The tragic death of a Tasmanian farmer has led a coroner to call for tractors manufactured before 1982 to be legislatively prohibited from use in commercial farming operations.
Coroner Olivia McTaggart also recommended as an alternative that Safe Tractor Access Platforms be required by legislation to be retrofitted to tractors manufactured before 1982 and used in commercial farming operations.
The recommendations were handed down as part of a report into the death of Ian John Barwick, who died as a result of mechanical traumatic asphyxia at his Chudleigh, Tasmania property on June 9, 2020.
Extraordinarily, the same tractor was also involved in the death of Mr Barwick's father.
Mr Barwick and his wife Patricia owned 640 acres of land at Chudleigh, where the Barwick family had been farming for more than 60 years.
"Mr Barwick had maintained and operated his own farm equipment for 50 years," the coroner's report stated.
"The David Brown 780 tractor involved in the death of Mr Barwick was at least 50 years old.
"In 1977, the tractor had rolled onto Mr Barwick's father, causing his death. Following this, Mr Barwick installed rollover protection on the tractor."
The coroner's report stated both Mr and Mrs Barwick were aware that the tractor had mechanical issues but continued to use it on the farm on several occasions per year.
In her affidavit for the coronial investigation, Mrs Barwick said that 15 to 20 years before Mr Barwick died, she experienced an incident with the tractor. The tractor had been set to neutral gear and the handbrake was engaged while Mrs Barwick alighted to deal with a hay bale. However, the tractor started to roll forward and picked up speed on a bank before running into a hay bale.
The coroner's report said on June 9, 2020, Mr Barwick left the farmhouse on the tractor to winter feed the cattle on the property.
But when he had not returned by 5pm Mrs Barwick became concerned and went searching for him with their son Jeremy.
Their son found Mr Barwick, deceased, at about 5.40pm.
"The tractor engine was running but it was not in gear," the report stated.
"According to the attending SES officer who arrived at the scene, the handbrake of the tractor was not engaged."
A scene analysis and a reconstruction of events was undertaken by experienced crash investigator Constable Nigel Housego to determine the sequence of events leading to Mr Barwick's death.
"Constable Housego formed the view that the tractor had not rolled onto its side at any stage, but had moved forward and trapped Mr Barwick underneath," the report stated.
Tractor inspection
On June 15 2020, the tractor was inspected by Barry Spencer, a Transport Safety and Investigations Officer employed by the Department of State Growth.
Mr Spencer found that the tractor was not safe for operational use, with the main safety issues being:
- The hand brake lever did not hold upwards when applied and instantly self-released by dropping downwards
- The left and right brake pedals could no longer be locked together to operate as a one pedal assembly due to a bent locking lever
- The left and right foot brake pedals applied the brakes at different heights with a 40mm difference in pedal height
- The clutch safety start switch had been previously damaged, had been bypassed and was no longer operational
- There was excessive circular free play in the steering wheel measuring 135 degrees, due to worn steering components
- Engine oil seeped onto the engine exhaust manifold and caused fumes in the vicinity of the driver's seat while the engine was running
- The front wheel bearings were loose and had a considerable amount of excess play, requiring attention and adjustment
- Diesel fuel was constantly dripping from the right side of the engine at the diesel lift pump
- The tractor had no grab handles and therefore the driver would have had to use the steering wheel to mount the tractor.
The report stated the most significant safety issue contributing to Mr Barwick's death appeared to be the non-operational handbrake.
For the investigation, the coroner commissioned a report from the National Coronial Information System on tractor incident deaths in Australia between 2012 and 2022.
The report indicated that there were 131 deaths within the decade, being an average of 12.3 deaths per year.
The vast majority of the deceased were male and 63.4 per cent of deaths were persons aged over 61 years.
The main causes of death were: rollovers (29pc); unexpected tractor movement (15.3pc); and defective braking systems (13pc).
The death of Mr Barwick was the fifth tractor death in Tasmania since 2017, with four of the deaths involving very old tractors (three with defects) operated by males aged between 63 years and 87 years.
"Constable Housego commented in his investigation report that not only do tractors deteriorate with age but the physical capacity of the operator to meet the demands of their operation diminishes over time," the report stated.
"Most often, old tractors are used in smaller family operations and may not be properly maintained, whereas larger working farms use more modern, safer tractors.
"These factors in combination mean that there is a high risk of danger to the operator of an old tractor and that further deaths or injuries are likely to occur."
Paula Thompson
Paula Thompson is ACM's National Machinery and Ag Tech writer. She has been an agricultural journalist for more than 20 years. Prior to her current role, she was a reporter with the Stock Journal, covering livestock markets and the grains industry.
Paula Thompson is ACM's National Machinery and Ag Tech writer. She has been an agricultural journalist for more than 20 years. Prior to her current role, she was a reporter with the Stock Journal, covering livestock markets and the grains industry.
