Coroner's Finding: Barwick, Ian John
Deceased
Ian John Barwick
Demographics
67y, male
Date of death
2020-06-09
Finding date
2023-05-19
Cause of death
Mechanical traumatic asphyxia from being run over by a tractor
AI-generated summary
Ian John Barwick, 67, died from traumatic mechanical asphyxia after being run over by a 50-year-old David Brown 780 tractor on his farm. While wintering cattle, Mr Barwick likely alighted from the tractor on a slope that appeared flat but had a 5.8% gradient. The tractor's handbrake was non-operational—it did not hold when applied and self-released immediately. The tractor either rolled forward after he jumped down, or he never engaged the ineffective handbrake. When Mr Barwick noticed the tractor moving, he attempted to remount but slipped and was trapped under the rear wheel. The tractor had multiple critical safety defects including failed braking systems, excessive steering play, and missing grab handles. The coroner recommended legislative prohibition of pre-1982 tractors in commercial farming or mandatory retrofitting of Safe Tractor Access Platforms to prevent operators being run over during mounting and dismounting.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Non-operational handbrake that failed to hold and self-released
- Steep terrain (5.8% gradient) appearing deceptively flat
- Aged tractor (50+ years old) with multiple safety defects
- Mounting and dismounting a moving or potentially moving tractor
- Absence of Safe Tractor Access Platform (STAP)
- Lack of grab handles on tractor
- Operator alighting on portion of track that appeared flat but had significant gradient
Coroner's recommendations
- Tractors manufactured before 1982 be legislatively prohibited from use in commercial farming operations
- Alternatively, Safe Tractor Access Platforms (STAPs) be required by legislation to be retrofitted to tractors manufactured before 1982 and which are used in commercial farming operations
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