CITATION:

IN THE CORONERS COURT

AT DARWIN IN THE NORTHERN

TERRITORY OF AUSTRALIA

No. D0212/2011

In the matter of an Inquest into the death of Rosalyn O’Neill

ON July 20 2011

AT Marrakai, on the Arnhem Highway

FINDINGS

Mr Greg Cavanagh SM:

Introduction

1. On 20 July 2011, the deceased, Ms Rosalyn Ellen O’Neill, was a passenger in a four wheel drive utility vehicle driven by her husband of 30 years, Mr Darryl Kendall O’Neill. They were the only two occupants in the vehicle, which was travelling South on the Arnhem Highway at Marrakai, towards Jabiru.

2. Shortly after 2pm, a sedan that was travelling north, towards Darwin, ran over a large granite rock that had been stationary in the middle of the northbound lane. After being hit by the sedan, the rock gathered momentum and was flicked up into the path of the oncoming car driven by Mr O’Neill. It entered through the windscreen of the vehicle at speed and struck the deceased in the head region.

3. The impact of the rock was so devastating that the deceased died almost immediately as a result of her severe head injuries. A number of travellers stopped to provide assistance, but there was nothing that could be done to preserve life.

4. Pursuant to s34 of the Act, I am required to make the following findings:

“(1) A Coroner investigating:

a. A death shall, if possible, find:

(i) The identity of the deceased person.

(ii) The time and place of death.

(iii) The cause of death.

(iv) Particulars required to register the death under the Births Deaths and Marriages Registration Act”

5. I note that section 34(2) of the Act also provides that I may comment on a matter including public health or safety connected with the death being investigated. Additionally, I may make recommendations pursuant to section 35 as follows:

“(1) A Coroner may report to the Attorney General on a death or disaster investigated by the Coroner.

(2) A Coroner may make recommendations to the Attorney General on a matter, including public health or safety or the administration of justice connected with a death or disaster investigated by the Coroner.

(3) A Coroner shall report to the Commissioner of police and Director of Public Prosecutions appointed under the Director of Public Prosecutions Act if the Coroner believes that a crime may have been committed in connection with a death or disaster investigated by the Coroner”

6. I have had the benefit of a very thorough brief of evidence prepared by the Officer in Charge (OIC) of the investigation, Sergeant Mark Casey. He had taken over as OIC from his colleague, Sergeant Serge Bouma, who did a significant amount of work on the brief of evidence and the initial investigation.

7. Both Sergeant Casey and Sergeant Bouma gave oral evidence relating to the nature of the incident and the police investigation. I also heard evidence from civilian witnesses, Scott Basnett, Michael Corley, Gregory Harris, Darcy Day, Phillip Thompson and Darryl O’Neill. I heard expert evidence from Ian Scrymgour, the Chief Geologist in the Northern Territory.

8. Although there is no individual who could be blamed for this death, this inquest has been an opportunity to consider the safety hazards posed by obstacles like rocks that are deposited on the highway. There are lessons to be learnt from this death and I intend to make a recommendation aimed at minimising the risk that a tragic accident in similar circumstances will occur again.

Relevant circumstances surrounding the death

Background

9. The deceased and her husband were retired and for a number of years prior to the accident they had been travelling around Australia in a four wheel drive utility trailing a caravan. They stopped for weeks or months at a time to explore an area and met up with friends and family along their journey. When they were not on the road, they lived with one of their daughters and her family in Cairns and they visited their other daughter in Melbourne.

10. In 2011 they travelled to the Northern Territory and stayed for several months at the camping ground of ‘Shady Camp’, within the Mary River National Park.

11. Mr and Mrs O’Neill were extremely proud of their two children and eight grandchildren. Before the inquest commenced, I receive a deeply moving, beautiful letter that was written to me by one of the daughters, Lana Maree Hart, who expressed the feelings that she and her sister and father felt at the loss of their mother. Tragically, Ms Hart and her sister Caroline lost their biological mother in a car accident. When they were small children, the deceased married their father and helped raised the children as her own. They called her “mum” and she was, obviously, a wonderful, nurturing, and loving wife and parent.

12. The deceased was only 65 years of age when she died and she and her husband were extremely active and healthy. Ms Hart gave me a unique insight into the type of person the deceased was, when she wrote in her letter:

“My mother was not just another number on the road fatality list, she was a very special women. She was a women who just loved life, loved her family, worked hard, never complained, and gave all she could to everyone. Nothing was ever too much trouble for mum. If ever anyone needed anything she was there for them. … Everybody who met her loved her, she made friends so easily and when she did they were life-long friendships”.

13. Each year, the statistics for fatalities on the road in the Northern Territory are alarming and significantly higher per head of population than they are in other States and Territories. That is likely to be a combination of the large distances people travel, alcohol related accidents, speed, driver fatigue and weather conditions. In the case of this death, there appear to be none of the usual issues listed above. This case has identified that drivers in the Northern Territory also have to contend with hazards on the road, that in rare but devastating cases, can prove to be fatal.

14. As was so eloquently put by Mrs Hart, the deceased was not just another number on the road fatality list, but rather a deeply cherished individual whose death has been a devastating loss for her family and friends, and the broader community.

The accident on 20 July 2011

15. On 20 July, Mr and Mrs O’Neill left Shady Camp in the morning to drive their Utility to Humpty Doo and Coolalinga to run some errands, stopping along the way at local tourist destinations. Traffic was light and the weather conditions were excellent.

16. After lunch they headed back towards Jabiru and were travelling south on the Arnhem Highway, at a comfortable speed of 80 or 85 km per hour.

17. On that area of the Arnhem Highway, there is a large amount of naturally occurring, good quality granite rock. As a result, the following three quarries have been established:

· The Halkitis Brothers Quarry, located adjacent to the crash scene

· The Ostojic Quarry, south of the Halkitis Bros Quarry

· The Boral Quarry, situated north of the crash site, towards Darwin

18. At around 2.30pm, Mr O’Neill was driving towards the entrance of the Halkitis Brothers Quarry, located around 69 kilometres southeast of the Stuart and Arnhem Highway intersection. As he drove, a large rock flew into the passenger side of the windscreen, smashing the glass and striking the deceased in the head region.

Cause of Death

19. There is no controversy in this case as to cause of death. I received an autopsy report from Dr Eric Donaldson, a Locum Pathologist working with the Forensic Pathology Unit of Royal Darwin Hospital. He confirmed that the cause of death was “severe head injuries”, including a fractured skull and traumatic brain injury.

20. Mercifully, the Pathology Report shows that the deceased died almost instantly she was struck by the rock and she would not have been in pain.

Where did the rock come from?

21. The issue that was the subject of some debate in this case concerned where the rock that struck the Utility had come from.

The Evidence of Mr O’Neill

22. I received a statement and heard oral evidence from Mr O’Neill who has a memory of the lead up to the incident. He told the Court that as he approached the entrance to the Quarry, he noticed a white truck heading towards the Utility that he and his wife were travelling in. He could not recall what type of truck it was, but he believed that it was a large road train, a couple of years old, with the front and sides painted white.

23. Mr O’Neill remembers that the truck had a number of rear trailers that were silver inside and were filled with a grey, granite type rock. At the top right hand corner of the trailer, which was not covered, Mr O’Neil saw a rock the size of a small football moving back and forward near the hinge of the tailgate. In a split second it was gone and disappeared behind the back of the truck.

24. The next memory Mr O’Neil had was that a car driving behind the truck swerved and a boulder about a foot off the ground moved across the road towards his vehicle. He heard the rock impact, but because he could not see a crack in the windscreen in front of him, he initially thought that it had hit the front of the car and he pulled over to the side of the road to check.

25. When Mr O’Neill looked towards his wife, he knew immediately that the rock had entered her side of the windscreen and that she had suffered fatal injuries. He tried in vain to save her, assisted by other drivers who pulled up along the Highway.

The Evidence of other witnesses

26. I heard evidence from a number of civilians who saw a rock fitting the description of the one that struck the deceased lying on the Arnhem Highway, a significant period of time before the accident took place. The weight of that evidence suggests that the rock cannot have fallen from the white truck as remembered by Mr O’Neill.

27. The trauma experienced by someone in Mr O’Neill’s position is unimaginable and I am not surprised that it affects the accurate recall of events. Although I am confident that Mr O’Neill is a very honest man, and that he genuinely believes that he saw a rock fall from the rear trailer of truck, that memory cannot be reconciled with the remainder of the evidence that was received in this inquest.

28. At around the same time that Mr and Mrs O’Neill was travelling towards the Halkitis Brothers quarry, Scott Basnett was driving a maroon 1991 Lexus in the opposite direction, heading north towards Darwin. Approximately 20 meters in front of him was a tray backed four-wheel drive. Mr Basnett saw a large obstacle in the middle of the road, just as it was cleared by the four-wheel drive travelling ahead of him. When he got close he could see it was a rock of considerable size and that if he drove over it at the same speed it might hit the under carriage of his low slung vehicle and do considerable damage.

29. Mr Basnett was not able to swerve around the rock because a large truck was travelling past the Lexis in the opposite direction at precisely the same time. He slowed the car down as quickly as he could and then lined the rock up to the centre of his car to avoid hitting a tyre or a steering component. He had put maximum pressure on the brakes when he first noticed the rock, but because that caused the car to dip, he released some of that pressure in the short time he had to think about it, in order to raise the front of the car.

30. Unfortunately, Mr Basnett could not avoid passing over the rock and as he did so it hit the underside of his car twice. After the impact, he looked into his rear vision mirror and saw the rock bouncing out of view into the path of oncoming traffic. He saw the Utility driven by Mr O’Neill swerve and then break intensely.

31. There were three other occupants in the car driven by Mr Basnett, two of whom noticed the rock on the road before it was run over. Beside Mr Basnett in the front passenger seat was his friend, Terrance Gerbrands. He too saw the large rock ahead of them in the centre of their in-bound lane, and saw that their Lexis straddled the rock, causing it to make a “large banging noise” as it passed underneath. Immediately afterwards, Mr Gerbrands looked over his right shoulder and saw the rock bounce and gather momentum behind the Lexis. Mr Gerbrands saw Mr O’Neill’s vehicle swerve a few times as the rock was bouncing.

32. Pauline Briggs, wife of Mr Gerbrands, was seated behind the front passenger. She also saw the rock on the road about 100 metres before the Lexis drove over it. She noticed a truck driving passed them in the other direction as the Lexis passed over the rock and she saw Mr and Mrs O’Neill’s Utility travelling behind the truck. When their Lexis had passed over the rock, she too looked behind her and saw the rock airborne. She noticed the Utility swerve from side to side.

33. An inspection of the maroon Lexis undertaken at the Northern Territory Police mechanical workshop showed that the under-body of the vehicle had sustained recent damage, consistent with having been struck with a rock.

34. Other civilians had seen the rock earlier in the day. At around 2.15pm, Michael Corley was driving his Holden Barina Combo (a panel van) at a speed of 80-85 kms per hour on a stretch of the Arnhem Highway approaching the Halkitis Brothers Quarry. He saw a large rock on the road that he described as being the size of an R2E2 Mango, the large deep red mangos that are twice the size of the average variety. At that time the rock was stationary in the middle of the inbound lane (towards Humpty Doo) and was located about 50 metres past the Quarry entrance. Mr Corley could not take evasive action in time, but his vehicle had enough clearance that the rock did not hit the undercarriage, or at least not hard enough for him to notice it.

35. A number of men working at the local quarry sites saw the rock on the road in the half hour prior to the accident. Gary Exner and Peter Lewis were working at the Boral Quarry at Mount Bundy and in the afternoon they travelled to the Halktis Brothers Quarry to borrow some tools to fix one of their conveyor belts. At around 2pm, as they approached the Quarry entrance in a Ford Ranger work Utility, both saw a rock in the middle of the inbound lane (in the direction towards Darwin), around 10-15 meters from the Quarry entrance. That rock was described as around 15cms, ‘browny grey’ in colour and round in shape with a point on the top of it. The rock was still there when they drove out of the quarry five minutes later.

36. Miljan Ilic was employed by the Ostojic Group as a truck driver and he loaded up his vehicle at the Halktiis Brothers Quarry in the afternoon. Some time around 2pm, he departed for Darwin and as he straightened and accelerated, around 200-300 meters from the Quarry turnoff, he saw a rock the size of a football just within his lane, but close to the centre of the road. He passed to the left of the rock without hitting it and although he did think about picking it up, he decided that it would be too dangerous to pull a fully loaded truck up on the highway in order to do so.

37. Darcy Day worked as a truck driver at Halktis Brothers Pty Ltd at the time of the incident and his job on 20 July 2011 was to pick up an empty vehicle at the Depot in Winnellie and travel to the Quarry, where he would load up with cracker dust (crushed sand) and return to the Depot to empty the load and start the process again. To get his first load he left Winnellie at 4.30am, filled up at the Halkitis Brothers Quarry around 7.30am and then headed back to the Depot along the Arnhem Highway. He did not notice a rock on the road as he entered or exited the Quarry. Mr Day emptied that load at Winnellie at around 10.30am and came back to the Quarry for a second time that day around 1.45pm, to load up his vehicle while Mr Harris was on lunch break. It was only when Mr Day left the Quarry for a second time, at around 2.15pm that he noticed a rock the size of two fists on the slipway, not in the middle of the lane.

38. Greg Harris was working as a Plant Operator at the Halkitis Brothers Quarry. At approximately 2.20pm, on the way back to the Quarry from his brief lunch break, Mr Harris noticed a large weathered rock on the road in the middle of the in bound lane (towards Darwin) that had not been there when he left for lunch half an hour earlier. He had not seen a rock of that size on the highway in the five years he had worked in that immediate area and he was concerned it would do damage to the undercarriage of a car. He too had thought about removing the rock, but he was worried about work and he thought he should get straight back to the Quarry and then alert someone there who could travel back to the site to remove it. Sadly, the accident occurred before he could do so.

39. Many of the witnesses expressed their regret at not having removed the rock after they saw it and I heard that some have experienced guilt or shame as a result. In his oral evidence, Mr Harris told the Court:

“ ….- sitting here now, I should have got out of my car and walked back and took that rock off that road, but I didn't and I blame myself. I was just too busy to get to work. I have to tell Phil Thompson or Shane Hamilton, 'Please, go out there and get that rock off the road,' but I was too late. I couldn’t find Phil, he was on my load out the back, I couldn’t find Shane. To this date, I feel very, very bad”.

40. In his statement tendered in evidence, Mr Corley described about how he felt after he heard about the accident. He wrote:

“I thought to myself, I must have sent that bloody rock and started thinking I should have gone back to pick it up, but you don’t think about things like that at the time. You just don’t expect things like that to happen”.

41. Although it is deeply regrettable that the rock was not removed from the road by anyone who saw it prior to the accident, those individuals cannot be held responsible for the accident and should not be burdened with a sense of guilt. They could hardly have foreseen the terrible confluence of events that led to the death of Mrs O’Neill.

Expert evidence

42. The expert evidence tendered in this inquest shows that the rock seized by investigating police some days after the accident was the one that came through the windscreen of the utility driven by Mr O’Neill.

43. Dr Ian Scrymgour is the Chief Geologist in the Northern Territory and he gave expert evidence as to the origins of the rock. The Court heard that the rock is a “K-feldspar and hornblende-rich granite”, which comes from the Mount Goyder Syenite, and can be found on either side of the Arnhem Highway between the old Mount Bundey mine and the Mary River. It is the type of rock quarried at the Halkitis Brothers Quarry because it occurs naturally in the area.

44. The rock did not, however, have the appearance of a freshly quarried rock. A number of the faces of the rock were weathered and smoothed and were partially covered in a layer of soil. On one side of the rock a fresh face had been exposed as a result of recent impact that had broken off a smaller section. With the exception of that recently exposed face, the corners of the rock were rounded. Dr Scrmgour concluded:

“Whilst it cannot be entirely ruled out that such a rock might have been incorporated with fresh rock during the quarrying process, the appearance of the rock is more consistent with having been buried in soil for an extended period of time, rather than being freshly quarried.”

45. Immediately after the accident, the scene was attended by police from the Crash Investigation Unit, who took measurements of marks on the road and photographed the scene. The rock was located at the time and was photographed, but instead of seizing it as an exhibit, an officer placed the rock on the ground a short distance from the crash site. It is difficult to understand why police did not seize the rock at the time, given its significance.

46. When Sergeant Serge Bouma took over the investigation, he recognised the error and on 28 July 2011 he tasked an officer to retrieve the rock, which was subsequently exhibited. Had that not been done, or had the rock not been found on 28 July, I would be critical of the police for making a mistake that might have compromised the investigation. In the circumstances, however, the mistake was rectified. I have carefully compared that rock (Exhibit 3) with photographs that were taken on the day of the accident, as have Sergeant Bouma and Sergeant Casey, and Dr Scrymgour. I am satisfied, as they were, that the rock seized is the one that struck and killed the deceased.

47. Weighing up all the evidence before me, I am not able to determine exactly how the rock came to be on the Arnhem Highway at the time of the accident, but I am satisfied that it had been on the road for at least half an hour beforehand and that it was run over by the Lexis, causing it to be propelled into the path of the car driven by Mr O’Neill. I base that finding on the following issues that were meticulously outlined by investigating police:

· First, nine independent witnesses had observed the rock on the road before the accident.

· Second, an examination of the Maroon lexis revealed damage to the under-carraige that was consistent with having been struck by the rock.

· Third, according to Dr Scrymgour, the rock was dirty and worn and could not have been freshly quarried.

· Fourth, when Police reviewed the records kept by the three quarries in the area, they discovered that no rocks of the size involved in the accident were loaded or transported on 20^th July.

48. Police have not been able to identify the driver of the white truck with a number of trailers that was described by Mr O’Neill. That truck is certainly not owned by Halkitis Brothers, whose vehicles are unmistakably orange.

Road and Weather Conditions

49. There is nothing about the road or weather conditions that impacted on the accident. The relevant section of the Arnhem Highway is a sealed bitumen dual carriageway road of 6.8 metres in width which is straight and level at the crash site. At the intersection with the entrance to the Halkitis Brothers Quarry (approximately 100 meters from the crash site), the road widens to accommodate a slip lane to allow for the safe merging of vehicle leaving the quarry. The speed limit in the area is appropriately and clearly marked as 130km/per hour.

50. The accident occurred during the dry season, when the weather was fine. Visibility at the time was good and would not have been affected by sunlight.

51. In the view of the investigating officers, Sergeants Bouma and Casey, one possible explanation for how the rock came to be in the middle of the lane is that at some stage it was caught between the dual tyres of a large truck and, unbeknownst to the driver, was later deposited on the highway. There is circumstantial evidence to support this theory in that the rock seized was coated in a black rubbery substance that may have been the inside of a tyre.

52. I heard evidence from Darcy Day, who has been driving trucks for many years, that rocks can get caught within the dual tyres of trucks. It is standard procedure for drivers to walk around their vehicle before each shift to do a safety check, which includes checking tyre pressure and checking between the duals. I was assured by Mr Day that he did this on the day he picked up his loads on 20 July 2011. Although I agree with the investigating police that one possible explanation for how the rock came to be on the highway is that it was trapped and later ejected from between the duals, I could not be satisfied that it was a truck that had been loaded at the Halkitis Brothers Quarry, and in fact, their first rate safety procedures suggest that it was not.

53. It is entirely possible that the rock fell from a poorly restrained load carried by a member of the public who was transporting rocks for their own purposes. There are a number of people who use rocks for their gardens or personal building projects, and that possibility could not be ruled out.

Broader safety issues identified

54. Road users share the Arnhem Highway with a large number of heavy vehicles carrying loads of different products, including rocks of all sizes. As in all States and Territories, heavy vehicle operators in the Northern Territory are required to comply with legislation that sets out how their load must be covered.

55. General issues relating to the covering of loads are dealt with in Regulation 24 of the Northern Territory Road Regulations, which specify that:

“(1) A person must not drive, or permit a person to drive, a vehicle carrying a load unless the load is arranged, contained, fastened or covered:

(a) in a manner that complies with the performance standards and principles in the Load Restraint Guide applicable to the load; or

(b) in a manner of equal or greater effectiveness in securing the load than that mentioned in paragraph (a).

(2) A person must not drive, or permit a person to drive, a vehicle carrying a load that flaps, sways, extends or overhangs the sides or the front or back of the vehicle unless the load is carried in accordance with a law in force in the Territory prescribing the manner for carrying the load”.

56. A penalty of 20 penalty units or $2,200 applies for a breach of the Regulation.

57. The Load Restraint Guide mentioned in the Regulations specifies that trucks and trailers that have rigid side bodies can be used to ‘contain’ loads consisting of rocks of the size and weight of the one involved in the accident without the need for a cover, or any other securing devise. The only requirement under the Guide is that the base of each item is well below the top of the sides to ensure that the load won’t be dislodged by movement on rough roads.

58. Regulation 24A mandates the securing of loose bulk loads. It specifies that any vehicle with a Gross Vehicle Mass (GVM) that exceeds 12 tonnes and is carrying a “loose bulk load” must be covered by a load cover. A loose bulk load is defined as a load that consists primarily of:

“ a) sand; or

b) soil; or

c) other material that is likely to be dislodged by the action of rough roads or airflow across the vehicle.

59. The Northern Territory Motor Vehicle Registry issued Information Bulletin V59 on 17 October 2008, which states that a “loose bulk load” can be described as light weight material such as sand, quarry products, primary produce”.

60. There is obviously room for some discretion in the way in which Regulation 24 and 24A, and the Information Bulletin are read, so that some loads of rocks, including rocks of the size involved in this accident, need not be covered. As a matter of common sense they may be thought to be loose loads, and yet they may not come within the legal definition. Since they could clearly still fall from a truck or tray and become a dangerous object, I intend to make a recommendation to encourage stricter guidelines that will ensure all such loads are covered in the future.

61. I received evidence that suggests to me that the Halktis Brothers Quarry is very well run, and takes pride in their safety record. There are regular “tool box” meetings to discuss safety concerns. The safety message is regularly reinforced with drivers, who are expected to make careful checks of their vehicles. Mr Nick Halkitis is presently on the board of the Extractive Industries Association and is a former member of the Road Transport Group.

62. On 3 August 2011, Sergeants Mark Casey and Serge Bouma conducted a site visit at the Halkitis Brothers Quarry and were given a tour of the open cut mine and its facilities by Quarry Manager, Mr Phillip Thompson. The police officers observed there was no dirt or soil within the operational areas of the Quarry and the different sizes of rocks and sand were sorted into neat, clean piles. Roads within the Quarry are graded and covered with finely crushed granite. The entrance road to the Quarry is a bitumen road, with dirt shoulders that are fenced on either side about one metre from the road. There were no loose or exposed rocks on the road or the dirt shoulders.

63. I understand that Mr Thompson and Halkitis Brothers Pty Ltd have cooperated with police fully and the Company has been very willing to assist this court with its inquiries. Although it is always possible that a stray rock was picked up within the dual tyres of one of their vehicles, and then subsequently deposited on the Highway, I am satisfied that they do all they can to guard against that occurring.

Conclusion

64. There are no individuals that can be blamed for this terrible tragedy and I could find no evidence that any of the quarries operating near the accident site were responsible. It was an extraordinary coincidence that a number of factors lined up so that at the moment Mr O’Neill drove his vehicle towards the entrance of the Quarry, a Lexis travelling in the opposite direction was low enough to the ground that it struck a rock lying in the middle of the highway, and unwittingly propelled it into the path of the four-wheel drive.

65. I express my sincere sympathies to the family of the deceased, who remain deeply traumatised and saddened.

Formal Findings

66. I find that Rosalyn Ellen O’Neill died on 20 July 2011, at approximately 2.30pm at Marrakai, on the Arnhem Highway, 69 Kilometres southeast of the Stuart and Arnhem Highway Intersection, as a result of multiple injuries sustained after a rock entered the windscreen and struck her while she was a passenger in a vehicle.

67. Pursuant to section 34 of the Coroner’s Act (“the Act”), I find, as a result of evidence adduced at the public inquest, as follows:

(i) The identity of the Deceased person was Rosalyn O’Neill (nee Blissett) born on 2 July 1946.

(ii) The time and place of death was 20 July 2011 at Marrakai on the Arnhem Highway, 69 kilometres southeast of the Stuart and Arnhem Highway Intersection.

(iii) The cause of death was multiple injuries sustained after a rock entered the windscreen and struck her while she was a passenger in a vehicle.

(iv) Particulars required to register the death:

1. The Deceased’s name was Rosalyn Ellen O’Neill.

2. The Deceased was of Caucasian descent.

3. The Deceased was retired.

4. The cause of death was multiple injuries sustained after a rock entered the windscreen and struck her while she was a passenger in a vehicle.

5. The cause of death was confirmed by an external post mortem examination carried out by Dr Donaldson.

6. The Deceased’s parents are Ellen and Clarence Blissett.

Recommendations

To the Northern Territory Government

68. That consideration be given to amending the Northern Territory Road Traffic Regulations and any other relevant legislation so that any vehicle carrying product out of a quarry must do so with a covered load.

69. That consideration be given to amending the Northern Territory Road Traffic Regulations and any other relevant legislation so that a “loose bulk load” is defined to include rocks the size and/or weight of that involved in this accident.

Dated this 10^th day of August 2012.

_________________________

GREG CAVANAGH

TERRITORY CORONER