Handbrake failed in farm worker's accidental death

A farm worker who was crushed by a tractor when its handbrake failed died as a result of an accident, an inquest has concluded.

Daniel David Sowerby, 26, died at the scene at Newlands Farm in Wigton, Cumbria, on 11 September 2024, shortly after he was found with severe injuries at the side of the road.

Coroner Robert Cohen said the handbrake failure was caused by a manufacturing defect to a component of the Case Maxxum 150 tractor, which had been recalled since the death.

Cohen said: "I hope this tragedy can be an opportunity to remind farmers who have any machinery that have been subject to a recall that it's vital that work is undertaken."

Summing up the evidence at the two-day hearing in Workington, Cohen said statements from family members showed the 26-year-old's "passion for farming".

The Bassenthwaite-born farm worker had attended Newton Rigg college and had worked for a number of farms on a self-employed basis.

He started work for Alan Gill at Newlands Farm around 2019 and was well-respected, the inquest heard.

Cohen said: "I liked the detail in one of the statements from Mr Gill, that Dan was always 15 minutes early for work apart from one day when he was involved in a serious car accident.

"He did come to work, but was 10 minutes late - it says a lot about the man Dan was."

The inquest heard on the day of his death, he was due to spread muck and had parked the tractor next to a barn to load a trailer with manure.

When he got out of the tractor the handbrake failed, causing it to roll down the slope, crushing him against the barn wall.

Cohen said he had suffered "unsurvivable" chest injuries and despite emergency services attending the scene, he went into traumatic cardiac arrest and could not be resuscitated.

The tractor was found "jack-knifed" in a beck about 2,165ft (660m) from the scene of the crash, having crossed three fields and a minor road.

The inquest heard evidence from CNH, the tractor's manufacturer, and Cofle, the firm contracted to make the part that failed.

Both companies launched investigations in light of the death. Cohen said CNH's evidence was that they had found eight other occasions involving tractor users "simply not being able to apply the handbrake".

He said this would be different from a handbrake initially working and subsequently failing, as the driver would not be aware to any issues after parking it.

Cohen said: "However that evidence wasn't entirely consistent with evidence I heard from Cofle, in which there seemed to be suggestions of incidents involving the break disengaging."

The inquest heard a batch of ratchet and pawl mechanisms which make up the handbrake in the tractor, were found not to conform to specifications.

The issue was with the parts being 30 to 70% "softer" than expected.

Massimo Mandelli, who is responsible for quality at Cofle, said the issue was found to be with a process used to harden the parts that make up the brake.

This was done by another firm, which was found to be "bulk-loading" components into the furnace, meaning some were hardening to the correct specification and some were not.

Evidence heard at the inquest showed firm Class, a competitor of CNH, had recalled a number of tractors in 2022, due to a similar problem identified in the tractor that the farm worker was driving when he died.

The part in question was also manufactured by Cofle and also concerned the heat treatment of a metal part.

Cohen said he was not satisfied the recall by Class was not "directly analogous" to what happened with CNH's failing part.

He said: "There's an issue that remains at large, which I don't need to determine, as to whether or not Cofle should or could have spotted at an earlier stage the deficiencies in the part that was supplied."

Mandelli's evidence said the Class component and its design were different to CNH's.

The coroner told the hearing the role of an inquest was not to apportion blame, but to determine how a person had died.

He said evidence from several witnesses had shown Newlands Farm's owner, Gill, ensured "his equipment was up to spec, well maintained and looked after."

"It is absolutely plain to me that there's no personal responsibility [from Gill] at all for this tragedy," Cohen said.

He added: "I have nothing but sympathy for Dan's family and friends. It's a cruel thing to lose somebody at such a young age."

Follow BBC Cumbria on X, Facebook, Nextdoor and Instagram.