|
Coronial Division
Friday, 17th May 2002
IN THE CORONERS COURT HELD
AT BURNIE
INQUESTS INTO THE DEATHS OF :
JUDITH
ANN FRANKLIN
YVONNE MacPHERSON
GEORGE MACKAY MacPHERSON
HENRY ALFRED MEREDITH
Before formally delivering my
findings as to the deaths of Judith Ann FRANKLIN, Yvonne MacPHERSON,
George Mackay MacPHERSON and Henry Alfred MEREDITH, I should first
indicate the function and duty of a Coroner when investigating deaths.
Section 28 of the Coroners
Act states:
28. (1) A coroner
investigating a death must find, if possible –
(a) the identity of
the deceased; and
(b) how death
occurred; and
(c) the cause of
death; and
(d) when and where
death occurred; and
(e) the particulars
needed to register the death under the Registration of
Births and Deaths Act 1895 and
(f) the identity of
any person who contributed to the cause of death.
(2) A coroner must,
whenever appropriate make recommendations with respect to ways
of preventing further deaths and on any matter that the coroner
considers appropriate.
(3) A coroner may
comment on any matter connected with the death including public
health or safety or the administration of justice.
There is one important
limitation that must not be overlooked and that is contained in
Section 28(4) which provides:
A coroner must not
include in a finding or comment any statement that a person is or
may be guilty of an offence.
These are the statutory
requirements in respect of all inquests held within the State of
Tasmania.
Pursuant to a written
authority (exhibit C1) under the hand of the Chief Magistrate of
Tasmania, in accordance with section 50 of the Coroners Act 1995, each
individual death was investigated at the one Inquest which was held,
by me, at Burnie in the State of Tasmania on the 25th and
26th days of October 2001.
At this point, I would like
to express my appreciation to Sergeant Rod Carrick, Coroners Associate
for his assistance in relation to this matter and all of the members
of the Hobart Coroners Office, without whose assistance I would not
have been able to deal with this matter as expeditiously as I have,
and I am indebted to them for their caring attitude towards the
families and friends of those who died so tragically.
I FIND THE DEATHS OCCURRED IN
THE FOLLOWING CIRCUMSTANCES:
The incident which led to
these four deaths, which I will describe as a tragedy, occurred in one
of Tasmania’s premier tourist destinations. It is a Wilderness World
Heritage Area. Tasmanian’s and tourists alike visit the area to
undertake a wilderness experience. The majority of visits to the area
occur in the warmer months of the year, October through to March.
As early as 1913, Waldheim
was well established as a tourist destination. The present road
essentially follows the original access corridor into the valley
leading to Waldheim. The road is a narrow, unsealed, winding route
passing through the World Heritage listed area of Cradle Mountain -
Lake St Clair National Park. Signage at the beginning of the route
restricts access to vehicles with less than 29 seats. Speed at the
time of the accident was restricted by sign to that of 40 kilometres.
The length of the tourist
road to Dove Lake, commonly referred to as Dove Lake Road, is 7.14
kilometres in length. The road is unsealed and it width varies from 3
metres to just in excess of 5 metres. The road is heavily treed in
places especially along the western side. On the eastern side the
ground generally drops down into the valley with slopes varying in
gradient from gently to steep.
At the time of the accident
there was no safety fencing, railing or guide posts on the eastern
side which delineated the edge of the roadway or provided protection
against a vehicle leaving the road in the areas of these slopes. It is
clear, that the road did not conform to the ‘Austroads Guide to the
Geometric Design of Rural Roads’, either in road width or sight
distance. However, according to the evidence, this road was never
formally constructed or designed, it has merely developed through
continued use over many years. The Guidelines apply to new roads
constructed after the establishment of the guide, and whilst they are
indicative of what would now be expected, they are not applicable or
have force of law as to roads existing prior to the establishment of
those guidelines.
There are limited
opportunities along this section of roadway, due to the width, for
oncoming vehicles to pass. Accurate judgement from drivers is not only
necessary but mandatory. Poor judgement, and perhaps driver
inexperience could have dire consequences when combined with the
narrow formation, lack of safety barriers, unsealed surface and steep
embankments. Areas of this road have been described as unforgiving in
relation to driver error.
I am satisfied on the
evidence that traffic volume varies significantly with higher numbers
using the road during the summer months. Doctor Giles, who gave
evidence before me, conducted a count of vehicles using the road only
2 days post accident. His count revealed a total of 218 vehicles using
the road in a period of 3 hours and 10 minutes. He quite properly
conceded in evidence that his count may well have been influenced by
the number of vehicles using the road as a result of the accident.
Vehicle usage data from 1990 to 31 January 2001 was tendered at the
Inquest. This data clearly establishes that the assessed annual daily
traffic as required by the ‘Austroad Guidelines’ was below 1,000
vehicles daily and therefore low volume when averaged.
The roadway is under the
control of the State through the Department of Infrastructure Energy
and Resources. A contractor (Civil Construction Corporation) is
engaged by the State to inspect and carry out maintenance and minor
repairs on the road. Records reveal that 1 to 1½ days work per week
on a regular basis was carried out by the contractor prior to the
accident. In addition to this the road is graded biannually. Shortly
before the accident there had been a light grade of the road and this
was in addition to the biannual grade. I am satisfied, on the evidence
presented before me, that the road was properly maintained.
This roadway had not featured
highly in accident statistics prior to the 18th day of
February 2001. There was evidence, in documentary form, of 4 reported
accidents. All of these have been attributed, in one way or another,
to the narrow road and have only involved property damage.
The evidence clearly
indicates that this road had been under review by the State (DIER) for
a number of years. The area of road at the site of the accident had
not been identified as requiring the installation or implementation of
any safety measures to ameliorate exiting and/or potential risks to
public safety.
I am satisfied the
installation of guide posts, delineators or a safety fence would not
have been contrary to the intent or application of the World Heritage
Management Plan. I am of the view that this area of road and its
surrounds should have been identified for the innate danger of an
errant vehicle rolling down the ravine, and it is surprising that
safety audits had not identified such problem, although with only 4
reported incidents, and those involving property damage only, it may
have been assumed that the road conditions themselves acted as a
deterrent to erratic driving.
Cradle Mountain Lodge, at the
date of the accident and since, have operated ‘Night Excursion
Tours’ in the area. The purpose of the excursion is for
tourists/guests to observe the unique wildlife via spotlight from the
comfort of a vehicle. As at February 2001 the night excursion
commenced from outside the Lodge at 9.45pm. The driver of the vehicle,
who was, at the relevant date, a lodge employee, also operated the
spotlight. On occasions the driver will request a guest on the tour to
act as a spotter. When an animal is observed the vehicle would be
stopped so that the passengers could view the animal by spotlight in
its normal surrounds
Persons wishing to partake in
the excursion were required to make a booking at the Lodge. If the
number of passengers was 12 or less a lodge vehicle would be used. The
Lodge vehicle is fully equipped with seat belts for all occupants. If
the number of person booking the excursion exceeded 12 passengers it
was necessary for the Lodge to utilise a Maxwell Mini Bus (19 seater).
In this vehicle, seat belts are fitted to the driver and front
passenger seats only. The Maxwell bus is located at the lodge.
On the 18th day of
February 2001 as there were 17 registrations for the excursion it was
necessary to use the 19 seat mini bus. The driver and guide on the
excursion was Kathleen Michelle Grayson. Miss Grayson had only been
employed at the lodge since early January 2001. Evidence presented
before me indicates that she was adequately qualified and properly
licensed to drive such a vehicle. During the course of her evidence
Miss Grayson fully detailed the experience that she had in relation to
the driving of similar and larger passenger vehicles. I have no
hesitation in finding not only was she qualified to drive the vehicle
but was also competent and well skilled in their handling.
The 17 passengers for the
tour were collected outside the front of the lodge at 9.45pm on this
evening. Out of the passengers there were 16 tourists to the state and
one former employee of the lodge a Miss Rachel White. Two seat belts
only were fitted in the bus, the front seat passenger, Miss White, was
wearing the fitted seat belt, and although a seat belt was fitted for
the driver, Miss Grayson was not wearing it at the time of the
accident.
The deceased, George MacKay
MacPherson and Yvonne MacPherson were seated on the driver’s side
one seat in front of the rear seat in the bus. Mrs. MacPherson had the
window seat and Mr. MacPherson was on her left. Judith Ann Franklin
was seated on the rear seat closest to the window on the driver’s
side next to her husband. Henry Alfred Meredith was also on the rear
seat to the right of his wife who had the window seat on the passenger
side.
The bus was driven out of the
car park, turned right and travelled past the visitor centre onto Dove
Lake Road. I find that when the excursion commenced it was dark and
the headlights on the bus were operating. I further find that at all
times the bus was being driven very slowly and at no time did it reach
or exceed the 40 kilometre per hour speed restriction. The bus stopped
on a number of occasions to view wildlife with the aid of a spotlight.
Approximately 4 kilometres
south of the visitor centre the lights of an oncoming vehicle was
observed by Miss Grayson. I find that this oncoming vehicle was a
Subaru Forester vehicle being driven in a northerly direction by
Charles David Livesey. Mr. Livesey, was at that time, a summer
interpretation ranger employed at Cradle Mountain by the Parks &
Wildlife Service, a division of the Department of Primary Industries,
Water & Environment.
I find that Mr. Livesey was
returning to his accommodation at Cradle Mountain after having taken a
number of tourists for a night walk at Waldheim. The night walks are
organised and operated on a regular basis by the Parks & Wildlife
Service.
The evidence before me
clearly indicates that Mr. Livesey had driven on Dove Lake Road on a
number of occasions. I find however, that he was unaware of the steep
ravine to the left hand side of the approaching vehicle (mini bus). To
explain this, whilst he was aware of the contours of the countryside,
the absence of lighting would make it impossible to pinpoint with any
accuracy where the vehicle was at a given moment unless you were
trying to identify particular landmarks as you drove along, and then
you would need to be using a torch or lighting device to illuminate
them. I am satisfied that Mr. Livesey was driving his vehicle in an
appropriate and proper manner and that his speed was under the
allowable maximum of 40 kilometres an hour.
Mr. Livesey, in evidence
before me, stated that he first saw the approaching headlights when he
was about 80 metres from the vehicle. He thought at the time that the
headlights of the approaching vehicle were on high beam due to the
fact that he had four (4) headlights coming towards him. Miss Grayson,
on the other hand, states that the bus headlights were on low beam and
the evidence of the accident investigator, Constable S Mason, supports
her belief. I formally find that the headlights of the bus were on low
beam and that Mr. Livesey is mistaken in his belief.
As Mr. Livesey approached the
mini bus he formed the view that the driver of the bus was stopping or
slowing down to allow him to pass due to the narrow dimension of the
road. Miss. Grayson in evidence agreed that initially she was
travelling in the centre of the road and when she saw the approaching
headlights she slowed and pulled over to the left to allow the vehicle
room to pass. Mr. Livesey was unsure as to how far the mini bus pulled
over to the left but, in answer to a question put to him by Mr.
McTaggart, counsel acting for Mr. Franklin and Mr. and Mrs. Tyler, he
stated that there was ample room.
Although, the phrase
"ample room" is a matter of interpretation. The accident
investigator measured the width of the roadway at the scene of the
accident at 4.6 metres. Approximately 35 metres north of the scene,
the road width was found to be 5.8 metres. The combined chassis width
of both vehicles excluding exterior rear vision mirrors was 3.6
metres. The measurements indicated that there was an area of less than
1 metre wide for both vehicles to pass safely at the accident site. I
should add, when I attended at the scene, I caused two vehicles to be
parked on the road near the accident site, and the photographs clearly
show that it would be difficult for two vehicle to pass comfortably at
this particular location without the benefit of illumination or side
of the road delineators.
Miss Grayson is unable to say
whether the mini bus was still moving forward slowly or had come to a
stop when Mr. Livesey commenced to pass. The evidence clearly suggests
that Miss Grayson had unintentionally driven the vehicle too close to
the eastern edge of the road in allowing room for the approaching
vehicle to pass. It is my view that this conclusion is unequivocal but
has to be viewed in light of the lack of road edge delineation in such
a treacherous area. It is more likely than not that the left hand
wheels have been balanced right on the edge of the road.
Mr. Livesey’s vehicle has
passed the bus, it can therefore be assumed there was sufficient
clearance for this manoeuvre to take place. It is clear that the rear
left hand wheel or perhaps both left hand side wheels of the bus have
slid off the edge of the road surface causing the bus to teeter and
rock on the edge of the road. This was seen by Mr. Livesey after he
had passed the bus. The bus has then rolled a number of times down the
steep ravine before coming to rest some 33 metres from the edge of the
road. From the evidence I formed the view that it was the rear left
hand wheel that had initially left the road surface, and this would
seem consistent with the manner in which the bus has rolled down the
embankment.
It would appear that whilst
the bus was teetering on the edge of the road a number of persons
seated on the right hand side (drivers side) of the bus have stood up
in their seats, and I refer to the affidavit evidence of Jeffrey
Richard Gray, (exhibit C35). There is insufficient available evidence
for me to make a definitive finding as to whether the actions of these
persons have contributed to the fate of the mini bus, but it could be
that this activity caused the bus to commence a rocking motion and
this may have, coupled with the precarious position of the bus led to
it slipping off the edge of the road.
There is no evidence to
suggest structural failure of the road. I am satisfied that the road
material that was dislodged from the eastern side of the road was the
result of the under carriage of the bus resting on the edge of the
road after the wheels have slipped off. The bus has then moved and
rolled to its left causing the displacement of the road material. It
is difficult to be definitive as to this, as when I attended at the
scene, much of the edge of the road had collapsed due to the movement
of rescuers during the night. I do not intend this to be a criticism
of the rescuers as they had no other alternative than to put the
safety of the passengers as a first priority.
Mr. Livesey returned to the
scene, by that time other persons had also arrived. The alarm was
raised and emergency services from the North West Coast were notified
and later attended. In the interim, assistance was offered and given
to the injured by those present at the scene, Parks & Wildlife
personnel and staff from the Cradle Mountain Lodge.
The deceased, Henry Alfred
Meredith, George MacKay MacPherson and Judith Ann Franklin all died at
the scene of the accident. Yvonne MacPherson died whilst being
transported by helicopter from Cradle Mountain to the North West
Regional Hospital at Burnie.
The assistance to emergency
services offered and given by the Parks & Wildlife Service and
Cradle Mountain Lodge staff should be highly praised.
Comments and Recommendations
The vehicle involved in this
accident was a 1987 Mazda T3500 19 seat mini bus. Inspection
subsequent to the accident did not reveal any defect that may have
caused or contributed to the accident.
As previously alluded to the
bus is fitted with two (2) seat belts only. One for the driver and one
for the front seat passenger. The bus at the time of its construction,
1987, was only required, by the Australian Design Rules (ADR), to have
a seat belt fitted for the driver. The same rule is applicable to the
subject mini bus. There is no evidence before me to suggest or imply
that the absence of seat belts contributed to any of the causes of
death. As to whether or not passengers in public vehicles should be
fitted with a seat belt is a perplexing question.
It is axiomatic and there are
many reports and studies which demonstrate that the fitting of seat
belts in motor vehicles has led to a reduction in the numbers of
deaths and serious injuries resulting from motor vehicle accidents. In
Western Australia a study found that a person was ten times more
likely to be killed in a road crash if that person was not wearing a
seat belt (See Analysis of Road Crash Statistics, 1990 to 1999, Road
Safety Council of Western Australia).
It is sometimes suggested
that the wearing of a seat belt in buses can cause further injuries,
others say that this is in a small number of instances only. There are
debates as to whether a lap and sash seat belt is safer than a lap
seat belt. Mr Elson in his evidence indicated that lap seat belts in
buses can cause greater injury as opposed to not wearing a seat belt
at all. There have been many reports and studies carried out but none
seem to have been definitive as to the appropriateness of a legal
requirement that buses should be fitted with seat belts.
One study examined the issue,
confining it to the fitting of seat belt in school buses, School bus
seat belts, Their Fitment, Effectiveness and Cost by Michael Henderson
and Michael Paine was prepared for the Bus Safety Advisory Committee,
New South Wales Department of Transport in December 1994 and
recommended, inter alia, that the mandatory fitting of lap-only or
lap/sash seat belts in large route service buses be not recommended. A
search of the internet discloses the issue has been hotly debated ever
since and continues to draw its advocates and opponents.
The current situation would
appear to be that many public vehicles still in use were never
designed or constructed to permit seat belts to be fitted and the
costs of requiring these vehicle to be modified to the standard
necessary for the fitting of seat belts would be prohibitive. New
vehicles are now required to be constructed with sufficient
strengthening to enable seat belts to be fitted to anchorage points.
However it would seem that the requirement to fit seat belts can be
avoided by having the backs of seats below a certain height and
therefore not suitable for lap and sash seat belts.
In my view I am not possessed
of sufficient information where I could make an informed
recommendation, as to the appropriateness of the fitting of seat belts
to passenger vehicles and I desist from doing so.
During the course of the
Inquest evidence was sought as to the desirability and suitability of
an ambulance being permanently stationed at Cradle Mountain. If so,
would we have had a different outcome in relation to the deceased? The
evidence of Mr. Stendrup indicated that manning an ambulance in the
Cradle Mountain area would be difficult due to the high turn over of
staff at the Lodge and also staff within the Parks & Wildlife
Service at the Mountain. The nearest ambulance is stationed at Waratah
approximately 35 minutes from Cradle Mountain. I find, that there is
no evidence to suggest or infer that the stationing or manning of an
ambulance at Cradle Mountain would have prevented the deaths’ of the
persons who are the subject of this Inquest. Three of the deceased, as
previously alluded to, died at the scene and Mrs. MacPherson died in a
helicopter on route to hospital.
I note that a very short time
after the accident the speed limit on Dove Lake Road was reduced from
40 kilometres an hour to that of 30 kilometres an hour. Although speed
was not a factor in this accident, it is my view, that the reduction
in the permissible maximum speed limit was appropriate and proper
having regard to the nature and construction of the road, and it
enabled the appropriate authority to given consideration to the making
of improvements to the area.
The Department of
Infrastructure, Energy and Resources also commissioned a road safety
audit to review the operation of the road and identify works required
to improve its safe operation. The site of the accident on Dove Lake
Road, was within the audited area. The audit was conducted by the
company Pitt and Sherry. The written report in relation to the audit
was tendered into evidence and marked, exhibit C 71.
It is clear that a number of
areas, including the accident site, were identified by the auditor as
requiring some form of attention for the purpose of safe operation.
The audit’s assessment priorities were identified in three (3)
categories, namely: For Immediate Attention: Important or Routine.
The area of the accident site
was identified as requiring immediate attention. It was one of the
narrowest sections of the road and on the eastern side there was no
safety fence, no guide posts to define the edge of the road. The
auditor on page 17 of his report makes the following comments:
"The consequences of
the slightest error of driver judgement is severe due to the fact
that there is no safety fence along the LHS of this section which
has a very steep drop of over 30 metres into the Dove River
Valley. No guide posts are installed to assist in defining the
edge of the road and at night drivers have no concept of the
presence of the steep unprotected embankment on their left.
Other sections of road
are similar width but provide passing bay (pull off areas). There
are no such facilities at this site meaning opposing drivers first
see each other after they are committed to driving this narrow
section".
As a result of the audit and
recommendations made thereunder road alterations and modifications
were undertaken in all areas that were identified as requiring
immediate attention – this of course included the area of the
accident. As a result of the Department alacrity in commissioning the
alterations, which I find were totally appropriate, the possibility of
an accident occurring in similar circumstances at the particular
location of this accident is highly improbable.
Although the width of the
road has been slightly reduced at the site of the accident a safety
fence has been erected on the eastern side and passing bays
formalised. Road signs either side regulate the passage of vehicles
through this area.
Evidence before me indicates
that in the course of the next 24 months further works will be carried
out on the road so as to address all issues identified in the audit.
This, to my mind, is an appropriate and proper response to the audit
by the Government.
During the course of the
coronial investigation a report, under the hand of Doctor D. L. Giles,
was received by my office. This report related to an audit that Dr.
Giles had carried out in relation to the Cradle Mountain Road. Dr.
Giles was summonsed at my direction and gave sworn evidence at the
Inquest. His report was tendered and marked as exhibit C 75. Dr. Giles
was questioned by Mr. Turner, acting for the State, at some length in
relation to his qualifications and motivation for preparing the
report. Dr. Giles stated in evidence his qualifications and experience
and I found his evidence to be enlightening and helpful to me in my
deliberations. Clearly, Dr Giles has a great interest in road
construction and it is pleasing to note that there are people such as
Dr Giles who are prepared to give of their own time to assist and to
put matter before an inquest in such a constructive manner. I am
indebted to Dr Giles for his very thorough and detailed investigation
and report.
As already alluded to the
road does not comply with the ‘Austroads Guide to the Geometric
Design of Rural Roads’ in some aspects. As I have already found, the
road itself was never designed nor constructed. The guidelines came
into existence sometime after the date on which the State took control
of the road. The Guidelines apply to the construction of new roads
however, they are followed by road authorities. Mr. Turner, at page 5
of his submission, makes the following comment:
"Many roads in
Tasmania and indeed throughout the country are in this category
– having been constructed or developed or maintained (or a
combination of these things) well before any guidelines became
applicable. Even Dr. Giles agreed with the proposition that it
would cost billions Australia wide and hundreds of millions in
Tasmania to have all roads compliant with the various
Guidelines;"
I agree with the comment made
by Mr. Turner. The suggestion of all roads (of the type referred to
above) being compliant with the various guidelines is unrealistic and
any recommendation made to the contrary would be unreasonable.
It is also clear that there
should not be substantial alteration to the roads in this area without
proper consultation with all interested parties, with proper
consideration, not only to the safety aspects but also environmental
concerns. It is the natural beauty of this area which attracts
tourists and, no doubt attracted the passengers on this fateful night,
it would be a pity to see it destroyed by the construction of
substantial roads merely because of a particular standard.
It is noted that some of the
concerns of Dr Giles have been or will be addressed following the
audit undertaken by the Department of Infrastructure, Energy and
Resources, although his main recommendation has not, and I do not
believe, from the evidence and information that I have received, I
could, or should, recommend the implementation of a redesign and
reconstruction of Dove Lake Road to "acceptable engineering
standards" as suggested by Dr Giles. Such development may unduly
impact on the World Heritage value of the area.
It is my view, there needs to
be a balance between protecting world heritage areas and the desire
and the right of citizens to have the opportunity of seeing and
viewing them.
There would seem little point
of having one of the world’s greatest natural assets and to lock it
up and deny the general population access to it. Equally, development
of roads and the provision of access should not unduly impact on the
natural beauty of the area, and should harmonise with it, whilst
ensuring the safety of those using such access.
Again, I would like to
express my gratitude to Dr Giles for his evidence. He has an obvious
passion in relation to road safety and has volunteered much of his
time in investigating the needs as he sees them, and has produced an
excellent report as to the ideal road requirement for this area as he
perceives it.
I would also like to express
my gratitude to Constable Sven Mason for his assistance and the
meticulous manner in which he prepares his files to assist the
Coroners. To have an officer with such extensive experience in
accident investigation is invaluable.
During his evidence,
Constable Mason referred to the reduced speed limit that was imposed
initially after the accident. It was his opinion, and one with which I
do not disagree, that the requirement that vehicles travel at a
reduced speed over a lengthy distance can lead to driver frustration
and inattention. With the modifications undertaken immediately
following the accident it is highly unlikely a similar incident would
occur. Whilst, I acknowledge that the reduction in speed was
appropriate at the time, it should now be reconsidered, noting that
speed was not a relevant factor in this accident, and there has not
been any reported accident due to excessive speed. I, of course, would
not recommend increasing the speed above the previously designated
speed limit, and any consideration should take into account the effect
such increase may have on the stability of the road.
I would also recommend that
regular safety audits be undertaken in relation Dove Lake Road to
consider implementation of modifications from time to time, which
would give consideration to road usage and its effect on the road
structure and the ever changing sight distances. The audit should also
take into account the greater stresses placed on the road structure by
the higher volume of traffic during the summer months. Whilst it
averages to less than 1,000 vehicles according to the statistical
information, it is clear that the volume is much greater during the
summer months, and therefore the resultant effect upon the road would
be greater during this period. This situation may become exacerbated
by the possible increase in tourist numbers with the provision of two
monohulls on Bass Strait, and the increased visitor numbers to the
Cradle Lake area.
On the evidence, that has
been presented before me, I find that the accident has been a direct
result of Kathleen Michelle Grayson driving a mini bus too close to
the eastern edge of the road whilst manoeuvring her vehicle to allow
the approaching vehicle being driven by Charles David Livesey to pass,
and in doing so has caused the rear passenger side tyre to move too
close to the edge of the road surface. This error in judgment has been
contributed to by the lack of appropriate road edge delineation and
appropriate safety railing in such a treacherous area. It is highly
probable that this manoeuvre caused the rear passenger tyre of the bus
to lose contact with the road surface with the resultant effect that
the bus lost stability causing the left rear corner of the bus to slip
from the road surface. It is possible that the movement of passengers
within the bus exacerbated the movement of the bus.
To the families of the
deceased I extend my sincere condolences on your loss. It is always
very hard to come to terms with the loss of a loved one.
I make no further comments or
recommendations.
This matter is now concluded.
DONALD J JONES
Coroner
 top
|
