Doubt over freak accident leads to rare second inquest into motorway deathby Donna Chisholm
A rare second inquest will be held in late November into an Auckland tradesman’s horrific death in a freak motorway accident.
Tavinor was decapitated when part of the driveshaft from an oncoming Mitsubishi truck flew out from under the vehicle, bounced over the median barrier and hurtled through his windscreen on the Southern Motorway in November 2000. Coroner Murray Jamieson examined the cause of the driveshaft failure and reported his findings in 2003. Jamieson found that mechanics who worked on the truck just days before the accident didn’t have the training to detect the badly worn and unsafe driveshaft, but added that the workshop failure was less important than the “substantial and remedial defects” in the road haulage industry.
Forensic engineers Timothy Smithson and Peter Morgan, of investigation firm Assessco, disputed the findings, and their lengthy investigation led to Morgan making a submission to the Solicitor-General last year, which triggered the second look.
Smithson and Morgan won’t go into detail in advance of the new inquest, which is scheduled to start on November 27, but Morgan says they believe a significant design flaw in a large proportion of heavy trucks on New Zealand roads puts them at risk of a similar catastrophic failure.
“There have been a number of instances where a sudden catastrophic failure has occurred,” Morgan told the Listener, “and it’s just by the grace of God that there haven’t been more people killed.”
Tavinor had been dead for more than seven years before forensic engineers Smithson, of Hamilton, and Morgan, of Auckland, began to question the cause of the accident that killed him. Smithson had been commissioned to investigate another driveshaft failure in a later model truck when he recognised similarities with the Tavinor case. “I thought, ‘I’ve read all this before’, and I realised where I’d read it.”
He says there have been other such failures since the Tavinor case “but fortunately nobody’s been killed. There is an issue out there with these trucks and it’s an issue that is not recognised by the regulators. My concern is the matter should have been investigated more thoroughly, and I don’t want to see this happen to someone else. My concerns may be dismissed, but given the evidence, I don’t think so.”
He says he’d always harboured doubts about the coroner’s findings because the explanations put forward for the failure didn’t seem to fit the way the accident unfolded. “From a mechanical engineer’s perspective, it didn’t make sense and it always concerned me. How it failed didn’t fit the evidence. Because of my background and nature, I don’t like mysteries.”
He has had personal experience with the inadequacies of official investigations – his 15-year-old son Cameron was killed in a crash with a truck in 1996, with police initially appearing to suggest the teen was to blame. Smithson investigated their report findings and was not convinced. After 15 months, he and his wife finally succeeded in getting a second inquest where he provided significant new information about the circumstances of the accident.
Coroner Jamieson’s report said the driveshaft that ultimately failed had been removed three times during servicing within nine and a half months – the last time on November 9, 2000, just 11 days before the accident that killed Tavinor. The November servicing was required to repair an oil leak that had begun soon after the previous service in August, and was done as a “defective repair”, meaning the truck operator wouldn’t be charged. The work, at Mitsubishi-owned Roadlife Trucks, was regarded as urgent.
Removal of the driveshaft meant removing the bearing straps from the front universal joint. The makers of the driveshaft had said the straps should not be reused, but the workshop foreman and mechanic said they did reuse them but that they had never read a manual for the driveshaft. They used a thread-locking adhesive on the strap bolts, a practice the makers specifically warned against, and did not use a torque wrench as recommended.
They said they replaced the leaking gasket with a new gasket. Jamieson said the replaced gasket was later found to be repaired, not new. “The mechanic could not account for this contradictory discovery.”
Three expert engineers told the inquest the wear on the driveshaft bearings – one of which failed, causing the fatal accident – was well in excess of the manufacturer’s limits and should have been apparent during the servicing.
Jamieson said the technical reasons for the failure were less important than the substantial and remediable defects in the road haulage industry generally. “The circumstances that failed to prevent this breakdown are not confined to a single brand or model of driveshaft, a single repair/maintenance workshop, a single vehicle manufacturer, a single haulier, but rather to the industry as a whole.”
But Morgan told the Listener that his submission to Crown Law said the expert witnesses’ conclusion that the bearing failed and the driveshaft suddenly separated from the truck essentially as a result of wear and tear was in his opinion “preposterous in the extreme”.
“Worn universal joints start to vibrate, and as wear increases, the vibration and resulting noise increase markedly. If heavy trucks’ universal joints indeed disintegrate as a consequence of the failure of one or more needle roller bearings in the front universal joint cross, the roads of New Zealand and the rest of the world would be littered with parts of universal joints and driveshafts. Clearly, they are not.”
Morgan says about four years ago, when the bearings in his 1992 Toyota Land Cruiser became so worn that the universal joints vibrated alarmingly, they made an excessive noise, but the joints did not disintegrate.
Morgan and Smithson have invested thousands of unpaid hours in their investigation. “You can either say it’s not my problem or you can decide within yourself – your own conscience dictates that you investigate something that you don’t necessarily get rewarded for,” says Smithson.
“You do it because you have a civic duty to do it,” says Morgan.
The death of Eddie Tavinor was originally treated as a possible manslaughter case. The police crash analyst involved in the case, former senior constable Stu Kearns, says the police executed nine search warrants relating to the Mitsubishi truck’s maintenance. Search warrants were usually sought when police were investigating “what might be a serious offence”.
“I dedicated a lot of time on that file,” he says. It is Kearns’ opinion that police “were lied to by certain parties within the inquiry”.
Coroner Gordon Matenga has been assigned to the new inquiry.
A pathologist’s concern
In the past five years, only three coronial inquiries have been reopened as a result of new information, despite nearly 40 requests to Crown Law. The third case was that of Hastings DJ George White, 52, who died in May 2004; his death was recorded as probably being the result of a heart rhythm disturbance.
An inquiry was reopened in 2013 after the autopsy findings were reviewed by prominent Wellington forensic pathologist John Rutherford, who considered White’s history of epilepsy a more reasonable cause of death. The new coroner’s report says White died from natural causes associated with epilepsy, which he developed following a head injury.
Rutherford, who came to New Zealand in 2006 after helping to get former GP Harold Shipman locked up for 15 of the 215 poisoning murders he is believed to have committed, has previously expressed concerns about New Zealand’s coronial system. The recently retired pathologist told North & South magazine last year that pathologists were frustrated that coroners frequently ignored their opinions and autopsies sometimes weren’t being done when the pathologists thought they should be, or were being done when there was ample evidence of natural causes.
He says that in an ideal world, every death would be looked at by a medical examiner before a death certificate is issued, “so every single death is reported not just to a doctor but to a doctor with a suspicious mind”.
He suggests that death-investigator units – small groups that might comprise paramedics, nurses or police – be established to assist coroners and pathologists, and says GPs should be referring more cases to the coroner than they currently are. Full or partial autopsies are conducted in only half the 6000 cases referred to the coroner each year.
This is an edited version of an article first published in the June 6, 2015 issue of the New Zealand Listener.
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