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Dr J Adeley's (the Coroner) closing remarks at the Inquest into the death of Jan van Alphen.

Tractor pulling bills itself as the most powerful motor sport in the world and the rules suggest that safety is paramount but the evidence suggest that the way in which the sport is administered does not deliver these aims.

In respect of the evidence given by Mr Butenhuis that it had not been thought that a weight box could pass through an end stop I find this statement has little merit.  Firstly, the ETPC Sled Rule book states at rule 7 (c ) that “in front of rails 2 sets of stops for box each stop strong enough to stop a fully loaded box free wheeling at any speed”.  This role clearly contemplates that a box may freewheel and may strike the end plate at speed.  Secondly, freewheeling boxes have been know about by the tractor pulling world for decades and have been discussed at meetings of the ETPC on a number of occasions as a code red or serious event.  Thirdly, it is a matter of common sense that the end plate is there as the last defence a driver of a tractor may have against the weight box.

Let me now turn to the ETPC sled inspections.  These are for the purposes of ensuring the sleds compliance with the rules of the ETPC and certification so that the sled can compete in tractor pulling events.  For sleds such as the Mighty Challenger such formal inspections take place every two years.  In 2006 the ETPC undertook a full inspection of the sled.  This occurs at an event with the sled stationary.  The inspection in 2006 was undertaken by ETPC authorised sled inspectors.  Some of the rules with which the sled has to comply are as follows:

1 e for all big and mini sleds the brakes on the drive axles must be fail safe.  The brakes must be able to lock the wheels when the sled is loaded with the maximum weight and hold the lock at any given position of the weight box

5 e  Box Drive train must be equipped with a brake mechanism capable of  stopping weight box fully loaded at maximum speed (presumably this should be fail to safe?)

6 e Weight box braking system must be capable of stopping a fully loaded box at maximum speed, the system had to be fail safe

7 c In front of rails 2 sets of stops for box each stop strong enough to stop a fully loaded ox freewheeling at any speed

 All of these rules relate to safety critical aspects of the sled operation and quite clearly demonstrate a concern as to the safety of the driver of the tractor who is directly in line with the weight box.  In respect of these rules all the systems inspected by the ETPC failed to operate correctly to prevent the loss of Mr Van Alphen’s life.

The formal 2006 inspection was conducted by two inspectors whose qualification for the task was that they had been associated with tractor pulling for some time.  If safety critical items could not be seen, such as the wheel box brakes, the sled owner was simply asked about the item,.  No reply was recorded and the box simply ticked, a practice which Mr Frackleton [HSE Specialist Inspector – Mechanical Engineer] described as “amazing” and would not constitute a proper inspection in his view.  In respect of the end stops the inspectors simply looked and thought that the stops would be alright, despite having no experience of the forces a weight box would generate, not being mechanical engineers or performing or having any access to calculations.  Consequently, had any calculations been performed these would have been noted as being wholly inadequate.

In respect of all the above rules of safety critical items passed by the ETPC inspectors in 2006 all failed to protect Mr Van Alphen.  In my view this is a very low standard of mechanical inspection in that it does not rely on personal inspection but the views of the sled owner.  Such a system of inspection would not be acceptable even for domestic cars on UK roads.  The inspection by the ETPC is then compounded by the sled owner having a certificate that implies that his or her sled complies with the ETPC safety requirements.  In my view the ETPC needs to re think the basis of their inspections as to how they ensure there is compliance with their rules and that safety critical components are properly inspected even though I note they now have made calculations as to end stop requirements and introduced weight box to wheel movement sensors to apply the brakes if there is a problem.

So far my remarks have been confined to the ETPC who are involved in this inquest.  In my view, after Mr Van Alphen’s death, to operate any sled which does not have a end stop whose strength is sufficient to stop a fully loaded weight box at the maximum speed that the box can attain in that class of tractor pull and without wheel to box sensors to detect problems is reckless in the extreme both for the sled operator and the organiser of any event and, in certain circumstances, could amount to either corporate or individual manslaughter and certainly breaches of health and safety legislation. 

Finally, there is the question of kill switches.  In my view the kill switch for the tractor should be separate from emergency stop for the sled  to remove the reticence of the sled driver to pull the tractors Kill switch, although from certain comments that have be made this may already be in hand.

♣ Note: The empasis in the second to last paragraph has been added by Liz Evans of the HSE who furnished me with the text of Dr Adeley's closing remarks.

Dr J Adeley's (the Coroner) closing remarks at the Inquest into the death of Jan van Alphen as a PDF document.