Coronial
TASother

Coroner's Finding: Selby, Robert Norman

Deceased

Robert Norman Selby

Demographics

75y, male

Date of death

2018-08-03

Finding date

2021-07-27

Cause of death

Crush injuries of the chest and pelvis sustained when overrun by a tractor

AI-generated summary

A 75-year-old experienced farmer died from crush injuries sustained when run over by a Ford 4000 tractor. While attempting to dislodge a hay bale from the tractor spike with a neighbour, Mr Selby engaged the tractor's gears from a standing position beside the vehicle, causing it to move forward and run over him. The tractor had safety defects: a disabled neutral switch and missing brake pedal locking pin. The coroner accepted expert opinion that Mr Selby likely engaged gears while standing in front of the rear wheel, intending to move the tractor forward to dislodge the bale—common farm practice but extremely hazardous. A Safe Tractor Access Platform (STAP) might have prevented the incident, though WorkSafe Tasmania cautioned that retrofitting could incorrectly suggest mounting/dismounting operational tractors is safe. Key lessons: never engage tractor controls while standing beside it; never attempt to dismount/mount moving tractors; maintain tractor safety equipment; enforce strict operational protocols despite practical farming pressures.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • Engaging tractor gears from standing position beside vehicle
  • Operating tractor with disabled neutral switch safety feature
  • Missing brake pedal locking pin on tractor
  • Attempting to dislodge hay bale from moving/running tractor
  • Tractor footstep contaminated with diesel and lacking anti-slip material
  • Common farm practice of adjusting implements while tractor in motion
  • Slight downward slope and damp ground reducing bale's anchor effect

Coroner's recommendations

  1. All operators of tractors comply with the recommendations of Worksafe Tasmania as to the safe use of tractors
  2. Owners of tractors consider retrofitting Safe Tractor Access Platform (STAP) devices, noting that such retrofitting does not alleviate the requirement to follow safe use recommendations
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