Deceased
Shane William Davis
Demographics
29y, male
Coroner
Hennessy
Date of death
2005-08-07
Finding date
2007-03-21
Cause of death
Multiple injuries from being struck by a tyre and rim assembly when attempting to remove them from a truck hauling coal, caused by failure and uncontrolled release of stored energy in the tyre due to a crack in the multi-piece rim assembly
AI-generated summary
Shane Davis, a 29-year-old truck driver, died from injuries sustained when attempting to remove a doughy tyre from a multi-piece rim on a coal haulage truck. The rim failed due to fatigue cracking, causing explosive release of stored energy in the tyre, propelling the tyre and rim fragments with fatal force. The death was preventable through multiple interventions: deflating tyres before wheel removal (a standard practice in tyre fitting but not implemented by Korn drivers), establishing adequate safety operating procedures specific to multi-piece rims, non-destructive testing of rims, proper training in mining-specific hazards for transport workers, and effective contractor safety management. Contributory failures included inadequate safety procedures, insufficient worker training on stored energy hazards, lack of rim maintenance protocols, poor communication between mine operator and contractor, and delayed development of the contractor's safety management system.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
TRANSCRIPT OF PROCEEDINGS CORONERS COURT HENNESSY, Coroner
IN THE MATTER OF AN INQUEST INTO THE CAUSE AND CIRCUMSTANCES SURROUNDING THE DEATH OF SHANE WILLIAM DAVIS ROCKHAMPTON ..DATE 21/03/2007 ..DAY 1 FINDINGS WARNING: The publication of information or details likely to lead to the identification of persons in some proceedings is a criminal offence. This is so particularly in relation to the identification of children who are involved in criminal proceedings or proceedings for their protection under the Child Protection Act 1999, and complainants in criminal sexual offences, but is not limited to those categories. You may wish to seek legal advice before giving others access to the details of any person named in these proceedings.
21032007 D.1 T1/KMG(ROK) M/T ROCK02/771 (Hennessy, Coroner) MR J TATE to assist the Coroner 1 MR G DALISTON appearing on behalf of CFMEU MS M CALLAGHAN on behalf of South Pacific Tyres trading as Beau repair Tyres MR HORNEMAN-WREN on behalf of Korn Mining MR P DE PLATER appearing on behalf of Chelsea Baker and next 10 of kin MS L M GRIFFIN appearing on behalf of RIMEX Australia CORONER: The matter this afternoon is for the delivery of findings in relation to the inquest into the death of Shane William Davis.
I will proceed to read these findings into the record. I do have a copy to leave with those people who are present in Court and a copy can be emailed to those persons on the phone at their request.
An inquest was held into the death of, Shane William Davis, in Mackay, in Rockhampton, from the 15th of May 2006 concluding on the 15th of December 2006. Davis was aged 29 years at the time of his death on the 7th of August 2005.
Introduction; Mr Davis was employed as a truck driver by Korn Mining Services at the Foxleigh Mine near Middlemount in Central Queensland. He had been employed by the company for 21 months as a truck driver, hauling coal from the Foxleigh Mine site to the German Creek Wash Plant.
21032007 D.1 T1/KMG(ROK) M/T ROCK02/771 (Hennessy, Coroner) On the 7th of August 2005 Mr Davis was working a dayshift when 1 he noticed that one of the tyres on the vehicle he was driving was "doughy." He went to the Korn workshop at the Foxleigh Mine site to attend to the tyre. Whilst a tyre fitter was employed at the workshop on a part-time basis, it was the duty of the truck drivers to remove wheel assembles with defective or damaged tyres from the vehicle, leave them to be attended to by the tyre fitter and replace the assembly with another.
Mr Davis was attending to this tasks when the drive wheel rim assembly he was handling gave way under pressure due to a wear crack in the rim. Mr Davis had not deflated the tyres on the wheel assembly. The tyre on the outer rim was forced from the assembly and it and parts of the rim struck Mr Davis, throwing him away from the vehicle.
He was immediately attended to by workmates and medical attention was sort. He suffered serious injuries which proved to be fatal. These findings seek to explain as far as possible how the accident occurred. As a result of the evidence in this matter changes to industry practise may be recommended with a view to reducing the likelihood of a similar incident occurring in the future.
The Coronial Jurisdiction was enlivened in this case due to the death of Mr Davis falling within the category of a "violent or otherwise unnatural death," under the terms of section 83B of the act.
21032007 D.1 T1/KMG(ROK) M/T ROCK02/771 (Hennessy, Coroner) The matter was reported to a Coroner in Mackay pursuant to 1 section 73 of the act. A Coroner has jurisdiction to investigate the death under section 11(2) in inquire into the course and circumstances of a reportable death and an inquest can be held pursuant to section 28.
A Coroner is required under section 45(2) of the act when investigating a death to find, if possible, the identity of the deceased, how, when and where the death occurred and what caused the death. An inquest is an inquiry into the death of a person and findings in relation to each of the matters referred to in section 24 are delivered by the Coroner.
The focus of an inquest is on discovering what happened, informing the family and the public as to how the death occurred, but not on attributing blame or liability to any particular person or entity. The Coroner also has a responsibility to examine the evidence with a view to reducing the likelihood of similar deaths. Section 46(1) of the act authorises the Coroner to, "comment on anything connected with a death investigated at an inquest that relates to,(c) ways to prevent deaths from happening in similar circumstances in the future." Further, the act prohibits findings or comments including any statement that a person is guilty of an offence or civilly liable for something.
Due to the proceedings in a Coroner's Court being by way if inquiry rather than trial and being focused on fact finding rather than attributing guilt, the act provides that the Court
21032007 D.1 T1/KMG(ROK) M/T ROCK02/771 (Hennessy, Coroner) may inform itself in any appropriate way, section 37, and is 1 not bound by the rules of evidence. The civil standard of proof, the balance of probabilities is applied. All interested parties can be given leave to appear, examine witnesses and be heard in relation to issues in order to ensure compliance with the rules of natural justice. In this matter the mine, the SSE, the employer, the union, the family of the deceased and other interested parties were represented at the inquest.
The investigation; the inquest was reported to Inspection Officer Mahash Dal, of the mines inspectorate and the senior site executive, the SSE, was instructed to cordon off the accident site. Inspectors Herbert and Smith were notified.
Inspector Smith and Mr Dal proceeded to the site upon learning of the death of Mr Davis.
The Queensland Police satisfied themselves that there were no suspicious circumstances and secured the scene for the mining inspectors. A thorough investigation of the scene and witness interviews took place over the following days and weeks. The report prepared by Inspector Smith detailed particulars of Foxleigh operations.
oxleigh Mine is an open cut coal mine near Middlemount in the Bowen Basin in Central Queensland producing around four million tonnes of coal per year. Foxleigh employed 238 employees at the time of the incident. Mr Ian Brown was the SSE in August 2005. Foxleigh is a smallish mine and relies on
21032007 D.1 T1/KMG(ROK) M/T ROCK02/771 (Hennessy, Coroner) contractors on a continuing basis in order to conduct the 1 mining operations.
Korn Mining Services, who employed Mr Davis, were contracted to haul coal from stockpiles to German Creek Mine for processing prior to transport to port. They also operated haulage contracts on other mine sites in the Bowen Basin. At Foxleigh the project manager, Mr Peter Reggardo, was the senior Korn employee on site and had responsibility for Korn safety management in the Foxleigh organisational structure.
An incident causal analysis method, ICAM, investigation was conducted on the incident. That investigation found that the lack of identification of the hazard of uncontrolled release of stored energy from the tyre, the lack of a physical barrier between the wheel and the worker, the removal of physical barriers or cleats whilst the tyre was still under pressure and the failure to deflate the tyres were major contributors to the incident. It was also noted that there was no evidence of the truck drivers being exposed to safety information relating to handling of multi-piece rims.
Inspector Smith's investigation revealed that a training needs analysis required under regulation 82 had been done but there had been no identification of a need for training on removal of wheels in the mining setting. There had been a similar incident or be it regarding much larger machinery at the Century Zinc Mine in Queensland on the 9th of February 2004 relating to the death of Peter Marshall. The department
21032007 D.1 T1/KMG(ROK) M/T ROCK02/771 (Hennessy, Coroner) issued a safety alert to the industry following this incident. 1 Access was not made to safety alerts or information on the website of the rim manufacturer.
Inspector Smith presented a very thorough and informative report to the Court concerning the incident including a video simulation of the assembly of the multi-piece rim and the probable consequence of events when the wheel assembly gave way. I am satisfied that the investigation was carried out in an appropriate, professional and thorough manner and the information gathered was of critical importance to the inquest.
The evidence; I have summarised only those portions of the evidence I consider necessary to explain the findings and recommendations I will make. I have taken all of the evidence before me into account in considering this matter. Even if it is not specifically referred to.
On the 7th of August 2005 Mr Davis commence day shift and took over driving truck 46, a B-double Kenworth C510 coal hauler known as a Big Foot, from Anthony McCarthy, the nightshift driver. Mr McCarthy reported no safety issues with the vehicle having conducted about four safety inspections of the truck during the shift. The truck, know as a Big Foot, is a vehicle which cannot be registered on Queensland roads due to its configuration. It is larger than a Prime Mover. It is more than a standard road transport vehicle.
21032007 D.1 T1/KMG(ROK) M/T ROCK02/771 (Hennessy, Coroner) On his seventh run to German Creek carrying coal, Mr Davis 1 informed his supervisor, Clyde Davis, also his uncle, that he had doughy tyres, low pressure and would need to change them.
He drove the truck into the right-hand bay of the Korn workshop. The crib room was beside the workshop and Mr Jeppeson and Mr Krajewski were working in the other bay of the workshop. Mr Davis also informed Mr Jeppeson of his intension to change a doughy tyre.
Mr Davis placed a hydraulic jack underneath the truck to lift the drive wheels from the concrete floor of the workshop. He used a rattle gun to loosen some of the cleats on the wheel.
His workmates heard the operation of the compressor driven tools but could not see Mr Davis. During the use of the rattle gun a loud sound like an explosion was heard by his workmates. Men went immediately to investigate and found Mr Davis with a serious head injury.
He was unconscious but breathing. Pressure was applied to the wound and emergency services were immediately notified. Mr Davis had been thrown back near the water truck from the impact. Unknown to Mr Davis, the inner wheel rim had cracked 40 and separated from the ring grove allowing movement in the components of the multi-piece rim. As the tyres on the dual assembly were still inflated when Mr Davis commenced loosening the cleats, the components of the rim gave way allowing the explosive release of pressure from the tyre. Only some of the cleats had been removed but the release of pressure sheared six of the wheel studs and bent four others. All of the components and the two tyres were expelled from the wheel assembly onto Mr Davis and into the surrounding space with the immense force. The rattle gun was also found in close 50 vicinity to Mr Davis.
The open cut examiner, Mr Anthony, attended the scene quickly and rendered assistance to Mr Davis. He gave evidence that
21032007 D.1 T1/KMG(ROK) M/T ROCK02/771 (Hennessy, Coroner) whilst Mr Davis did not regain consciousness, he seemed to 1 respond to a question by squeezing Mr Anthony's hand and muttered some words. The Middlemount ambulance attended and took Mr Davis from the scene towards the airport to meet with the medical evacuation aircraft. The doctor met the ambulance in transit, Mr Davis died before the airlift.
Sergeant Blain of Middlemount Police attended the scene and handed over to the Inspector after ascertaining there were no suspicious circumstances requiring police investigation. In his evidence the sergeant commended Korn management and employees for the manner in which they secured the scene and stated that all Korn and Foxleigh personnel were very cooperative with police on the day in question.
Autopsy results; an autopsy was conducted by Dr Fitzpatrick in Mackay. The examination revealed that Mr Davis suffered a large jagged laceration to his forehead and extensive scull fractures with displacement and exposure of the brain. There was also a peppering of small abrasions to his head area and jagged laceration to his left knee. The pathologist view was that Mr Davis died from multiple injuries due to the workplace accident. There was no evidence of alcohol or drugs in Mr Davis's system at the time of the incident. Dr Fitzpatrick stated that the injury sustained by Mr Davis caused very very severe brain damage, that he was unconscious quickly and it would have been a quick passing.
21032007 D.1 T1/KMG(ROK) M/T ROCK02/771 (Hennessy, Coroner) Development of Korn Bulk Haulage as a business; Mr Des Korn 1 had been involved in transport trucks for 30 years and his father before him. He started Korn Bulk Haulage at Dysart with one truck, carting gravel for 16 years. He obtained a contract at Enshame Mine in 1991 where he was working six trucks in coal haulage. He ended up taking over all of the coal haulage at the site and was operating 15 trucks.
He worked under the mining operator's safety management system here and after referred to as the plan or SMS. He was then approached by Thiess at Collinsville to cart coal onto an off site and entered into a four year contract between 2000 and
He was also approached by Thiess to tender against Brambles at Oakey Creek and a few weeks later Foxleigh came on board. He had 30 trucks by then and described his business as doubling overnight. At that time he realised that his wife and he could no longer cope with the running of the business on their own.
21032007 D.1 T02/CDB(ROK) M/T ROK02/771 (Hennessy, Coroner) At each site he used the mining operator's procedures. You 1 said that the mines knew that they were a small operation but around the time of taking over the Foxleigh contract from McKenzie River Bulk Haulage, BMA told Korn that he was big enough to have his own system in place so they started to develop one.
He employed a safety consultant to commence that process. He hired experienced employees to assist in the running of the business and worked on the basis of trusting in their knowledge and experience. Getting experienced and qualified people was not easy.
Mr Korn's reliance on documents such as contracts was not strong and he managed business relationships on a handshake and trust. He sorted out problems as he got the job done. He approached the coal hauling as just hauling in a different setting.
David Rix commenced with the company in May 2003 as general manager. Mr Korn had a health issues at that time and was becoming more involved in the maintenance side of the business whilst Mr Rix attended to the business side.
Mr Korn stated in evidence that in all his years in the trucking industry he had never deflated tyres when removing wheels and he never expected the danger of the explosion of the tyre. He stated that he always had a good safety record.
Continually looked to upgrading and considered himself to be
21032007 D.1 T02/CDB(ROK) M/T ROK02/771 (Hennessy, Coroner) proactive. His company motto was safety management 1 production. He said he was never concerned about the cost when safety was involved.
Korn Management Issues: The Korn shift supervisors who gave evidence including Mr Clive Davis, stated that they had achieved the required supervisor qualifications for the mining industry but received no training beyond that. They were not given instruction on the SMS, were not trained or assessed as competent against the SOPs. Were not trained in hazard identification or risk assessments or on how to train or assess competence of workers in a formal sense.
Given the pressure of other duties they did not usually attend the SOP reviews with workers. There day to day activities included driving around site checking on progress. Relieving for drivers who were ill or not at work. Checking in at the workshop and generally lending a hand where needed. They reported to Mr Reggardo.
Mr Reggardo was the project manager for Korns at Foxleigh at the time of the incident. He was therefore the senior Korn person on site and had obligations under the Foxleigh safety management structure and safety management system. He admitted in his evidence that he had not familiarised himself with the contract with Foxleigh nor the Coal Safety and Health Management Act 1999 provisions.
21032007 D.1 T02/CDB(ROK) M/T ROK02/771 (Hennessy, Coroner) He explained that this was due to difficulties he encountered 1 with reading such documents. He had not made high levels of management aware of this issue. He stated that he had no training in relation to safety obligations attaching to his position other than the supervisor competencies. He was not provided with a list of his responsibilities under the SMS.
This situation, combined with Mr Reggardo's difficulties with formal documents meant that he was never in a position to fulfil his obligations effectively.
Mr Reggardo gave evidence that he conducted work area inspections to identify hazards such as tripping hazards. He saw the tasks undertaken in the company as low risk. The only reviews he conducted of the worker's knowledge of SOPs after their initial induction was reviews of SOPs on wet days.
Safety meetings were held as informal and brief shift change toolbox meetings each day. No records were kept of those meetings. Mr Reggardo said that the Foxleigh contract manager checked on those meetings and was satisfied with them.
Mr O'Dwyer was next in chain of command above Mr Reggardo. He had previous mining experience as a truck driver since 1995.
He became area manager of Korn in 2000. He maintained contact with the project managers on each site including Mr Reggardo at Foxleigh. In his words his duties were "To help with the day to day running of jobs." Despite his position he was unaware of the terms of the contract with Foxleigh or of Korn's responsibilities under the
21032007 D.1 T02/CDB(ROK) M/T ROK02/771 (Hennessy, Coroner) contract. Any contact he had with Foxleigh related to haulage 1 production targets. He did not attend safety meetings with Foxleigh they were usually attended by Mr Reggardo.
Mr O'Dwyer answered to the general manager for Korn Bulk Haulage, Mr Rix. Mr Rix came to the company with business experience holding a degree in postgraduate certificate in business management as well as trade qualification of fitting and turning. He managed all aspects of the business and answered to the owner, Mr Korn.
Mr Rix was responsible for contractual and pricing matters.
Mr Rix gave evidence that Mr O'Dwyer's description of his role was incorrect and that his duty actually was to oversee the management of all operations and ensure they were running smoothly in consultation with the project managers. Mr O'Dwyer when recalled to give further evidence seemed to have a much clearer understanding of his role. He put his earlier vagueness down to nerves.
His further statement of duties including liaising with project manger's talking to clients on issues relating to haulage, ordering tyres and dealing with mechanical and plant issues and helping the project managers run the sites. Mr Korn, by the time Mr Rix came to the company, assisted with maintenance issues and liaised on issues of maintenance with the maintenance manager and attended to purchasing and selling of machinery and equipment. He was not involved in the day to day operations of the company.
21032007 D.1 T02/CDB(ROK) M/T ROK02/771 (Hennessy, Coroner) Qualifications and Inductions for Truck Drivers: Employees of Korn who were driving trucks including the big foots were required to have a MC driver's license for road trains. Have obtained a black coal competency, three days. Underwent Foxleigh for six hours and Cap Coal inductions to work on the Foxleigh and German Creek sites and had a Korn induction.
Mr Reggardo, the project manager for Korn Bulk Haulage, gave evidence that there was not really a Korn induction as such.
The workers went through the Korn SOPs which included one for removal of rims from vehicles for bolt on, bolt off, not multi piece rims. Driving capability was assessed by Korn supervisors over varying periods of time depending on the experience of the worker but maintenance issues, including wheel changing, was not assessed.
Mr Schiekowski, an employee of Korn, was concerned that the inductions are done quite quickly and that more time could be taken to allow workers to digest the information being presented. He felt the time pressure in the inductions meant that he was multi tasking and not retaining a lot of information and that he was provided with no reference materials to take away with him.
He was uncomfortable with the method of teaching and felt that a lot of other attendees were to. He advised that workers were not given the opportunity to hold onto a copy of the SOPs or other procedures and there was no central book of them to
21032007 D.1 T02/CDB(ROK) M/T ROK02/771 (Hennessy, Coroner) which the workers had access. Whilst there was a copy of 1 information in the Foxleigh training room he said that the Korn workers had little or no occasion to go there. He was unaware of the copy in the Korn crib room.
Mr McCarthy, a truck driver at Korn, underwent a general black coal induction in Rockhampton for two days and a general site induction at both mine sites, Foxleigh and German Creek, of one day each. He went through the Korn SOPs with Mr Reggardo the following day. He stated that at that stage he was lost due to the amount of information being presented over the couple of days and that the inductions gave some awareness of the issues but not a total understanding.
He stated that most of the information was repetitive between the inductions and there was a risk of not fully understanding the information as it was all mulched in together. He said that at the time of starting with Korn he did not have a clue what was going on and that earlier on it was very confusing and completely different world to the workplaces he was used to. Things were happening thick and fast and it would take anyone a long time, in his opinion, to become a hundred percent comfortable in the workplace.
His driving skills were assessed on the job over a two day period by Korn supervisors. Despite his previous experience he had never heard of deflating tyres before wheel removal but did become aware of that information on site at some time. He
21032007 D.1 T02/CDB(ROK) M/T ROK02/771 (Hennessy, Coroner) was unable to specify when. He said that stored energy was 1 covered in the generic induction in a general sense.
All of the drivers had experience in the road industry or with trucks in general. Their previous experience was relied upon in relation to maintenance issues and their competence was not assessed in that regard. They were given no instruction on maintenance tasks.
Duties of Drivers at Korn: Mr Davis' duties included driving Kenworth C510 coal haulage trucks known as big foots hauling coal from Foxleigh Rom run of mines stockpiles to the wash plant at German Creek neighbouring the Foxleigh operations.
The distance of that journey was about 20 to 25 kilometres in each direction and the vehicles were operated 24 hours a day in two shifts seven days a week.
There were truck drivers per shift. Other road train vehicles were used in addition to the big foots to haul the coal on site. Drivers were responsible for minor repairs on the trucks not requiring the maintenance crew and changing wheels was part of the drivers general duties. The drivers conducted pre-start checks on the truck and at the commencement of each shift. During the shift they would check tyre pressure again and make visual and tap inspections of the tyres for damage.
Mr McCarthy indicated that he attended to this after every two loads or so.
21032007 D.1 T02/CDB(ROK) M/T ROK02/771 (Hennessy, Coroner) Gary Ballard was a subcontractor for Korn providing a truck, a 1 Kenworth but not a big foot, and his services driving it and carting coal. He was also a very experienced truck driver having 30 plus years in the industry but was unaware of the deflation of tyres issue. He had never thought that there was any safety issues in this regard and used split rims over the years without problem. He did not look into Korn's SOPs for changing tyres as his wheels were of a different type and he took his own spares on the site and attended to changing them himself, usually in town.
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) Mr McCarthy was also a truck driver for Korns. He had years 1 of previous experience in the Australian Army and the road transport industry. He had worked with some multi piece rims but his experience was mostly with single piece rims.
Supervision And Training Of Drivers: It was suggested to Inspector Smith in evidence that there may be an ill fit between the road transport industry operations and mining competencies.
The evidence generally disclosed attention between the road transport industry culture and the particular application of the use of road transport vehicles in a coal mining setting, including the significant differences in loads, the risk around coal mines, additional corrosion departs occasioned by exposure to coal et cetera.
Mr Schiekowski who commenced work with Korns in December 2004 indicated that there was no training on the Korn safety management system or the SOPs, and that he was effectively left to his own experience and discretion on the job. He had 16 years experience in driving trucks but had no understanding of the hazards relating to tyres, and had no prior experience with these rims or split rims in general.
He had never been aware of deflation of tyres until this incident. He stated that deflating both tyres on a dual assembly takes little effort, is a simple task, and does not take a lot of time.
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) He said that the safety meetings were usually quick discussions at the shift changes and safety issues were not regularly addressed. Mr Reggardo would discuss safety information about once a week on an ad hoc basis but that the supervisors were always available to discuss issues that arose and provide advice.
His experience since leaving the Foxleigh site, he is now at Oaky Creek, is the significant change in the safety culture with twice weekly tool box meetings.
Mr Jeppesen, a diesel fitter, was aware that the drivers had no training in tyre removal and that he was not himself aware of the hazard of stored energy in tyres prior to the incident.
He frequently saw drivers removing tyres as part of their duties and it was not a practice at Korns to deflate tyres.
He had no training in the SMS or SOPs.
He was not encouraged to access the SOPs as it was felt that he had sufficient experience. It was not his practice to do a JSA before completing a new task. He stated that he often assisted drivers to remove rims as their weight and size made them too big to handle alone.
Mr Clive Davis was the shift supervisor on shift on duty on the day in question. No safety issues regarding the task of tyre changing were discussed with Mr Shane Davis prior to him undertaking the task.
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) It would seem that the task was considered so routine that an experienced driver would be expected to undertake the task safety.
Mr C Davis, nor any of the drivers who the Court heard from, used the procedure of deflating tyres before removal.
Evidence was given that most of the employees of Korn had previously worked in the road transport industry and deflation prior to rim removal from the wheel was not a practice in that industry.
The evidence was that it would have been a relatively quick and easy task to deflate the tyre in the workshop prior to removal if there had been a wish to do so.
Vehicle Maintenance Issues: Korn operated a system for reporting of vehicle defects and safety issues to management for attention. Drivers were required to complete a Korn plant safety checklist and defect form by filling out the details at the commencement of shift, the signing off on the form at the completion of the shift, when the form was provided to the shift supervisor.
Despite their being a provision for the shift supervisor to sign off on the form that was not the practice adopted within Korns at Foxleigh. The forms were then placed in a mailbox for collection and actioned by Mr Reggardo.
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) Depending on Mr Reggardo's shifts, it could be a number of 1 days before the forms were actioned. Mr Jeppesen advised that there were delays with Mr Reggardo's processing of the forms of up to two weeks.
Urgent maintenance issues were referred directly to the supervisor for immediate attention. Most of the time those issues were communicated through verbal reports to the mechanics and were not recorded or tracked.
Vehicle servicing took place on the basis that the workshop was allocated a vehicle to service on a particular day. One vehicle would be serviced at a time. If a service was unable to be completed in a shift, the vehicle would be returned to work if there were no serious faults, with the service to be completed at another time.
Mr Jeppesen was one of the diesel fitters responsible for the 200 and 1,000 hour services of the trucks. A 200 hour service was described as taking about six to eight hours to complete.
Vehicles were also briefly inspected when otherwise in the workshop.
Mr Rix, the then general manager, advised that services were recommended by the vehicle manufacturer to be carried out every 250 hours of operation, but due to the mining application, Korns adopted a conservative approach and conducted the services every 200 hours.
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) In relation to truck 46, a 200 hour service was conducted on 1 the 5th of August 2005 but was not completed. The service documents noted that the vehicle needed new drive tyres. They were not fitted during this service.
Mr Reggardo surmised that the reason for this was that the 5th was on a weekend and it was probably a matter that could wait until the Monday when the tyre fitter was available.
The safety checklist forms for truck 46 in the days leading up to the incident noticed various defects or matters requiring attention, including faulty tyres and wheel nuts.
Mr Reggardo had significant difficulty in being able to identify what the problems noted on the form actually referred to, given that the information was so non-specific. Certainly a seriousness of the defect could not be determined from the face of the form. Mr Reggardo's comment was that as long as the vehicle was not going to fall apart it would be sent back out to work.
Mr Atkinson, one of the drivers, stated in evidence, that there were differing opinions amongst drivers as to faults, especially relating to tyres and that the information recorded on the forms was not objective or to any particular standard.
In any event their assessment could be overruled by a supervisor of a different opinion.
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) Mr Jeppesen gave evidence that Mr Reggardo would inform him 1 verbally of what needed doing to what truck. Trucks would be rotated in and out of the workshop in order to keep as many vehicles as possible on the haul road. Depending on the seriousness of the defect, the vehicle would come to the workshop when it had time.
Hazard Of Uncontrolled Release Of Stored Energy: The hazard of the uncontrolled release of stored energy from tyres has existed for many years in the road transport industry.
Deflation of tyres prior to the removal of wheels from road transport vehicles is still not mandated in that industry at present.
There was varying evidence as to the extent of the use of multi piece rims in that industry. It seems that the big foot vehicles, whilst registrable for road use in Western Australia, are not in Queensland and would not be used in that context here.
In Western Australia the hazard has been formally identified.
In February 2005 the Department of Industry and Resources Safety and Health Division published a guideline regarding tyre safety, fires and explosions.
It is noted on page 4 in section 3.3 that, "Divided wheels, split rims and locking ring wheel and tyre assemblies are especially likely to explode if poorly maintained, incorrectly fitted or if assembled or disassembled while inflated. It is essential to deflate tyres before wheel removal to ensure that removing the
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) wrong nuts does not result in a serious or fatal 1 accident." A guideline was directed to, "Everyone handling tyres and those with a duty to prevent injuries when working with tyres," but was distributed under the Mine Safety and Inspection Act 1994 of Western Australia.
Deflation Of Tyres: A tyre and rim assembly has been described in the evidence as a pressure vessel which stores energy. Releasing the energy prior to working on the assembly to avoid potential harm from the uncontrolled release of that energy was essential for safety in these circumstances.
Mr Mann, a tyre fitter, and Mr Krajewski of Rimex both gave evidence that tyre fitters are trained to deflate tyres in a multi piece rim assembly before removal from the wheel and in the hazards of stored energy generally.
Mr Mann was employed by Beaurepaires as a tyre fitter and worked at Foxleigh under an agreement between Korns and Beaurepaires two days a week. He worked at Korn workshops on other sites for the balance of the week.
His duties included replacing tyres on rims which were removed and left in the tyre bay. He had to maintain the tyre racks with usable tyres on rims for replacement on vehicles.
Visually inspect trucks for tyre defects, and do pressure checks on tyres on vehicles on a regular basis.
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) He gave evidence that there was no recording of any 1 particulars of rims or tyres by Korns. Mr Reggardo confirmed that Mr Mann was not required to do any testing or checking of rims beyond a visual inspection at the time of tyre changes.
He removed rims or assisted in their removal from vehicles on about six occasions per week.
He cleaned the rims with a wire buff and visibly checked them for cracks or damage, replacing about 30 to 35 tyres per week.
He described his workload as flat out, and said that at times he struggled to keep up. His role did not include providing advice to Korns on any matters or giving any direction to Korn staff, he was purely there to maintain the tyres.
He would regularly receive reports of doughy and partly deflated tyres and see punctures, leaking valves and leaking O rings. Mr Reggardo estimated that 10 to 15 tyres were week were replaced, most of which were trailer wheels.
He described the average lifespan of a tyre on bigfoots to be about four months, with the rim being inspected at every tyre change. In the event of a visual crack being detected the rims were discarded for inspection by Korn management and replaced at their discretion. A couple of rims would be discarded per month with Korn management ordering replacements.
Mr Mann stated that he knew to deflate both tyres on a dual assembly before working on them, which task took about five to
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) 10 minutes. Sometimes drivers would assist and he conceded 1 that the drivers may have seen him removing rims from vehicles without deflating tyres. He did not deflate tyres about half of the time due primarily to the pressure he felt from some of the truck drivers to get the job done quickly so they could get moving again.
The commercial imperative for the company was to haul as much coal as it could in order to earn the most income. It was in the company's interest to have the trucks on the road for the maximum amount of time possible.
In contrast, drivers were not paid any bonuses or commissions on their haulage rates, so there would seem to have been no financial pressure on them to stay on line.
He gave evidence that Korn drivers had discussed the issue of deflated tyres in general conversation on numerous occasions but in the context of not fully inflating tyres to be placed in the go rack.
There was also discussion along the lines that he, as tyre fitter, should be doing all the tyre work including removal from vehicles. He gave evidence of a conversation he had with Peter Reggardo in which he asked why the tyres that were left for him to work on were not being deflated prior to removal from the vehicles.
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) His evidence was that Reggardo told him it was to make his job 1 easier and quicker for him, an inflated tyre being easier to manoeuvre on the ground. Mr Reggardo denied this conversation.
Mr Jeppesen stated that it was not a practice at Korns to deflate tyres before rim removal from the vehicles as the tyres became too hard to handle when they were soft. He said that Mr Mann did advise him a couple of months before this incident to deflate to about 20 to 30 PSI but he did not have occasion to remove a tyre after that time.
He had decided that he would not follow that advice due to the difficulty in handling. He said Mr Mann did not mention any risk of explosion in relation to deflation.
Mr Reggardo surprised all in the Inquest when he revealed that he was aware of the issue of deflation prior to the incident, and had in fact instructed some of the truck drivers to always deflate tyres before removal of rims from vehicles.
He stated it only took five to 10 minutes to deflate the tyres and that the time issue was not critical from an operational point of view. He stated that he raised this warning in early 2005, having become aware of it in his previous position at another site in about November 2004.
He stated that he did not conduct inspections to ensure that the drivers were complying with his instruction and that he
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) could not be sure that he informed all of the drivers, but 1 felt that most of the bigfoot drivers would have been told, including the deceased. He stated that he had informed Mr McCarthy to deflate to 20 PSI, the same level as the tyres in the go rack.
He also indicated that he fed that information into the review of Korns SMS and went as far to say that he had informed the reviewers that he had been verbally telling the men to deflate tyres and that was already happening.
Shift supervisors reported that there was not any information given to them regarding deflation by Mr Reggardo or in their presence. Both Mr O'Dwyer and Mr Rix were surprised by the evidence of Mr Reggardo that he had made this information known, as they said they had not heard of that until it was said in Court.
Mr Reggardo's evidence in this regard flies in the face of the evidence from the supervisors, managers and workers at Korn, and must be treated as extremely suspect and self serving.
Very few of the witnesses were aware of the incident at Century Mine which took the life of Peter Marshall, in a situation where there was an explosive release of pressure from a tyre on a dump truck.
Of that incident related to earth moving machinery, the hazard was the same as the one in the present case. A safety alert
21032007 D.1 T3/BMN(ROK) M/T ROCK02/771 (Hennessy, Coroner) had been issued by the inspector following the incident. 1 Despite the evidence suggesting that safety alerts were at least placed on the crib room noticeboards and went to Korns, little attention seems to have been paid to this incident.
Mr O'Dwyer said he was aware of the incident but had no concern regarding it as it related to earth moving equipment which Korns were not involved with.
There does not seem to have been any appreciation of the application of that hazard to the vehicles Korn were operating.
The Rim: The rim involved in this matter was produced by Rimex in Canada in February 2001. Rimex supply heavy duty rims to the earthmoving industry with the mining industry making up most of the wholesale market. They do not sell rims directly in the retail market. There are about three rim manufacturers in the Australian market. The style of rim was MES-T and it is a five piece rim assembly.
21032007 T4/ZMO (ROK) M/T ROCK02/771 (Hennessy, Coroner) It's said to be quite different to rims regularly used in the 1 road transport industry in Queensland. It's likely that the rim was sold by the Perth branch of Rimex to Kenworth for fitting to vehicles during manufacture.
The rim was not sold directly to Korn. The manufacturer does not and is not easily able to keep track of the users of the rims. For instance, in this case the Kenworth vehicle was supplied at some stage to McKenzie River Bulk Haulage who later operated in Queensland and then to Korn's who were themselves unaware of the brand of rims on the vehicles they acquired second hand.
There was evidence from Mr Krajewski of Rimex that the life span of the rims under normal operating circumstances would be in the area of two years. Normal operating life was said to depend on the conditions of operation including the driving surface, turning circles, air pressure maintenance, the speed at which the vehicle is being driven, maintenance and cleaning of the rim, vehicles being talked up properly, studs and nuts being maintained in good condition and operating hours.
Coal haulage on mine sites was said to be a harsh application.
In harsh conditions, the life of the rim may be in the vicinity of six months and up to two years in good conditions.
They are covered by a warranty of 12 months. The warranty documents are the only documents speaking of longevity of the rims and this information is not available on the Rimex website.
21032007 T4/ZMO (ROK) M/T ROCK02/771 (Hennessy, Coroner) Most of the employees of Korn who gave evidence, even those with some previous experience of multi piece rims, were not aware of any separate safety issues relating to multi piece rims over single piece rims. They were not instructed in relation to any different handling techniques that they should adopt in relation to such rims or of the importance of deflation of tyres on the rims. The only risk of uncontrolled release of pressure they seemed to be aware of was in connection with the inflation of tyres after fitting.
Mr O'Dwyer gave evidence that Korn's had no system in place regarding procedures for rims and tyres. No rim register or monitoring of rims, no inspection or testing regime and no system for assessing competence of workers in maintenance issues. He said that he organised the purchase of new tyres and rims.
It seems, however, that there was a system of a sort in place in the Korn operations at Blackwater mine. A rim register was kept and some non-destructive testing was undertaken through Beaurepaires in Emerald on heavy earthmoving rims and some big foot rims of 24 inch diameter and above. On that site, Klinge and Company conducted an audit of all contractors in relation to tyres and rims on behalf of BMA.
As a result of that report, which is Exhibit 30, Korn's did action some of the recommendations and commenced some rim management strategies. Mr Rix maintained in evidence that the
21032007 T4/ZMO (ROK) M/T ROCK02/771 (Hennessy, Coroner) Klinge audit related only to earthmoving equipment but the 1 report clearly indicates this is not the case.
Further, some of Mr Rix's notations on the report would seem to support this proposition. Some of the issues noted by Mr Rix were not implemented. He was unsure why all of the recommendations were not implemented but thought that it was likely due to BMA not following the matters up with them.
Rimex maintain a website with open use to the public. Their website contains safety and general information regarding the products. This facility was available prior to the incident.
Exhibit 12, a video on rim maintenance, included information on complete deflation of tyres prior to working on the assembly, need for inspection for wear and replacement and the need for, amongst other tools, a pneumatic torque wrench to be used instead of a rattle gun to ensure accurate torque in fitting of the rim and tyre assembly to the vehicle.
The evidence disclosed that an important element of rim maintenance is record keeping. Such records should include having the available information accessible regarding the position of the rim identified by number on the vehicle and regular inspections per a certain amount of hours of use.
Non-destructive testing is far superior to visual inspection and allows minute cracks or faults to be detected at an early stage. Magnetic particle testing is a form of non-destructive testing and was described by Mr Krajewski as world's best
21032007 T4/ZMO (ROK) M/T ROCK02/771 (Hennessy, Coroner) practice in rim maintenance. The Australian Standard 4457 1 includes reference to such testing. There are apparently moves for the testing to be included in international standards.
Mr Reggardo, the person at Korn's responsible with Mr O'Dwyer for the decision to replace rims, was not aware of the availability of non-destructive testing on rim assemblies. He was also unaware of the need for regular inspection of rims.
There was no rim register, identification or marking of rims in service or records of the length of service of rims at Korn's. He stated that when new rims were supplied, they did not have any accompanying information, warranties or safety warnings.
Mr O'Dwyer stated further that Beaurepaires did not suggest that visual inspection of the rims was not sufficient and there was never a suggestion or recommendation regarding crack testing or preventative maintenance.
Mr Korn gave evidence that he had only been aware of crack testing in the context of earthmoving equipment. Mr O'Dwyer was generally aware of the availability of non-destructive or crack testing in relation to steel structures but said that it had never occurred to him to have a systematic inspection process including such testing for rims.
The approach was simply that when they wore out or were damaged, they were replaced. He had never investigated what
21032007 T4/ZMO (ROK) M/T ROCK02/771 (Hennessy, Coroner) rims were being used by the company and when replacement was 1 being arranged, he would either source rims from Beaurepaires or another company, depending on availability. There did not seem to be any preference for one brand over another.
Mr Krajewski gave evidence that the five piece rim costs about 900 to $1,000 per assembly. The cost of magnetic particle testing is approximately $325 per assembly including a service of the rim. Following the incident, Mr Brown, the SSE at the time, ordered all Korn rims to be tested. Of the 46 rims tested, 14 failed inspection; not all were Rimex rims. Since this incident, Rimex have increased the amount of safety information available including safety posters.
Mr Krajewski has also been involved in the development of a double gutter rim for use in this application which won a 2004 Australian Safety Award. The rim is designed so that it always stays on the hub and the tyre is able to be removed from the rim whilst the rim is still fitted to the vehicle. A tyre is not able to be removed from the safety assembly without being deflated.
Technical Analysis of the Rim. The rim was technically analysed by ETRS. Mr Paul Triton prepared a report dated the 25th of October 2005 which was tendered and he gave evidence at the inquest. Upon analysis of the rim by ETRS, areas of corrosion and pitting in the rim were identified which are consistent with the extended use of the rim. It was noted
21032007 T4/ZMO (ROK) M/T ROCK02/771 (Hennessy, Coroner) that there were multiple locations of cracking, with 1 separation occurring once the cracks joined up.
The area was heavily corroded on the surface of the cracks, indicating that the cracking was happening over an extended period of time. The ETRS report stated that the material used in the manufacture of the rims was appropriate for use. The rim had high residual stresses from manufacture and the failure began at the bottom of the lock ring grooved and was caused by high cycle low stress metal fatigue.
The failure appeared to be as a result of the use of the rim over an extended time, as opposed to ill use or overloading.
The crack appeared to occur over a period of time; weeks to months. There was evidence that the tyre on that wheel may have been last changed on the 6th of April 2005, at which time a visual inspection of the rim would have been carried out.
It was highly probable that the extended use of the rim in the harsh conditions beyond its expected life span would have contributed to the cracking of the rim.
Contractual Arrangement with Beaurepaires. Mr Rix gave evidence that he employed Beaurepaires to manage tyres and rims, inspect rims and provide technical assistance and advice on maintenance of tyres and rims. Korn's entered into an informal arrangement with Beaurepaires for the supply of tyres and the services of the tyre fitter. Mr Mann was the fitter on site at Foxleigh and worked there two days a week filling in the balance of the week at other Korn sites.
21032007 T4/ZMO (ROK) M/T ROCK02/771 (Hennessy, Coroner) The agreement with Beaurepaires was not reduced to a written document, other than for some references in the exchange of some brief correspondence as to the pricing structure for and the supply of tyres. There was no arrangement for any inspection of rims according to Mr O'Dwyer. Ironically, whilst Mr O'Dwyer was unaware that rims had a particular service life, he considered it Beaurepaires' responsibility to ensure that the service lives of the rims were not exceeded.
Mr Rix gave evidence that the understanding with Mr Backer of Beaurepaires was that he would visit each site once a month and conduct analysis on tyres and rims and speak to Korn staff regarding relevant matters and review the operations of the tyre fitter. He would then report back to Mr Rix on what he had found during site inspections but none of those reports or meetings were documented in any way.
Mr Rix said that on the 7th of October 2004 Mr Backer made presentations to Korn project managers and operators on tyre failure and maintenance. Mr Rix stated that Mr Backer often gave advise on rims and related matters. Mr Korn gave evidence that he considered Mr Backer to have good information on rims as he had assisted in having tightened reengineer rims for a particular application for Korns. He added, however, that he did not expect to receive advise from him regarding rim maintenance.
21032007 T4/ZMO (ROK) M/T ROCK02/771 (Hennessy, Coroner) Mr Backer had experience in the tyre industry since 1978. He 1 was not trained in tyre fitting but had knowledge of the manufacture of tyres. He had no experience or qualification in relation to rims. He said he did not give Korn the impressions that he had, but would have given them his thoughts on rims from a salesman's point of view.
He gave evidence as to his role in this way. As company representative he would check on stock on site, inspect tyres in use and scrap tyres, look at the haul roads, do some spot pressure checks on tyres in use, look at tyre life and make recommendations to O'Dwyer regarding tyre issues. He stated that he would deal with O'Dwyer in relation to all sites. His only correspondence was in relation to pricing issues.
He described the company's tyre fitter, Mr Mann, as quite competent. The branch manager was responsible for the tyre fitters and consequently, Mr Backer was not his supervisor.
Mr Backer would sometimes assist Mr Mann and while it was not his role to advise on safety issues if he saw any unsafe practices being used by Mr Mann he would have told him immediately. He was unaware of multi-piece rims and stated that deflation of tyres on a multi-piece rims assembly was not necessary in his experience, and further, he would not have considered it unsafe if he saw a wheel being removed without deflation.
The procedure was that Mr Mann would discard any rims which were cracked and Mr Backer did have discussions with Korns
21032007 T4/ZMO (ROK) M/T ROCK02/771 (Hennessy, Coroner) about patterns to rim wear as well as overall discussions but 1 did not specifically monitor rim wear. He said that he would discuss basic issues such as the effect the state of the haul road roads would have on tyres and particularly what pressure would be maintained in tyres in particular situations. He made one specific recommendation in regarding the use of wedge bands which information he had picked up from a competitor and passed on to Korns.
Safety and Health Management System: A mine is required to have a Safety and Health Management System and Principal Hazard Management Plan under the Coal Mining Safety and Health Act 1999. The legislative requirement for such a system to be developed lies with the operator of the mine and not on individual contractors.
When there is any change to the SMS the safety officer for the mining operator has a responsibility to make those changes know to all on site including contractors. A copy of the SMS is kept in the Foxleigh training room and crib rooms and on computer. Changes to such matters are discussed at pre-start meetings attended by Foxleigh staff but not usually the contractors. A copy of the reports were placed on the Korn noticeboard. As new SOPs were developed they were provided to Korn for inclusion in their copy of the SMS.
Foxleigh Mines safety and health management system was called the Foxleigh integrated management system or FIMS. The transport principal management plan was developed after a risk
21032007 T4/ZMO (ROK) M/T ROCK02/771 (Hennessy, Coroner) assessment was carried out across the Foxleigh site in 2001. 1 A standard work procedure was developed for the then transport contactor, McKenzie River Bulk Haulage in relation to tyre changing. No procedures in the plan referred specifically to Korn or required review when contractors changed. There was a provision for audits every two years.
Generally contractors coming on to site are required to either work under the SMS of the mine operator or to develop their own system or SOPs for tasks not included in the mine operator's SMS. Such material must be passed by the SSE of the mine as being of a similar standard to the mine operator or better.
The Foxleigh contractor management system requires the Foxleigh contract manager to provide all information relating to hazards on site, risk assessments and controls to the contractors. Mr Anthony gave evidence that a copy of the SOPs were provided to Korn for display in their area and that job safety observations and audits were only conducted on Korn workers to compare their work to the SOPs where they were operating similar equipment to Foxleigh.
Mr Smit, employed in the Foxleigh workshop, gave evidence that occasionally, usually when time permitted, a random inspection would be carried out on Korn's workshop in relation to basic safety standards. The safety culture in Korns was described by some of the employees as being good, others described a focus on production with safety second. At best, the safety
21032007 T4/ZMO (ROK) M/T ROCK02/771 (Hennessy, Coroner) arrangements such as meetings, assessments, and reviews of 1 procedures could be described as limited and ad hoc.
SOP reviews only occurred on wet days when the trucks could not haul. Even then the supervisors did not always attend those reviews. Mr O'Dwyer estimated there were about five to 10 wet shifts in a 12 month period commenting that not much rain was needed to pull the shift up.
21032007 D.1 T05/CDB(ROK) M/T ROCK02/771 (Hennessy, Coroner) Mr Jeppesen, a diesel fitter at Korn at the time of the 1 incident with 30 years experience, described the safety culture at Korns as "not brilliant." He said that there was often poor replacement of broken components on vehicles and electrical faults. He stated that the driver's toolbox meetings were held every couple of weeks to six weeks when they could be fitted in and were not regular.
Communication With Contractors: Mr Shane Donnollan was the contract manager for Foxleigh at the time of the incident. He liaised with Korn through Mr Reggardo in relation to haulage plans and arrangements. Those arrangements included where to haul the coal from and to, the stacking plan and hauling targets. The organisational chart for Foxleigh shows Mr Reggardo as reporting to Mr Herron of Foxleigh who reports to Mr Donnollan as contract manager.
Mr Donnollan described his obligation regarding the contract as relating to production issues only with overall contractual responsibilities sitting with the general manager. He did not consider that he had any role in overseeing Korn in relating to safety matters. Cap Coal used Mr Donnollan as a go between with Korn as did the Foxleigh safety department due to the operational liaison role Mr Donnollan undertook with Korn.
Following an incident on the Cap Coal German Creek site unrelated to this matter, Mr Richards, safety and health training manager for Foxleigh, requested Mr Donnollan follow up Korn requesting a review of the SMS and assessment of
21032007 D.1 T05/CDB(ROK) M/T ROCK02/771 (Hennessy, Coroner) employees on the SMS. He followed up that request with Mr 1 Reggardo and was informed that it was being done. He advised Donnollan that the employees had been assessed and the assessment signed off on and regular toolbox meetings were being held.
Mr Richards stated in evidence that in relation to safety issues he felt that he could approach the contractors in the same way as Foxleigh's employees and require rectification of the safety situation and training to avoid recurrence in the future. He stated that there was a contract of management plan in place to manage hazard space by contractors. The system to ensure competency of contractors included overview of the SMS, the extent that the SSE would approve the plan.
Standard Operating Procedure Number 38: Foxleigh SOP number 38 "Fit, Remove, Test, Maintain and Repair Tyres and Rims", the 2004 version, relates to the control of light vehicle tyres and wheels. Evidence from Foxleigh employees indicated that this SOP was not intended to apply to Korn vehicles which were of a different nature and used in a different application. In practice, Foxleigh vehicles in this category were usually maintained in Mackay and not on site.
The SOP for heavy mining vehicles was covered by the major mining contractor. When Foxleigh took over the mining operations in 2004 the inspectorate conducted an audit as part of a series conducted at all surface mines. The 2005 version of the SOP was expanded significantly to reflect this change
21032007 D.1 T05/CDB(ROK) M/T ROCK02/771 (Hennessy, Coroner) and incorporate the audit results. The 2005 version specified 1 the requirement to deflate tyres before removing rims including dual assemblies. It was accepted by Inspector Smith that SOP 38 was a competent document when completed.
There was some evidence that Foxleigh personnel discussed this issue with Korn management. Peter Reggardo denied any knowledge of the audit prior to this incident and could not recall being involved in any discussions with Foxleigh staff about the audit or the rewritten SOP 38. He denied being provided with a form in February 2005 relating to the audit which required him to enter information and return it to Foxleigh.
Once procedures were detailed but failed to include the need to deflate tyres before the removal of a rim or dual wheel assemblies. They had no SOP that related to the task that Mr Davis undertook relating to that type of rim. Korn was, at the time, in early 2005, reviewing it's safety management system. A draft procedure for the maintenance of tyres and rims dated 25th of May 2005 was a part of the draft SMS and included a requirement that all heavy vehicle tyres be inflated or deflated to a pressure of approximately 30 psi for demounting.
The procedure was in draft, had not been developed after consultation with a cross section of the workforce and had not been communicated with the workers or supervisors.
21032007 D.1 T05/CDB(ROK) M/T ROCK02/771 (Hennessy, Coroner) Inspector Smith gave evidence that the recommended deflation 1 would reduce the risk of uncontrolled energy but still exceeded the provisions of the Australian Standard 4457.
I'll move now to the Australian Standard 4457. In the opinion of Inspector Smith this standard relates to the wheel in the present case under the definitions even though the intention of the standard when drafted was for application to wheels used on earthmoving vehicles. It was said that the application of the standard was determined by size of the wheel and not the nature of the vehicle.
The standard relates to rims of a minimum diameter of 24 inches. The rim in question here was of 25 inch diameter. It was generally established on the evidence that big foot trucks are not considered to be heavy earthmoving equipment but are not light medium vehicles either.
In the coal mining haulage application the trucks certainly haul a significant volume of coal per load, a 270 ton estimate, on a par with some earthmoving machinery, 150 ton for loaded dump trucks. Similar vehicles used in the road transport industry are not subject to those loads.
Distinguishing the vehicle in the present case from AS 4457 would seem to be artificial in light of these facts.
The standard is currently under review. The revision is in an advanced stage and is likely to include the strengthening of the language relating to the need for tyre deflation. The
21032007 D.1 T05/CDB(ROK) M/T ROCK02/771 (Hennessy, Coroner) size of wheel that the standard will apply is still under 1 discussion but there is unlikely to be a change in focus from earthmoving off-road vehicles. If the standard does not apply to the vehicle in issue here then a deficiency in the standard has been established in my view.
Review of Korn Safety Management System and SOPs: A safety consultant was engaged by Korns to go over the SMS McKenzie Bulk Haulage had been operating under when Korns took over the Foxleigh contract. This review was necessary in order for Korns to commence work on the Foxleigh site. That safety consultant was followed by a safety officer for 12 months.
Around the time Korn took over the Foxleigh hauling Mr Richards became Foxleigh safety manager. Mr Richards' role was to manage safety on site on a day to day basis. When a new contractor came onto site the process was for them to go through a general induction, ascertain the type of work to be done, assess which competencies were needed, obtain evidence that the competencies had been obtained by the contracting staff, ensure that there was up-to-date drug and alcohol testing conducted, have them read the relevant SOPs and sign off on them, have the OCE conduct a mine familiarisation with them and introduce them to the persons they would be reporting to.
The contracting company would either adopt the mines SMS or introduce their own through a consultative process with the mining operator. Mr Richards had no knowledge of the haulage
21032007 D.1 T05/CDB(ROK) M/T ROCK02/771 (Hennessy, Coroner) contract with Korn's except to the extent that they were 1 responsible for having a SMS in place and approved by the SSC.
He asked Mr Reggardo to show him Korn's SMS and found it quite long in the tooth. In some places still referring to McKenzie River Bulk Haulage. He considered the SMS to be redundant.
He requested that a review of the SMS be undertaken in about July 2004 and gave evidence that Mr Reggardo agreed to do that. In the meantime Mr Richards had established a safety committee and conducted regular meetings that Mr Reggardo would attend. Mr Richards regarded Mr Reggardo as very safety conscious in attempting to attend to matters expeditiously.
Further there was difficulty with the idea of a contractor merely adopting the Foxleigh SMS. Some of the tasks undertook Foxleigh did not and consequently there was no SOP to govern it. For instance, SOP 38 particularly relate to the type of equipment used by Korns. In those areas of difference Korn's were still required to conduct consultative risk assessments and develop SOPs for those tasks or plant for checking and auditing against the mine operator's SMS.
After requesting the review of the SMS Mr Richards made inquires on a weekly basis as to the progress of the review.
He found that it was going fairly slowly. He was told by Mr Reggardo that they were getting on with it and had outsourced the work. Mr Richards passed these updates onto the SSC at the weekly meetings.
21032007 D.1 T05/CDB(ROK) M/T ROCK02/771 (Hennessy, Coroner) As the review was still not complete in August 2005, 13 months 1 later, it would seem that the follow-ups by Foxleigh were ineffective. They did eventually receive a draft review in late 2005. On a parallel plain, when Mr Rix joined Korns he wanted to ensure that the SMS of all projects were reasonably complete and he met all the project managers to ensure they had a copy of the SMS on site and they had SSC approval in each case.
He assumed that the SMS had been approved by Foxleigh when he arrived at the company as he felt sure that if it had not Korns would not be operating on this site. He knew that the SMS had been reviewed after Korns purchased McKenzie River Bulk Haulage in late 2002. In the end result Mr Rix was not happy with the SMSs across the board as he was having difficulty mapping the SMS on another site against that mining operator's system.
He implemented a review of the plans on all sites. He stated clearly this was his initiative and was not prompted by any request from Foxleighs. As Korns operated under differing SMSs on each site Mr Rix was looking to have a generic SMS that could be adapted to the needs of each site.
In September 2004 he engaged Mr McMillan. He did that as Mr McMillan was already conducting black coal competency training and to his knowledge as performing similar tasks for other companies. Mr Korn gave evidence that if he had know Mr
21032007 D.1 T05/CDB(ROK) M/T ROCK02/771 (Hennessy, Coroner) McMillan had not undertaken this sort of work before he would 1 not have allowed him to be engaged.
In late 2004 Korn engaged New Horizon Safety and Training from Rockhampton, Mr McMillan's company, to conduct a review of it's SMS. This arose from a desire at Korns to update and review the SMS. Mr McMillan, the principal of the firm, had worked as a plant operator. Later in 2000/2001 as a safety officer in the construction industry, and he held a Workplace Health and Safety Officer ticket.
After perusing the plan that Korns had in place Mr McMillan proposed that a new plan be drafted from scratch. He commenced with basic information that Korns were a contracting company carting coal. He used his own template for the plan and set up the format of the SOPs and started building them on the understanding that the risk assessments would follow from that document.
Mr McMillan did not maintain a file for the project and could not provide any background or other information on his work or instructions given to him. Mr McMillan did not appreciate any need for priority for the plan as he assumed that Korns were operating under Foxleigh's plan during the period of the drafting. He dealt with Mr Rix and occasionally, Mr O'Dwyer.
At the time of the inquest commencing the plan was not complete. Mr O'Dwyer's understanding was that it was a matter for Mr Rix to assess the draft of the reviewed documents and
21032007 D.1 T05/CDB(ROK) M/T ROCK02/771 (Hennessy, Coroner) approve them. Mr Rix approved the policy sections of the 1 document and stated Mr O'Dwyer was responsible for an overall read of the plan.
Mr O'Dwyer stated in evidence that he received some documents including SOPs from New Horizon from time to time. He attended a couple of meetings with New Horizons to review the drafts of the SMS and that he was liaising with Mr Rix on this issue. It came to light that he had, in fact, spent a couple of days in the Rockhampton office of New Horizons for the purpose of reading and reviewing the draft plan. He said that he did not have sufficient time to read most of the document and there was still a lot of information to be included in the draft. He did not tell McMillan or Rix that he had not reviewed the document in full. He told Mr Rix that the document was moving forward and was still being worked on.
Mr McMillan drafted the plan by having reference to plans from other companies, the Act and relevant Australian Standards.
He did not access data basis for technical assistance. He did not seek a copy of Foxleigh's plan or SOPs until after this incident. He stated that he did not access Foxleigh's information as Korn was involved with too many mines for their information to be of use to him. Mr McMillan was aware of that audits had been conducted on some of Korn's SOPs but was not aware and did not inquire as to the outcome of those audits.
15122006 D.1 T6/MEL(ROK) M/T ROCK02/771 (Hennessy, Coroner) The draft SMS 035, which had been provided to Korn's in draft 1 in about May 2005, addressed the issue of deflation of tyres prior to rim removal and if it had been in place and known to the workers this incident may have been avoided. Mr McMillan indicated that he thought he had obtained the provisions relating to deflation of tyres and non-destructive testing from the Australian standard. Mr O'Dwyer was unaware of those specific provisions in the draft plan.
Mr McMillan obtained a specimen of Mr Korn's signature with his consent and copied it on to documents so that he could organise the setup of the document. The signature at face value purported to be a signature of approval of the managing director of the company, whose document was that Mr McMillan stated there was no intent or approval attached to the signature. The document produced prior to the incident was only ever a discussion draft.
Various drafts of the document were dated, but due to the computer system Mr McMillan used, there could be no confidence in the dates shown on the documents. Drafts were not date tracked. The plan was for the draft SMS to be submitted to the mining operator at each site Korn's was contracting for - ah sorry - for approval by the various SSC's. In practice, that took place in the form of submitting draft documents to various sites prior to the risk assessments being conducted by a cross-section of the work force, undertaking particular tasks to which the SOPs related.
15122006 D.1 T6/MEL(ROK) M/T ROCK02/771 (Hennessy, Coroner) It seems to me that this was not what is envisaged in the 1 legislation. Regulation 10 of the Coal Mining Safety and Health Regulations lays down the requirements for the development of SOPs. In effect, that a standard operating procedure involves a risk assessment of a task by cross10 section of the workforce involved in that task, followed by a drafting of the procedure which would then be submitted for comment and approval, and once approved the workforce would be trained on that procedure.
The procedure adopted by Mr McMillan envisaged the risk assessment be carried out after the approval and principle stage, which would seem to be noncompliant with the legislation and particularly - and sorry, potentially result in an unsafe or impracticable procedure being approved.
Edit 2, revision 2 of the plan was handed out for review and comment to all of the mining operators Korn's were contracted to. Mr Korn indicated that it went to Curragh first, as they were about to start working on that site and then have the plan approved. Curragh did provide feedback on the plan. Mr McMillan described the plan as being savaged by them. Korn's received the draft plan in about May 2005.
Mr Rix gave evidence and it had been Mr O'Dwyer's responsibility to ensure the revised SMS translated into new systems and practises being put in place on site. Mr O'Dwyer confirmed receiving the final draft before the present incident. He agreed that he had responsibility for overall
15122006 D.1 T6/MEL(ROK) M/T ROCK02/771 (Hennessy, Coroner) implementation of the plan. He stated that he - he stated 1 that the draft was sent to Foxleigh safety officer into July 2005 to see if it was okay to be implemented or whether changes were needed. At that time Mr O'Dwyer was not aware of all of the contents of the document. He put that failure down to time constraints, being tied up on other things and something always coming up.
Further, Mr O'Dwyer was completely unaware, not having read the Act or regulations, that there was a necessity for the workforce to have been involved in the development of the SOPs and that it was inappropriate to supply Foxleigh with the plan in those circumstances. After the incident in question Foxleigh demanded that the SOP relating to tyres and rims be completed. Mr McMillan then assessed - accessed a copy of the Foxleigh SOP and completed the draft SOP within three days.
Mr Brown, the SSC, rejected a number of drafts and with comparison to the Foxleigh SOP required various changes before the approval was given. Mr McMillan stated that he was on a big learning curve and that he had not realised there would be so much in the preparation of the plan. He had not drafted a plan before this time. Mr McMillan stated that if he was engaged to prepare an SMS again, he would ensure that he obtained a scope of work, would diarise all discussions with the client, maintain a file, ensure the integrity of dates and drafts, and not obtain specimen signatures.
15122006 D.1 T6/MEL(ROK) M/T ROCK02/771 (Hennessy, Coroner) Improvements Since the Incident: Korn has instituted a system 1 of a noticeboard for general and safety inclination enabling workers to now see OCE's reports and safety information as it becomes available. Pre-start meetings are now more structured and more informative. Korn SOPs have been reviewed and rewritten, and the staff trained on them. Korn supervisors are encouraged to give written instructions to workers.
Korn's now managed rims by numbering them, maintaining a rim register and crack testing all rims every 12 months. Tyres are also deflated as a secondary safeguard.
Foxleigh has conducted a review of the whole SMS and SOPs, reviewed contract and management system and conduct regular audits of contractors, and pay particular attention to the standard of their SMS. They have checked all appointment letters in accordance with the legislation and all appointments have been renewed and competencies checked.
Principle Hazard Management Plan has been reviewed. Tyres and rims are subject of SOPs.
Findings: I can not be satisfied on the evidence that Mr Reggardo gave an instruction to the drivers regarding the need to deflate tyres before the removal of rims. It seems that no one, apart from Mr Mann, who was the only person trained in tyre fitting was aware of the risk of not deflating, despite extensive experience in many of the weaknesses. In hindsight, however, there were references to hazards in SOPs relating to other vehicles. The Marshall safety alert, given the risk is the same despite the size of the machinery and the draft Korn
15122006 D.1 T6/MEL(ROK) M/T ROCK02/771 (Hennessy, Coroner) SMS provision. Given that the lack of identification of the 1 hazard was so widespread hindsight should be used with caution.
Findings Required by Section 45.2: I am required to find, as far as possible, the medical cause of death, who the deceased person was, and when, where, and how he came by his death. I have already dealt with this last aspect of the matter, the manner and circumstances of the death. As a result of considering all of the information contained in the exhibits and the evidence given by the witnesses I make the following findings: Identity of the Deceased: The deceased was Shane William Davis who was born on the 10th of April 1976.
Place of Death: Davis died in transit from Foxleigh Mine near Middlemount in Central Queensland to medical evacuation.
Date of Death: Mr Davis died on the 7th of August 2005 aged 29 years.
Cause of Death: Mr Davis died as a result of injury sustained when he was struck by a tyre and rim assembly when attempting to remove them from a truck he was operating hauling coal.
The incident occurred primarily due to a failure in the rim and the resultant uncontrolled release of stored energy in the tyre on the adjoining rim in a dual assembly. There is no
15122006 D.1 T6/MEL(ROK) M/T ROCK02/771 (Hennessy, Coroner) evidence of contributing factors such as alcohol, drugs, or 1 impairment of the deceased.
Comments on Issues and Preventative Recommendations: Section 46 provides, in part, that a Coroner may comment on anything connected with a death that relates to ways to prevent deaths from happening in similar circumstances in the future. I'll deal firstly with the issues.
Expanding Coal Industry: Due to the rapid expansion in the coal mining sector in Queensland in recent years there are currently a large number of people without high level of familiarity with the industry working in it. Mr Brown stated that it is a significantly different industry now to that which was seen in the past. Mine operators have placed increased reliance on contractors to provide services on site.
Some contractors are large companies with mining experience but there are also those like Korns who have grown rapidly along side the expansion in the industry and are operating on numerous mine sites under a number of different mining operators.
It was submitted that the use of contractors is a commercial decision for mine operators. The issues that contractors bring to a mining enterprise are a fact of life in the current industry and need to be managed appropriately. One issue that was identified by Mr Korn was that there is a need for more lead in time for contractors coming on to site to commence contracts.
15122006 D.1 T6/MEL(ROK) M/T ROCK02/771 (Hennessy, Coroner) His evidence was that, at times, mining operators required contractors to start operations almost immediately. Time was needed for the contractor to properly attend to start up issues including inductions for staff, training on SOPs and SMS applicable on site. The development of new SOPs for tasks not formerly undertaken and not covered in the operator's SMSs and competency assessments.
Many processes of the mining operator need to be approached in a different way regarding contractors, including SMSs, communication and organisational structure issues, audits and competency assessments and the operator should be aware of those issues and plan accordingly. Mine operators need to ensure that great care is paid to the selection and control of contractors in order for the SSC to be in a position to ensure contractor compliance with the legislation.
One Safety and Health Management System on Site: A major factor in this matter was the absence of an SOP relating to a particular task undertaken by contractor workers. The SOP and the operator's SMS was related but applicable primarily to different machinery and was characterised by virtually all the witnesses as not strictly applicable to the Korn task.
The delay which was occasioned in the development of Korn's revised SMS allowed the situation to exist in which workers were inadvertently placing themselves at risk due to the lack of identification of the hazard of uncontrolled release of
15122006 D.1 T6/MEL(ROK) M/T ROCK02/771 (Hennessy, Coroner) stored energy from truck tyres. Mr Korn identified that it 1 would be more beneficial to contractors for there to be one SMS on site that all could operate under. SOPs in relation to contractors specific tasks could then be submitted to the SSC in the usual way for inclusion in the SMS.
Mr Korn envisaged that contractors operating on a number of sites would then be working under similar SMSs without the need to go to the time and the expense of attempting to develop their own SMS which would need to be varied from site to site according to the mining operator's requirements. The lack of potential duplication of systems which would be brought about by one system on site could assist in training for workers and competency assessments across site.
21032007 D.1 T7/BMN(ROK) M/T ROCK02/177 (Hennessy, Coroner) Further, given that the SSC is in the position with 1 legislative responsibility for the SMS on site, administration of one SMS may assist in the fulfilment of that obligation.
Recognised Standards: It has been suggested in submissions that a recognised standard be developed in relation to the procedures to be adopted for the, "Use of rubber tyred vehicles including tyre and rim safety, maintenance, inspection, record keeping and communication requirements." Recognised standards are a means of meeting safety obligations under the Coal Mining Safety and Health Act 1999, part 5 section 71 to 73. A recognised standard is a third tier safety management process under the legislation which effectively obviates the need for the use of risk analyst techniques to manage a particular hazard or reliance on a regulation as a prescription for performance of a task.
Such an approach could be seen to take the initiative and therefore flexibility away from the mine operator and SSE as to the appropriate approach to such activities on their site, when the mine operator should be in a position to meet the standards required by the Act.
Further, a recognised standard would be a concessity in fairly general terms in order to ensure widespread application.
Skills Of Organisations Conducting Safety Management System Production Or Review: In this matter the qualifications and
21032007 D.1 T7/BMN(ROK) M/T ROCK02/177 (Hennessy, Coroner) experience of the principal of the company undertaking the 1 review or redraft of Korns are of particular concern, given the importance of the undertaking.
Undoubtedly Mr McMillan undertook the task in an earnest way and he was the first to admit that it was a much more involved undertaking than he expected. Of particular concern was some the processes adopted including the development of draft SOPs without following the provisions of the legislation in that regard.
Further, the length of time for the redraft was not acceptable and poor communication and lack of appropriate review of the drafts as released compounded the problems. The draft SOP and the Korn SMS was overlooked by inattention to detail.
However, it seems quite clear that there was widespread lack of appreciation of the stored energy hazard in other than earthmoving vehicles.
Of course the SSE is the person with responsibility under the Act for the development of the SMS. A contractor engaging a third party without input from the SSE to perform that task tends to remove the immediate control of the process and progress of the development from the SSE.
It has been submitted that consideration should be given to a amendment of the Act and regulation for, "A system of accreditation, licensing, competencies or qualifications for persons providing independent advice or other services to the industry in relation to safety and health management issues."
21032007 D.1 T7/BMN(ROK) M/T ROCK02/177 (Hennessy, Coroner) Such a system does not fit within the current ethos of the 1 legislation and would certainly place significant impost on the resources of the Department which does not currently play a role such as would be envisaged by this suggestion.
The creation of competencies for persons fulfilling this role would achieve a similar objective within the current framework.
Contractor Management Issues: There were a number of specific issues in the present matter which contributed to operational communication difficulties. Whilst the personnel involved were competent that the communication between Foxleigh and Korn was working well, in hindsight there was room for improvement.
For instance, Mr Donnollan had no real awareness of the responsibilities of his position in relation to safety issues of the contractors. Further, neither Mr O'Dwyer nor Mr Reggardo had a copy of the contract with Foxleigh and were not aware of the provisions of that contract, making it very difficult for them to properly attend to Korn's obligations under the contract.
Mr Anthony commented that there was a need for improved and more regular communication with contractors regarding safety matters and that integration and monitoring of the contractor systems with the mines and vice versa needed improvement with supervision by competent personnel supported by a regular
21032007 D.1 T7/BMN(ROK) M/T ROCK02/177 (Hennessy, Coroner) audit regime. Use of external auditors would provide another 1 control in the audit regime to ensure effectiveness.
Results of audits need to be properly documented and followed through to resolution of outstanding issues within a reasonable timeframe. This was an issue in the present case.
Most mining operators already foster positive safety culture and a proactive approach to safety issues on site to prevent or reduce normalisation of risk within their own business.
Such an approach should also be adopted in relation to supervision of contractor activities.
Contractors need to be made aware of all changes to SOPs in the mine operators SMS as soon as possible after the changes.
The use of electronic flags for reviewed or revised SOPs where the SMS is accessed in an electronic format would ensure that the changes are immediately identifiable.
Of course the mining operator should ensure that contractors have electronic access to the SMS if that is the system they are operating under.
Transport Culture In A Mining Setting: With the increasing use of contractors in the mining sector acknowledgement of the inclusion of cultures from other industries in the mining setting is needed. The mining industry culture which is heavily safety focused needs to be identified and discussed
21032007 D.1 T7/BMN(ROK) M/T ROCK02/177 (Hennessy, Coroner) with contractors on site to ensure all workers adopt that 1 culture.
The evidence presented by Inspector Smith indicated that employees of Korn including Mr Davis, did not hold national mining competencies MNCG10131A, remove fit and adjust wheels, or MNCG1032A, remove, repair and refit tyres and tubes.
Mr Davis' experience in the road transport industry was considered to be extensive, but Inspector Smith commented on the need for competencies to be achieved to ensure a broad base of knowledge and information in all workers particularly to ensure mining specific issues and points of variance with other applications.
Inductions: There is a need to ensure that inductions, whether they are generic, site specific, or contractor based fit the audience to which they are being delivered so that the information being imparted is able to be retained by the worker.
A large volume of information is given to workers in a short period of time and many of the drivers in this matter indicated that they encountered difficulties with understanding and retaining the information from inductions.
In many cases one would presume that the workers being inducted may not have ever undertaken education further to
21032007 D.1 T7/BMN(ROK) M/T ROCK02/177 (Hennessy, Coroner) school, TAFE or trade qualifications and perhaps even that, 1 not for many years.
In that situation it may be that the induction needs to be framed in a different way than it would be to those comfortable with a tertiary education method of learning.
Further, workers should be given the opportunity to retain a copy of the SOPs or other procedures of information contained in the induction. Access to a central copy within their organisation may be of limited use depending on the time a worker is able to access the information and the internal culture relating to continual revision of knowledge.
Supervisors Competencies: It was evident from the evidence of the shift supervisors that they were experienced people in the field having come up through the ranks, they had obtained the required supervisory competencies but it did not seem from the evidence that anyone had turned their mind to the supervisory capabilities of those men and whether they had the skill set needed to undertake the position.
As it turns out, their knowledge in that regard could have been enhanced. Mr Clive Davis felt that the supervisors needed to have competency in risk assessment, hazard identification and controlling risks.
21032007 D.1 T7/BMN(ROK) M/T ROCK02/177 (Hennessy, Coroner) He also indicated that the supervisors should be trained and 1 assessed as competent against all of the SOPs and be able to train and assess workers in the SOPs.
He was of the opinion that there was insufficient assistance to him regarding the training and supervision of staff and that on the mine site supervision played a much more important role than he had thought it would.
It would seem that the skills sought would be covered in the G2, implement and imply the risk management process and G3, establish the mine risk assessment and control system and qualifications.
Whether this is necessary would be a matter for the advisory counsels. It may be that training and practical supervision skills would suffice.
Training: The hazard of uncontrolled release of stored energy in all tyres but particularly with a fixed multi-piece rims, irrespective of size or application, now having been identified, it will all be for nought unless all persons who are exposed to that hazard are made aware of it and trained in the appropriate safety measures to reduce or eliminate the risk.
Earthmoving Versus Transport Vehicles In Australian Standard 4457: Clarification of the application of the Australian Standard to this type of vehicle needs to be made. If the
21032007 D.1 T7/BMN(ROK) M/T ROCK02/177 (Hennessy, Coroner) standard does not apply then consideration should be given to 1 the development of the standard for haulage vehicles in this application, including a requirement to perform non-destructive testing on all multi-piece rims.
Controls: The premier controls addressing the risk from the hazard in this instance would be hard controls such as engineering the problem out. For instance, a possible hard barrier could be designed in, for example, the user is unable to release nuts without prior deflation. A containment mechanism to prevent projectiles from multi-piece rims coming into contact with people in the event of a release of stored energy might be a secondary engineering control.
Self controls could also be introduced such as secondary safeguards including improved training and supervision, promotion of good safety ethics in the business, committing to maintaining standards under and Act and regulations covering the task being performed.
Truck Manufacture: Truck manufacturers should give consideration to reviewing designs of their products for the application they are being used in to ensure components are appropriate for the usage and the machinery is fit for purpose.
Section 446 of the Act requires a supplier of plant who becomes aware of a hazard relating to the plant to be responsible to inform users of the nature of the hazard.
21032007 D.1 T7/BMN(ROK) M/T ROCK02/177 (Hennessy, Coroner) Some companies may not be aware of this requirement. The inspector should attempt to inform manufacturers and suppliers of this provision, perhaps through the issuing of a guidance note.
Warnings: In this case all those using the rim were unaware of the need for any different action to that adopted in relation to the removal of wheels from trucks.
If warnings were able to appear on the rim and/or be affixed to the vehicle, instructing users to completely deflate tyres before the removal of the rim from the vehicle, users could be alerted to the hazard.
Manufacturers including more safety information on websites and encouraging users to access such information would help increase awareness of the hazard, including safety information in the literature provided to users in the normal course of commence, for example, invoices would also assist.
Rim Maintenance: Cracking of rims does occur over a period of time. Some cracking can be detected upon visual inspection in related stages. It was discovered on examination of the rim that the critical cause of the release of pressure in the wheel assembly at the time of the incident was a crack in the rim assembly which had occurred over a reasonable period of time.
21032007 D.1 T08/CDB(ROK) M/T ROCK02/772 (Hennessy, Coroner) The absence of tracking the age and hours of use of the rim, a 1 regular non-distractive testing regime, and the reliance on visual inspection only all contributed to the present incident. It was quite clear that with proper coordination of information it was within Korns capabilities to properly monitor rim life and maintenance at the time of the incident given their procedures at Blackwater Mine.
Mr Chuden advised inspection regimes should be introduced for rims. Every time one changes the tyre inspect the rim and all parts of it thoroughly. Adopt an non-distractive regime, adjust inspections as considered appropriate given the application the rim is being used in. Users should also take advice from the manufacturer. Manufacturers of rims should consider affixing serial numbers on manufacture or markings to the rims to assist users to track rims in their business.
Access to the Site for Emergency Services: David Low of the Queensland Ambulance Services gave evidence that most mine sites have large gate signs and warning signs situated on the roadside at the entrance to the lease. He commented that if the ambulance had been attending Foxleigh at night the signage was such that the ambulance officers may have missed the entrance to the site. He advised that reflective signs a couple of hundred metres prior to the turnoff to the site was needed.
Sergeant Blain indicated that police would not have any concerns about increased signage impacting on road safety. Mr 68 60
21032007 D.1 T08/CDB(ROK) M/T ROCK02/772 (Hennessy, Coroner) Brown advised that the flight time of one hour from either 1 Rockhampton or Mackay for the rescue helicopter services can be of critical importance in serious incidents on mine sites in Central Queensland. Whilst not directly related to this matter, given the seriousness of the injuries suffered by Mr Davis, consideration should be given to the location of a helicopter rescue service in the Bowen Basin.
Notification of Next of Kin: It was of great concern to me that Mr Davis's partner, his next of kin, was informed of the death of her partner by a third party and not an official from the mine. In this particular matter Mr Clive Davis, the uncle of the deceased, who was the shift supervisor on the day in question made the contact. It seems that given Mr Davis was employed by a contractor his details were retained at the head office of the contractor company and not at the mine.
Of course it is generally the case that the mine manager or a very senior person in the mining company would make contact with the next of kin to inform them of the death of their loved one. Local police also usually play a role in this regard. Coordination of this issue is imperative in order to avoid adding to the distress of a family of a deceased person.
Recommendations: Whilst progress has been made regarding some of the issues which arise from this matter there are some areas requiring further attention. Many of the issues have industry wide application and for that reason I will proceed to make recommendations to the industry as a whole with a view 69 60
21032007 D.1 T08/CDB(ROK) M/T ROCK02/772 (Hennessy, Coroner) to reducing the likelihood of a similar occurrence in the 1 future.
Following the inquest representatives of the mines inspectorate, CFMEU, Foxleigh Mine representatives, and other interested parties, met and formulated submissions to the Coroner regarding recommendations which would operate to mitigate against similar occurrences in the future. To my mind this is the best possible advice a Coroner could receive given that it's drawn from significant experience and practical knowledge of the business involved, representatives of the workforce and the regulator. I sincerely thank those parties involved in the discussion and preparation of the resultant submissions. I trust that the industry will acknowledge the strength of the recommendations and the experience and expertise which lies behind them.
I have carefully considered all of the submissions. I consider that many of the submissions have merit and that most of the proposals made are supported by the evidence in this matter. Of course I am bound by the strictures of the provisions of The Coroner's Act in relation to matters connected to this death. I also acknowledge the submissions from which I have drawn information included in these findings.
I recommend that: 70 60
21032007 D.1 T08/CDB(ROK) M/T ROCK02/772 (Hennessy, Coroner)
The coal mine operators critically review the 1 effectiveness and implementation of their mine safety and health management system as they are obligated to do under section 41(f) of the Coal Mine Safety and Health Act 1999. It is recommended that particular attention be paid to how the mine system controls the activities of contractors and ensures they are carrying out their task in a safe manner.
2.1 That senior site executives of coal mines be required to have a competency such as MNCG1107(a) establish and maintain the mine occupational health and safety management system.
2.2 The safety and health advisory counsel consider the range of competencies required for supervisors and persons charged with the development of safety and health management systems.
2.3 All SSEs of coal mines develop a system to ensure that all supervisors are able to and are effectively applying risk management competencies in the performance of their duties.
21032007 D.1 T08/CDB(ROK) M/T ROCK02/772 (Hennessy, Coroner) of the hazardous aspect of, or defect in the equipment 1 that the supplier has supplied to a coal mine.
That a body such as the Resources and Infrastructure Skills Counsel develop a suite of competencies for persons providing advice on safety and health management systems in the coal mining industry.
5.1 The earthmoving committee of Standards Australia review the suitability of retaining rim sizes as a limiting factor in determining the applicability of Australian Standard 4457.
5.2 Standards Australia should review all associated tyre and rim standards and, if necessary, introduce a standard in similar terms to AS5547 which applies to all multi-piece rims irrespective of size and industry application.
6.2 This position should be included in accordance with section 55 of the Coal Mining Safety and Health Act 1999 72 60
21032007 D.1 T08/CDB(ROK) M/T ROCK02/772 (Hennessy, Coroner) in the management structure of the mine as a senior 1 position and the role and responsibilities of the position should be specified.
7.2 That the protocol between the Inspectorate and the Queensland Police Service be reviewed to ensure effective and timely communications between the organisations during the investigation.
And
73 60
21032007 D.1 T08/CDB(ROK) M/T ROCK02/772 (Hennessy, Coroner) Are there any submissions? 1 MR TATE: No, your Honour. May I say that the recommendations that your Honour has made, I am certain, will keep the regulator, the union, and the industry busy for a long period of time and perhaps, in so far as it's appropriate for me to say so, Shane hasn't past away in vane. There will be great safety advances from your Honour's recommendations. 10 Your Honour, there is one short procedural matter that I should deal with and that is Inspector Smith currently holds the rim and components as well the Rimex aid on behalf of your Honour. I'd simply ask that an order be made that he continue to do so until such time as the Court otherwise orders.
CORONER: Thank you, I'll make that order. Ms Baker was there anything that you wanted to say? Mr Dalliston, no submissions? 20 MR DALLISTON: No, thank you, your Honour.
CORONER: Mr Horneman-Wren?
MR HORNEMAN-WREN: No, thank you, your Honour.
CORONER: Mr De Plater? Mr Griffin? I'd like to thank everybody that's been involved.
A 50-year-old RAAF Flight Sergeant with Major Depressive Disorder and anxiety died from a self-inflicted gunshot wound to the head after police responded to a domestic disturbance. He had received appropriate, evidence-b…
Two workers, Ashley Morris (34) and Humberto Leite (55), were fatally crushed by collapsing concrete wall panels on 6 October 2016 while installing foul water settling tanks at Eagle Farm Racecourse. The work system desi…
Jordan Robert Crocker, a 25-year-old qualified electrician, was fatally electrocuted in a roof space while diagnosing a U4 fault code on a Daikin ducted air conditioner system. The circuit supplying the air conditioner w…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries are for educational purposes only and must not be treated as legal documents. Report an inaccuracy.