Inquest into the death of Blaine ROZS
Deceased
Blaine Rozs
Demographics
19y, male
Date of death
2014-12-01
Finding date
2016-12-13
Cause of death
Traumatic asphyxia
AI-generated summary
Blaine Rozs, 19, died from traumatic asphyxia after falling from a turf harvester while reversing. He was struck and crushed underneath the machine. Clinical lessons include: (1) traumatic asphyxia causes death within minutes through chest compression preventing ventilation; (2) crush injuries may rapidly become unsurvivable before emergency services arrive; (3) dispatcher protocols for crush entrapment need review to balance patient safety with scene safety—the decision not to lift the machinery early, while following standard protocol, may have been suboptimal given the victim's likely rapid demise; (4) in crush injuries, removing weight entirely (not partially) might theoretically help if done safely and immediately, but the risks of sudden decompression, uncontrolled bleeding, and rescuer injury must be weighed; (5) workplace safety systems must go beyond initial training to include ongoing reinforcement, compliance monitoring, and adherence to manufacturer instructions, even when established practices differ.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Blaine riding on rear platform of harvester during reverse motion
- Rear platform not locked when raised, creating instability
- Operator reversed without confirming stacker was in safe position
- Inadequate ongoing safety training and supervision at Turfco
- Work practices at Turfco deviated from harvester manufacturer's manual
- Blaine reportedly lifting rear platform while harvester was moving
- No mirrors or reversing alarm on harvester to improve operator visibility
Coroner's recommendations
- NSW Ambulance Service to conduct a review of protocols and procedures for persons trapped under heavy equipment, with view to improving patient outcomes prior to arrival of emergency personnel
- Suppliers of turf harvesters should consider provision of mirrors/devices allowing larger field of vision to rear and reversing obstruction alarm prior to sale
- Currently owned/operated turf harvesters should consider retrofitting mirrors/devices for rear vision and reversing alarm where risk of person being struck exists
- Turf harvesting businesses must implement system of work: operator remains in control during operation; reverse only when absolutely necessary; stackers leave harvester and move to safe visible position; operator does not reverse until confirming stackers are in safe location; operator monitors path during reverse and keeps stackers in sight; operator stops when alarm sounds to check path is clear; workers trained in system
- Turf harvesting businesses to regularly monitor work through supervision and consultation to ensure system is being used and effective
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