on the ground their answers will criminate or tend to criminate them, and if the witness gives evidence “to the satisfaction of the coroner”,56 the coroner must give the witness a Certificate. The effect of the Certificate is to render the answers of the relevant witness inadmissible in evidence in criminal proceedings against the witness, with the exception of a prosecution for perjury committed in the inquest’s proceedings.57 After Mr Robinson had been sworn in as a witness, and before he was asked any questions by counsel assisting, I advised Mr Robinson of the provisions in section 47 of the Act.58 In her subsequent examination of Mr Robinson, counsel assisting elicited from Mr Robinson that as he exited the truck parking area and went onto Great Northern Highway he was driving slowly and looking at what his prime mover had hit.59 Counsel assisting then asked Mr Robinson the following:60 And did you realise then, at that point, it was a body?---Yes. I’m not sure what I saw, to be honest.

Well, in your interview with Senior Constable Cobanov - - - I then interrupted counsel assisting and said:61 55 Section 47(1), Corners Act 1996 (WA) 56 Section 47(2), Coroners Act 1996 (WA) 57 Section 47(2), Coroners Act 1996 (WA) 58 ts 9.3.2023 (Mr Robinson) pp.153-154 59 ts 9.3.2023 (Mr Robinson) p.197 60 ts 9.3.2023 (Mr Robinson) p.197 61 ts 9.3.2023 (Mr Robinson) p.197

[2023] WACOR 17 I think in fairness to the witness, notwithstanding my careful instructions to him before he gave his evidence, that he really should be objecting to these questions now, Ms Markham.

With that prompting, Mr Robinson elected to object to answering questions regarding this aspect of his evidence.62 I then advised Mr Robinson’s counsel it was my view that it was necessary for the ends of justice to compel Mr Robinson to answer these questions. I also added that I would grant Mr Robinson a Certificate under section 47 of the Act if he answered those questions to my satisfaction. Counsel for Mr Robinson did not oppose that course of action.63 Part of the subsequent questioning of Mr Robinson included reading out to him what his mother had said he told her in their conversation at 7.34 pm, including that he said, “I think I might have killed somebody”.64 I then asked Mr Robinson: 65 So do you agree that that’s the conversation you had with your mum?---Yes.

Yes. So then that would suggest that when you did look as you drove onto the highway, that you first realised it wasn’t a kerb and it looked like it was actually a body?---Yes.

Would that be right there?---Yes.

Okay. And that’s why you have said, “I think I might have killed somebody”?---Yes.

… MARKHAM, MS: Thank you. And I think, Cody, you wanted it to be a kerb or some sort of other object that you hit, but is it fair to say that deep down you knew that it was a body?--- Yes. Yes … At that point – so you have said – you accept you knew it was a body at that time. Did you think at that time that it was Darren Twine?---No, not at all. I didn’t. Yes.

At the conclusion of his evidence, I advised Mr Robinson that I was satisfied with the evidence that he had given and I would therefore be granting him a Certificate pursuant to section 47 of the Act.66 After the completion of the inquest I signed the Certificate on 9 March 2023, and it was forwarded to Mr Meyer, counsel for Mr Robinson.

Based on the evidence before me, I am not satisfied Mr Robinson was either aware or ought to have known that Mr Twine was in front of his prime mover as he began to drive from the truck parking area. However, I have noted the oral 62 ts 9.3.2023 (Mr Robinson) p.198 63 ts 9.3.2023 (Mr Robinson) p.197 64 ts 9.3.2023 (Mr Robinson) p.204 65 ts 9.3.2023 (Mr Robinson) pp.204-205 66 ts 9.3.2023 (Mr Robinson) p.224

[2023] WACOR 17 evidence of Mr Robinson that he was compelled to give at the inquest and the circumstantial evidence which established that the prime mover had driven over Mr Twine after he was struck. After a careful consideration of that evidence, and being mindful not to insert hindsight bias, I am satisfied to the required standard that after the prime mover had struck Mr Twine and then driven over him, Mr Robinson would have suspected he may have hit and driven over a person.

That suspicion was then confirmed a matter of seconds later when he drove onto Great Northern Highway and looked in the direction of the truck parking area and saw a body lying on the ground. Accordingly, I make that finding.

REPORT TO THE DIRECTOR OF PUBLIC PROSECUTIONS Section 27(5)(a) of the Act provides that a coroner may report to the DPP if the coroner believes that an indictable offence has been committed in connection with a death which the coroner investigated.

As already outlined above, Mr Robinson gave evidence that he saw a body in the truck parking area as he drove away from the Roadhouse. This evidence was in response to questions that I compelled him to answer,.

The heading to section 54 of the Road Traffic Act 1974 (WA) is: “Driver in incident occasioning bodily harm to stop, ensure assistance and give information”. Relevant to this inquest, this section provides: (1) If a vehicle driven by a person (the driver) is involved in an incident occasioning bodily harm to another person, the driver must stop immediately after the occurrence of the incident and for as long as is necessary to comply with subsections (2) and (6).

(2) If a vehicle driven by a person (the driver) is involved in an incident occasioning bodily harm to another person (a victim), the driver must ensure each victim receives all the assistance, including medical aid, that is necessary and practicable in the circumstances.

(3) A person who contravenes subsection (1) or (2) commits a crime.

Penalty for this subsection: imprisonment for – a) 20 years, if the incident occasioned death, and in any event, the court convicting the person must order that the person be disqualified from holding or obtaining a driver’s licence for a period of not less than 2 years; … (5) It is a defence to a charge of an offence under subsection (3) for the accused to prove that the accused was not aware of the occurrence of the incident.

The answers given by Mr Robinson in his compelled evidence at the inquest would be clearly relevant to an investigation considering a charge or charges pursuant to section 54(3) of the Road Traffic Act 1974 (WA).

[2023] WACOR 17 However, at the conclusion of the inquest, I advised counsel that I had formed a preliminary view I would not be making a recommendation under section 27(5)(a) of the Act. At that time I gave two reasons; the first and primary reason was that the compelled evidence from Mr Robinson was inadmissible in any criminal proceedings and the second was that I had reservations whether it would be in the public interest to proceed with a prosecution this long after the event.67 After further consideration of the matter, I confirm that I have decided a report to the Director of Public Prosecutions is not warranted. A further reason for my decision is that a Senior State Prosecutor at the DPP has already carefully considered the matter and determined there are no reasonable prospects of conviction. No additional evidence which would be admissible was elicited at the inquest that bolsters a prosecution case with respect to any charges pursuant to section 54(3) of the Road Traffic Act 1974 (WA).

ACTIONS BY WORKSAFE It was very disconcerting to hear that window shades like the one affixed by Mr Robinson to the bottom of his truck’s windscreen are often used by heavy vehicle operators in the same manner. As the evidence demonstrated at the inquest, this significantly extends the blind spot in front of trucks that are flat face/cabover (i.e. trucks that have a body style or design where the cab is positioned directly above the engine and front axle).

As the Court was aware there was an investigation into Mr Twine’s death by WorkSafe, advice was sought from the WorkSafe Commissioner as to whether any alert had been issued by WorkSafe regarding the dangers of using window shades in this manner.

By letter dated 15 June 2023, the WorkSafe Commissioner advised that WorkSafe had published a Significant Incident Summary (the Summary) on its website, “which seeks to highlight the increased risk visors of this nature may cause to exposing other persons to the hazard of a moving heavy vehicle”.68 A copy of the Summary was attached to the WorkSafe Commissioner’s letter. I commend the Commissioner for this action and it was reassuring to read that WorkSafe has undertaken to maximise distribution of the information in this Summary to industry participants.69 I have attached a copy of the Summary to this finding. The two photographs in the Summary are of Mr Robinson’s prime mover and show the window shade fitted in the position it was in when Mr Twine was run over.

67 ts 9.3.2023, p.229 68 Letter from the WorkSafe Commissioner to the Principal Registrar of the Coroners Court dated 15/6/2023, p.1 69 Letter from the WorkSafe Commissioner to the Principal Registrar of the Coroners Court dated 15/6/2023, p.1

[2023] WACOR 17 CONCLUSION Mr Twine was tragically run over by a work colleague’s prime mover as it was driven away from a roadhouse parking area in Port Hedland. The injuries he sustained were so significant that they were immediately non-survivable.

Regrettably Mr Robinson, the young driver of the prime mover, continued to drive away from the scene, notwithstanding the fact he was aware that he had run over a person. I attribute this course of action to his panic-stricken state. To his credit, Mr Robinson returned to the scene a short time later and notified attending police that he was responsible.

I have found that the death of Mr Twine was a tragic accident. In so finding, I am satisfied that Mr Robinson could not have reasonably anticipated that Mr Twine was in front of his prime mover when he commenced to drive from the truck parking area. I am also satisfied the window shade that Mr Robinson had positioned at the bottom of his prime mover’s windscreen significantly extended the area in front of the prime mover that could not be seen by a person sitting in the driver’s seat. As this blind spot measured more than a metre for the driver even without the window shade in position, I have not been able to determine whether the window shade was a contributing factor in Mr Twine’s death. That is because I have not been able to precisely determine how or when Mr Twine approached the prime mover or the distance he was from the front of the prime mover when it began to move.

Nor have I been able to provide an explanation as to why Mr Twine, a very experienced and safety conscious truck driver, would position himself in front of a prime mover that was about to drive forward without the driver’s knowledge he was there.

The footage from body worn cameras belonging to the attending police officers starkly demonstrated the traumatised state Mr Robinson was in when he returned to the Roadhouse. From his evidence at the inquest, it was clear to me that he continues to be traumatised by what he had done. When asked at the completion of his evidence if he wanted to say anything further, Mr Robinson replied :70 Just, you know, like, it was horrible and I wish it never, ever happened and if I could – you know, I – yes, I just, yes, wished this never happened. I – I don’t want to be here; I know no-one else wants to be here.

It is my fervent hope that the dangerous practice of heavy vehicle operators using modified foil window shades at the bottom of their windscreens (particularly in cabover vehicles) will cease. Given the efforts by WorkSafe to 70 ts 9.3.2023, Mr Robinson, p.223

[2023] WACOR 17 alert these operators to this dangerous practice, I have not felt it necessary to make any recommendation with respect to this matter. I also note that the evidence before me was that Norwest Crane Hire had prohibited its drivers from engaging in this practice shortly after Mr Twine’s death.

From my research since the inquest, it has been reassuring to find that manufacturers of heavy haulage vehicles have begun introducing safety features designed to avoid collisions with other road users, including pedestrians. These systems incorporate a combination of warning alerts and automations that are designed to be activated when a potentially dangerous change in the driving environment is detected.

One active collision avoidance system developed by a major manufacturer in 2020 can be retrofitted to its vehicles produced from 2011 onwards.71 It was clear to me that Mr Twine was a much-loved partner, father and work colleague and his sudden death caused indescribable grief to so many people.

As Ms Scrivener said in her statement she read at the inquest :72 Nothing can ever prepare you for that knock on the door to tell you that your person, the one you shared and built your life and family with, is never coming home.

Ms Scrivener also read out a message she had received from one of Mr Twine’s work colleagues :73 Kerrilee, your amazing husband touched the hearts of an untold number of people far and wide out on the road and everywhere he went, his generosity to help anyone, the passion he had for everything he did. He would make you laugh; he would make you cry.

… His ability he had to brighten your day even on your worst and the love and commitment every day for his family.

He was, is and will always be everyone’s old mate.

As I did at the completion of the inquest, and on behalf of the Court, I extend my heartfelt condolences to the family and friends of Mr Twine, particularly his partner and three children, for their sad loss.

P J Urquhart Coroner 31 August 2023 71 The Mobileye collision avoidance system produced by Western Star 72 ts 9.3.2023, Ms Scrivener, p.225 73 ts 9.3.2023, Ms Scrivener, p.227

[2023] WACOR 17 WORKSAFE’S SIGNIFICANT INCIDENT SUMMARY Significant Incident Summary No. 3 Installing non-original internal sun visors that reduce field of view Background WorkSafe’s investigation is ongoing. Information contained in this significant incident summary is based on evidence at the time of writing.

WorkSafe is investigating an incident, which resulted in a worker sustaining fatal injuries after being hit by a truck at a workplace. At the time of the incident, the worker was positioned in close proximity to the front of the cab of the truck. The driver of the truck did not see the worker prior to setting off.

The truck involved in this incident had a non-original, reflective foil visor installed at the base of the windscreen.

Truck with non-original sun visor fitted at base of window.

From inside the cab, trucks generally have restricted visibility (‘blind spots’) of some areas around the vehicle. These blind spots, which are much larger than in other vehicles, are a hazard to truck drivers and other people in close proximity to the trucks.

The installation of a non-original visor at the base of a truck’s windscreen increases the size of existing blind spots immediately in front of a truck. This increases the risk of exposure to the hazard of a moving vehicle to other people in the immediate vicinity.

[2023] WACOR 17 WorkSafe’s investigation into the incident has established that similar non-original visors are widely used by drivers of heavy vehicles operating on public roads in Western Australia.

Under the Road Traffic Code 2000, a driver is required to have an uninterrupted and undistracted view (r. 263).

View from cab of truck with non-original sun visor fitted.

Contributory factors

• The sun visor may have further restricted the view of the driver so that the worker was unseen when the vehicle moved off.

• The person conducting a business or undertaking (PCBU), including persons having control of the workplace, not identifying the potential hazards associated with the use of non-original sun visors being installed in the windscreen of trucks.

Actions required

• Educate workers of the potential dangers from installing non-original items to vehicles that may further restrict the field of view and increase blind spots.

• Conduct regular checks of the cab to ensure non-original items have not been added to vehicles that may further restrict the field of view of the driver.

• Encourage workers conducting maintenance on vehicles to alert the PCBU to the presence of such items when completing routine maintenance.

• Remind drivers to conduct a pre-start check before setting off to ensure as far as practicable that no persons are in the vicinity of their intended direction of travel.

Further information Department of Mines, Industry Regulation and Safety

• Guidance Note – Safe movement of vehicles at workplace

• Safety alert 01/2015 – Vehicles and mobile plant causing deaths at workplaces