After the Race

Below is a summary of the full Coroners Inquisition that occurred on Monday the 10th of October 1994

 

Page 1 - Page 19:
This part of the inquisition mirrors the below court case . It's almost identical, word for word. 

Page 20:

Post Accident Response. This is where you'll find the start of an itemised menu list of things to come. You'll read this page and get excited about knowing the things you don't know. Finally we'll be getting answers to the very questions that have plagued the aftermath of this event.

 

Page 21: 
This conclusion before reading all the statements listed:

"After carefully reading the above material I am satisfied as to the following matters
1. that there was an adequate response to the accident by all concerned

2. that the accident scene was properly controlled and traffic appropriately diverted from the scene and

3. that medical and paramedic personnel and others at the scene did all they could to assist the four persons involved in the accident."

I don't know that this is something that should be at the front of reading 18 different statements and records of events. It puts the reader at a bias that almost feels deliberate. Why wouldn't the coroner allow the person reading the Coroners Report come along for the journey and make up their own mind before putting a bias in place?

Page 23:

"Also in the area of the table (where the Cannonball Officials Tim Linklater and Keith Pritchard were seated) were two Japanese media representatives waiting to take photographs of some of the Cannonball competitors as they entered the checkpoint."

Whoa hang on... this is new. Two Japanese photographers actually sitting at the checkpoint with cameras. Where were these guys at the court case. No one has mentioned these guys before. They would have photographs. As if you wouldn't be taking photos as the leading / first car comes into the checkpoint. Amazing. Who are they and where are there photographs?

This page goes on to give a blow by blow account of Keith Pritchard waving his arms to get the Ferrari to slow down, and how Keith Pritchard and Tim Linklater then started to run. This is impossible to know without first hand knowledge. How could you know that one person now deceased was waving their arms at two people, now deceased, next to another official, now deceased? Only a witness could give that much detail. in streps the two Japanese photographers no one has mentioned before.

"The impact between the Ferrari and the Cherokee also caused the right side of the Cherokee to lift off the ground, a height of 0.57 metres. Whilst still off the ground, the right front side of the Cherokee impacted with the front left side of the Holden sedan. It was during this impact that Pritchard was trapped between both vehicles, sustaining injuries that culminated in his death."

Man this page 23 has it all.  Take a read of this page, it has so much more you can picture the whole event like a movie scene.

Page 24 - 27:

All about how the estimated speed entering the lay by and impact speeds were calculated. Great for math geeks. 

Page 28 - 42: 
Reconstruction of the vehicle movements from impact to resting position. Senior Constable Potts gives a evidence based approach to what happened from the time the Ferrari hit the lay by section to the resting point of all three cars after the incident. Everything from speed of entry, angle of entry, to the 86km/h estimation of impact. Some great police work here. 

Page 42 - 48:
Constable Potts, I don't know why, but I found myself reading his statement like he was a Texan. There was something in the way he speaks and how it comes across on paper. It's funny, I read it again just 'reading' and the voice in my head went all 'Texan' again. 

Page 49:
The description of what happened in the sliding of the Ferrari F40 is much better on this page with the use of "clockwise" and "anticlockwise" to determine the trajectory.  

Page 51:
The whole incident took around 4 seconds from entering the Lay By to impact.

Page 61:
Mr Allan George Moffat takes the stand. With all the maths laid out by the previous to witnesses as to entry speed into the lay by, and impact speeds over the previous pages, Mr Moffat concludes he has a hard time  accepting these facts. Mr Moffat goes on to say he found it surprising that the driver of the Ferrari F40 Mr Kabe lost control with the experience he had. Yes, however he did, and four people died Allan. Let's not dwell on what we already know as fact.

Page 67:

No mechanical defects found on the Ferrari F40 after the incident.

Page 68:
How they identified each of the Ferrari F40 occupants.

Cause of death for Akihiro Kabe (Ferrari F40 Driver) "Blunt Head Injury" - Right Temple
"The impact would have been minimised by use of a crash helmet"

Cause of death for Takeshi Okano (Ferrari F40 Navigator) "Blunt Head Injury - Left Temple) & Blunt Chest Injury"
"The impact would have been minimised by use of a crash helmet"
Injury to the chest would not have caused death where medical help is rapidly available.

At first I thought.. if these two clashed heads as stated on page 23 and again on page 69, and no helmets were being worn, why did Kabe have an injury on his right temple, and Okano on his left temple? Kabe was the driver. Was the navigator driving? (This is on the rumours page) "The F40 Japanese weren't wearing seat belts; and, having had a big one the night before, the driver chucked the keys to the navigator."

So, just to check I had a look at the picture of the Ferrari F40 we have, no, it was a left hand drive Ferrari F40. This shows the rumour to be false. This has now been changed on the Rumours page to reflect this.

Page 69:
Timothy Linklater, one of two marshals at the check point died with the same diagnosis as the competitors in the Ferrari; "Blunt Head Injury". It is explained that "Death would have been both inevitable and instantaneous"

Keith Allan Pritchard died from "Multiple Injuries"
Death being immediately and inevitably fatal. He was crushed and dragged.

This next bit... amazing:
"Dr Lee was asked his view as to the likely injury to the head of both Mr Kabe and Mr Okano, had they been wearing safety helmets. He stated: "Certainly, the injury that was present to the head would've been minimised by use of a crash helmet and I would regard it as being extremely likely that that would've been an entirely survivable, and in fact, probably a walk-away situation."

Why wasn't it mandatory to wear helmets like every other car race in Australia?
Answered on page 111 

Page 86:

CAMS has said that the roads needed to be closed to the public, and not exceed an average speed of 130km/h

Mr Barry William Chambers: (Deputy Secretary of Transport and Works for the Northern Territory Government)"However when one reads a competitive stage where speeds are not greater than 130 kph one would have to wonder a little bit about whether they were talking about an event where the cars get out of second gear."

Page 98:

Mr Wlliam Leedert Goedegebuurre (Deputy Commissioner of Police of the Northern Territory) starts his time on the stand. (That name is pronounced "good-e-g-bur" I used to know his son Simon back in 1986/87.)

Page 105:
Superintendent Terence James Ey takes the strand

Page 107:
Mr Bruce Charles Nichol, Chairman of the Queensland State Council Confederation of Australian Motorsport (CAMS) takes the stand.

Page 111:
Mr Nichol explains why the use of helmets may have been left off:

"For long distances they're - they're a heavy item, they're restrictive of your ability to move in the vehicle. If there is a considerable amount of noise, you need an intercom system to be able to hear what your co-driver's
saying and that, therefore, becomes a more complicated system than a - a normal helmet. And maybe the case of feeling more secure in - in the knowledge that you've got a helmet on perhaps may make some people think they can travel more safely, simply because they have a helmet on." 

Now because of the position Mr Nicol held, that statement holds credibility, and it was something I personally never considered.

Page 114:
Mr Edgar Ray Ritchie takes the stand. CEO of CAMS.

Page 116:
The permit to have the Cannonball Run as a CAMS sanctioned event was signed on the 17th of May 1994 (less than a week before the Cannonball Run started) and was on the provision that two conditions were met:

1. Helmets
2. That the competitors would be limited to a maximum average speed of 140km/h 

Page 117:
Timothy Theodore Schenken, Motor Racing Manager for CAMS, takes the stand.

Page 120:
Bruce Malcolm Keys, Manager of CAMS Rally Division takes the stand.

Page 123:
Mr Keys told the Court that the first supplementary regulations were drafted by him and approved by Mr  Schenken. The witness was referred to page 8 of the supplementary Regulations Manual dealing with safety helmets. There was a requirement there that safety helmets were to be worn during all competition sections of the Run by all crew members, but not required to be worn during the Grand Tourer Sections. He was at the
same time referred to page 8 of the Rules Procedures and supplementary Regulations Manual. There it was stated: "The wearing of safety helmets is not compulsory, however it is recommended during the flying mile challenges. He was then taken to the further Supplementary Regulations. On page 3, paragraph 7 at (f) the following appeared: "Failure to wear a safety helmet as specified in the 1994 CannonballRun supplementary
Regulations Section 3 Article 3."

This wouldn't have saved the lives of Mr Kabe and Mr Okano because where the incident occurred was not a designated flying mile section. Interesting.

Page 124:
CAMS Press Release on the day of the incident

Mr Keys told the Court that he had played a part in the press statement issued by Mr Tait on 24th May relating to the Cannonball Run. That press release Exhibit 39) is set out in full a s follows.

 

"CAMS STATEMENT - CANNONBALL RUN
The Vice President of the Confederation of Australian Motor Sport (CAMS), Mr David Tait, said the sport was in shock at the news of the deaths today in the Northern Territory Cannonball Run.
 

Two competitors and two officials lost their lives after a crash near Orange Creek during the third day of competition. The driver, Akihiro Kabe, and his co-driver, Takeshi Okano, were leading the event at the time in their Ferrari F40.
 

Mr Tait said while competitors may size up the risks of competition and accept them, the deaths of two volunteer officials was particularly upsetting.

 

We understand the Ferrari entered the finish of a Cannonball Special Section (average speed section), lost control and hit the control officials who were standing beside their vehicles at the time." he said.
Mr Tait said CAMS' administration had been assured that not only were the CAMS guidelines being adhered to but the Northern Territory road rules were also being strictly enforced.

The Northern Territory of course has no set open speed limit but CAMS required that a maximum average speed of 140 km/h be placed on all open road sections.

He said CAMS is aware that the Northern Territory and its Chief Minister had been working very hard to ensure that this exciting new event would be conducted with safety.

There is no doubt that the government and t he police will be looking at the circumstances of the crash and, together with the organisers, we are available to give any necessary assistance.
 

On behalf of the sport, we extend our deepest sympathy and condolences to the family and friends of the crash victims, " Mr Tait said.

It was Mr Keys firm understanding that when the event started that a maximum average speed of 140 kph applied.

Seems a bit unreasonable to expect competitors in a Cannonball Run to drive at a maximum average speed of 140km/h when a member of the public could sail past you at ay speed they like. However, this is how RaceCage Pty Ltd got CAMS to back the event. 140 was the maximum average speed allowable. 

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Page 125:

Mr Michael Andrew Bell (CAMS Appointed Chief Steward for the Cannonball Run) takes the stand.

Page 127:
Mr Graham McVean, a director of RaceCage Pty Ltd took the stand. (This is essentially where the "other side" tells their side of the story)

Page 130:
"We had discussions with members of the steering committee, with members of the Chief Minister's office, and it generally decided, and our words to CAMS were always that people in the Northern Territory go to work at average speeds Faster than 130/140. To put that sort of a restriction on our event, we would virtually be faced with cancellations. " Said Mr McVean

Page 131:

Mr McVean was asked about his understanding on the issue of speed. He stated: "I assumed that CAMS had accepted a compromise in their 140 kph suggestion or requirement, because they had compromised on almost every other issue that we had put before them."

Page 135:

"As to the type of skills drivers had Mr McVean said: "..you assume that somebody with a high performance car has had the opportunity on occasions to get it up to those speeds." He agreed that was an assumption. He also agreed that he took no steps to test the accuracy of that assumption.

Wow. So because I can afford to buy a high performance car, I can drive that high performance car at high speeds.

Page 139: 

"Mr McVean agreed that on Day 3 of the route instructions there was no mention of the right-hand sweeper prior to the control point."

 

Page 140:
"There was also a police car on each morning that left ahead of the field and generally stayed in the top five or six cars." 
 

Well, this begs the question, how was a police car meant to keep up with the top six competitors, and if this was the policy, where was this police car on Day 3?

Page 141:
Mr Douglas Scott Fraser takes the stand

Page 147:
As to why he moved Peter Kimber, Mr Fraser said:
"I came through - when I came through, I came through as a - as a competitor would with the same eyes, if you like, as a competitor would have. Yeah, with the eyes of a competitor. Each time I had - I had been through previously, obviously, there wasn't a control point set up, so it was always going to be this was the first time that - that anybody had seen the control point from the view of how a competitor would view it. I had a very clear view of the control point from a long distance back. I believed in my opinion that if I moved Peter further towards the - towards Alice Springs, it would give an even longer distance sign that the control point was coming up."

 

Allan George Moffat retakes the stand

 

Page 154
Everything Allan Moffat is saying to this point is everything we've read before until this:
 

"He (Allan Moffat) said that occurred on the first day between Darwin and Katherine and on the trip back. There was a trial event-imposed speed limit of 180kph. When asked why a limit was imposed on the first day, Mr Moffat stated:

 

"It was imposed because as organisers we had the benefit of hindsight before the event. By that I mean, in the non-glibbed fashion, we had done a number of surveys. We were aware of the relatively twisty nature of the road between Darwin and Katherine, vis-a-vis what could be expected on the following days. We were also aware that people were coming up to a very strange never-before event and as part of our bridle - if I can continue to use the term, which I wouldn't like outside the court, for the benefit of future advertisements - it was a way of controlling people's introduction to the event. No car on the field was supposed to be doing more than 180 on the first day from the Darwin wharf to the Katherine showgrounds.”

 

I thought... "Hang on... this is new. So we asked the drivers that competed in the event if they remember this restriction of 180 km/h being placed on them during Day 1 of the competition. Turns out this was not true.

We sent an email to the winning car driver Ron Conrad and asked the question:

25/06/2023

"Mate, I have a question about what I’m reading in the coroners report. It’s something I’ve never heard before and I just need to know if you can recall this occurring before I ask the group. If you remember it, no need to ask the group, if you don’t remember it, I’ll ask the group.
Do you recall if on the first day of the Cannonball Run, from Darwin Wharf to Katherine, of everyone was restricted to doing a maximum of 180km/h?
I have never heard of this before."

26/06/2023

"Hi Russ,

There was no speed limit from Darwin to Katherine. Only the speed limit in Darwin City itself.

Once we left Darwin it was unrestricted (as per all vehicular traffic). - Kind Regards, Ron Conrad." 

Hmm, it appears Mr Moffat may have embellished the truth a little here.
 

Page 159:
"Mr Moffat did not agree at all with the suggestion that Mr Kabe was confused as to his location. Mr Moffat believed that the route instructions were sufficiently detailed to meet the varying intelligence or competitors.
Mr Moffat was sure that the fact that a flag marshal was warning of a shutdown zone had been communicated to competitors during briefing sessions. He agreed that the route instructions did not indicate the whereabouts of marshals. MrMoffat told the Court that had he been in Mr Fraser's car on the morning in question he would have posted Mr Kimber in the shutdown zone."

 

Incredibly Allan Moffat was not asked why the sweeping right hand bend was omitted from the route instructions of Day 3 just prior to the check point.

Page 164:

This is where the Coroner starts with his findings. This is where it starts like a “How to Guide” for running a successful Cannonball Run.
 

The Direct Cause of Death 

"The direct cause of the accident was driver error on the part of Mr Kabe."

"As Mr Kabe approached the checkpoint he braked heavily and veered sharply to his left onto the lay-by. Almost immediately the Ferrari side-slipped to the left. Mr Kabe applied a steering correction, but overcorrected with the result that the Ferrari underwent a rapid weight transference to the right. This caused the Ferrari to move off the lay-by onto the Stuart Highway. Once on the Stuart Highway, Mr Kabe applied a second steering correction to the left. This correction induced a yaw of the vehicle in the opposite direction to the initial yaw, rotation now being in an anti-clockwise direction. The Ferrari, now being in a total broadside travelled back onto the checkpoint on collision course with the two support vehicles parked at the checkpoint with which the Ferrari eventually collided." - Coroner

Page 167:
Contributing Factors
 

"It was further suggested that Mr Kabe's failure to be aware of the shutdown zone and upcoming checkpoint was due to a number of factors:
1. Excessive speed;
2. The presence of the vehicle driven by Mr Castaldi;
3. The lack of appropriate warning signs prior to the checkpoint;
4. The location and nature of the checkpoint;
5. The accuracy of the Cannonball Run route instructions:
6. Lack or comprehension of the route instructions by Mr Kabe and Mr Okano, or lack or familiarity with the instructions.

I am satisfied on the balance of probabilities that Mr Kabe entered the lay-by in his Ferrari at the speed and in the manner in which he did as a result of suddenly becoming aware of the presence of the checkpoint." - Coroner

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Page 174:

"I am satisfied on the balance of probabilities that the presence of the Lexcen played a significant part in the circumstances that caused the accident." - Coroner

Page 178:

"It is an inescapable conclusion that the presence of the Lexcen at the precise time and place during the running of the special section of the Cannonball Run from Alice Springs to Stuart Well was a significant contributory factor in the accident" - Coroner

Page 189:

"In my opinion, if the shutdown zone and checkpoint had been more explicitly described in the route instructions by reference to a physical feature, such as the right hand sweeper, that would have assisted competitors in determining the whereabouts of the shutdown zone and checkpoint. However, that would not obviate the need for there to be adequate signage warning or the shutdown zone and the checkpoint." - Coroner

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Page 191:

Formal Findings

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Page 192:

Comments & Recommendations

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Page 198:

"In my opinion, the Northern Territory Government failed to discharge its fundamental responsibility which was to ensure public safety in relation to the planning and running of the Cannonball Run." - Coroner

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Page 199:

"The Government failed to address its area of primary responsibility which was to ensure that the very structure of the cannonball Run was consistent with public safety."  - Coroner

"It is no answer for the Government to say that it relied upon Mr Moffat's considerable experience in driving competitive vehicles and his and the other organisers careful attention to safety. Neither Mr Moffat nor the other organisers had any prior experience in organising an event like the Cannonball Run. In any event the Northern Territory Government could not, in effect, delegate the responsibility for public safety to the
organisers of the event." - Coroner

 

Page 200:
"Nor is it an answer for Government to rely upon the particular circumstances of CAMS involvement in the lead-up to the CannonballRun." - Coroner

Page 201:

"The accident occurred as a result of the Ferrari attempting to enter the lay-by at a sharp angle and at a speed which was excessive in all the circumstances. The accident can squarely be put down to driver error. It is also important not to overlook the significant part played by Mr Castaldi's Lexcen. It's presence not only had the effect of slowing down the Ferrari, but contributed to Mr Kabe's driving error." - Coroner

 

Page 204:
Cams issued the permit for the Cannonball Run on 18th May 1994. (Just two days before the events started)

​

Page 208:

"The apparent confusion as to any requirement that safety helmets be worn during the Cannonball Run once again demonstrates an inattention to detail on the part of CAMS, and does not reflect favourably upon an organisation which is the peak body for motor sports in Australia." - Coroner

​

Page 210:
"In my opinion the organisers (referring to Allan Moffat's RaceCage Pty Ltd) lacked the relevant expertise to properly analyse and evaluate the issue of speed as one of the parameters of safety in the Cannonball Run."  - Coroner

Page 211:

"The organisers, (Racecage Pty Ltd) and even taking into account Mr Moffat's vast experience in motorsports, did not collectively have the relevant expertise to stage such a unique event as the Cannonball Run in such a way as to ensure the safety of the public." - Coroner

Page 213:

The recommendations should a future Cannonball Run be considered.

 

Page 224:
"It seems clear that in the event of a second Cannonball Run being considered there is a real need to inhibit the speed at which vehicles might travel during the course of the event." - Coroner

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Page 225:

"Due to my finding that the presence of the Lexcen, a public vehicle, was a contributory factor in the accident, an independent review and an evaluation or the 1994 Cannonball Run should seriously question the desirability of having roads open to public use during the running or any second Cannonball Run." - Coroner

Page 228:

"If another Cannonball Run is to be held those conducting the independent review and evaluation should closely examine the screening process adopted in the Targa Tasmania, and seriously consider putting in place a similar screening process which focuses on the assessment of driving skills, in particular the defensive driving aspect. Given the very important role played by navigators in an event like the Cannonball Run, I
would also recommend that screening procedures for navigators be considered during the course of the evaluative exercise." - The Coroner

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Page 229:

"Given the presence of Mr Castaldi's Lexcen, I am satisfied on the balance of probabilities that had there been a flying finish at the Stuart Well checkpoint the particular accident which took the lives of the two Japanese competitors and the two marshals would not have occurred." - The Coroner

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Page 234:

"Given under my hand this Tuesday, 20th day of December 1994." John Allan Lowndes - Coroner

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Questions:

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1) How did Allan Moffat get to be first on scene after Johnny Karlbetzer (Car 67) in his 1979 white Porsche 911 Turbo that was in the race?

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Johnny Karlbetzer (yes 'the' Johnny Karlbetzer) driving Car 67: a white 1979 Porsche 911 Turbo was the first car on the scene and pulled the co-driver from the Ferrari. Allan Moffat was the third car to arrive. Johnny says that he was amazed that none of the spectators or journalists came to help.

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2) Mr Yan says he was taking pictures from above in a plane....and then the guys in the back of the Lexon, say they were taking pictures?

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Only one picture ever comes to light and no photographer is listed for the Wheels magazine picture, why? What is so bad in the pictures? Surely even in this age before digital cameras the film cameras would have taken some photos. No pictures from the plane over head, yet people say they have seen footage on TV.

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What about the Japanese journalists that had their car parked at the checkpoint, where are their pictures, where was their testimony. Where are the official police photographs? These were not produced, not even at the inquest.

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4) There was a rumour that a "white car was pacing the field the day before" why was this ignored by the organisers?

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The big thing is the pictures... why is there such a lack of pictures both official and or amateur? Out of the blue only one photo surfaces that could only have been taken by the Japanese Journalists.