Brasher, Gryphyn David
Deceased
Gryphyn David Brasher
Demographics
9y, male
Date of death
2007-08-17
Finding date
2009-05-14
Cause of death
Hypovolaemic shock due to massive blood loss from ruptured right lung as a result of trauma caused by being struck by a motor vehicle; also suffered ruptured liver and spleen
AI-generated summary
A 9-year-old boy, Gryphyn Brasher, was struck and killed by his father's Ford Explorer that rolled backward down a steep driveway (18.6-23.6% gradient) in Toowoomba, Queensland. The vehicle was parked in Park with the handbrake engaged, but moved when a 5-year-old sibling interfered with controls. The coroner identified multiple contributing factors: failure of the brake-shift interlock actuator's mechanical locking mechanism (allowing the gear shift to move from Park without depressing the release button), failure of the actuator's electrical circuit (which had been previously repaired via steering column replacement in 2005), and a grossly inefficient handbrake that Safe-T-Brakes had identified as needing urgent repair four days before the incident but failed to address or clearly communicate the severity to parents. The coroner found that a properly functioning actuator would have prevented the incident, and a functioning handbrake would likely have prevented it entirely.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Failure of vehicle's actuator mechanical locking mechanism allowing T-bar gear shift lever to move from Park position without depressing release button
- Failure of electrical circuit in vehicle's actuator
- Poor condition and gross inefficiency of vehicle's handbrake
- Steep driveway (18.6-23.6% gradient)
- Interference by 5-year-old child with vehicle controls
- Failure of repair workshop to address identified handbrake fault urgently
- Inadequate communication to parents regarding severity of handbrake fault
Coroner's recommendations
- Ford Australia cause Australia-wide advertisements to be published informing all owners of UT Ford Explorer 4WDs with automatic transmissions of a potential fault in the brake-shift interlock actuator and recommend mechanical inspection by accredited Ford repairer with remediation at Ford's expense
- Mechanical repairers give written notification to owners of vehicles of any faults potentially dangerous to operation found during services and repairs, with written acknowledgment by owners on vehicle collection
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