Coroner's Finding: Mansell, John Ernest
Deceased
John Ernest Mansell
Demographics
71y, male
Date of death
2013-04-17
Finding date
2016-01-20
Cause of death
neck, chest and abdominal injuries sustained in a motor vehicle crash
AI-generated summary
A 71-year-old business owner competing in Targa Tasmania 2013 died when his Porsche became airborne at 200 km/h over an unmarked crest, crashed into a tree, and sustained fatal neck, chest and abdominal injuries. The coroner found the primary cause was excessive speed combined with driver inexperience and failure to heed his navigator's warning. Contributing system failures included: absence of speed-limiting devices, failure to apply CAMS Tarmac Rally Standing Regulations, inadequate safety reviews, lack of mandatory HANS devices, and inconsistent breath-alcohol testing. The deceased had pre-existing severe ischemic heart disease. The coroner made eight recommendations including mandatory CAMS regulations, formal safety reviews, speed limiters, safety assessors, and pace notes accreditation. While multiple system failures were identified, the coroner did not conclude that any single failure directly prevented the death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Excessive speed (200 km/h) over unmarked crest
- Driver inexperience and lack of professional skill in high-speed rally driving
- Failure to heed navigator's warning instruction to stay right and prepare for drop
- Open window preventing driver from hearing co-driver's instructions clearly
- Absence of speed-limiting devices (chicanes) on the stage
- Failure to apply CAMS Tarmac Rally Standing Regulations
- Inadequate and informal course safety review process without documented outcomes
- Contractual prohibition on use of chicanes preventing consideration of speed-limiting devices
- Pre-existing severe ischemic heart disease with severe atheroma
- Inadequate pre-stage breath-alcohol testing enforcement on day of event
Coroner's recommendations
- CAMS Tarmac Rally Standing Regulations (TRSR) apply to the running of any future events
- Compulsory alcohol testing for all competitors before all stages in future events
- Formal, transparent system of review of course design and safety after each event, including recording of outcomes
- Consideration of appointment of safety assessor to assist the event course checker
- Separate beginners briefing for all first-time competitors in the event
- Mandatory use of HANS devices for all competitors
- Consideration given to accreditation of those who prepare pace notes for sale, including system of uniformity of symbols and meanings
- Dispensation with contractual prohibition on the use of chicanes (real and/or virtual)
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