A Glengarry man died after being run over by a tractor in August 2018 when helping a neighbour feed cattle, a Coroner has found.
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Robert Norman Selby, 75, was feeding hay when the tractor he was using rolled forward and ran him over causing fatal crush injuries.
Coroner Andrew McKee commented in his report that farmers should consider retrofitting a safe access tractor platform (STAP) on their tractors despite the opposition of Worksafe Tasmania.
Mr Selby was using a Ford 4000 tractor to feed cattle when the accident occurred.
He spiked a round bale and drove to the feeding out area and attempted to dislodge the bale by lowering the spike.
"Mr Selby stopped the tractor, dismounted from it and with the assistance of his neighbour [Mrs J Comrie] tried to remove the bale of hay ... it did not dislodge," Mr McKee found.
"Mr Selby returned to the left-hand side of the tractor.
"The tractor remained running but was stationary.
"At this point, Mrs Comrie was looking at the cattle.
"She did not observe Mr Selby get on the tractor or touch the controls."
When she turned back she observed the left back wheel of the tractor running over the top of Mr Selby.
She provided assistance but he told her he would be all right prompting her to chase the tractor pull the engine stop button.
Neither Mr Selby or Mrs Comrie had mobile phones so she ran to the house to contact emergency services.
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Despite treatment by a paramedic, he was pronounced dead at the scene.
Mr McKee accepted the evidence of First Class Constable Nigel Housego about how the incident unfolded.
"I believe that the tractor has been stationary with the engine running while Mr Selby was on the ground," he said.
"Mr Selby has then walked around to the left side of the tractor and stood in front of the rear wheel.
"[He] has then engaged the gears causing the tractor to move forward in an attempt to force the hay off the lower spike.
"Mr Selby has been caught out by the speed the tractor has moved forward due to it being in a higher gear than expected and the rear left wheel has run over him."
Mr McKee agreed with Constable Housego that a STAP, which is an accepted construction interstate, would have prevented Mr Selby's death.
"A safe access platform was designed so that a person could no longer stand between the front and back wheels of a tractor," a report from Safe Work Australia said.
"This makes it much less likely that an operator will slip and fall under the tractor wheel if the tractor moves forward unexpectedly."
Safe Work Australia said the STAP had proven effectiveness in reducing run over incidents in a 2013 report.
However, Mr McKee noted that Worksafe Tasmania was opposed to STAPs because it did not want to send a message that it was appropriate to access or egress a tractor whilst it was in operation.
But noted support from the Selby family for STAPs.