Davis, Shane William

Contributing factors

• Failure to deflate tyres before wheel removal
• Inadequate safety operating procedures for multi-piece rim handling
• Lack of training on hazards of stored energy in tyres
• Rim fatigue cracking from extended use beyond expected lifespan
• Absence of non-destructive testing regime for rim maintenance
• Inadequate contractor safety management system
• Delayed development of comprehensive safety management system
• Poor communication between mine operator and contractor regarding safety updates
• Reliance on visual inspection only for rim defects
• Lack of awareness of stored energy hazard among drivers and supervisors

Coroner's recommendations

1. Coal mine operators critically review the effectiveness and implementation of their mine safety and health management system with particular attention to contractor control
2. Senior site executives of coal mines be required to have competency MNCG1107(a) for occupational health and safety management systems
3. Safety and health advisory counsel consider competencies required for supervisors and persons developing safety and health management systems
4. All senior site executives develop systems to ensure supervisors effectively apply risk management competencies
5. Amend section 44(6) of Coal Mining Safety and Health Act 1999 to require manufacturers and suppliers inform the regulator of hazardous aspects or defects
6. A body such as Resources and Infrastructure Skills Counsel develop competencies for persons providing advice on safety and health management systems in coal mining
7. Standards Australia review suitability of retaining rim sizes as limiting factor in applicability of Australian Standard 4457
8. Standards Australia review all associated tyre and rim standards and introduce a standard applying to all multi-piece rims irrespective of size and industry application
9. All coal mines employing contractors create a senior position for control of contractors with duties including monitoring and safety management system implementation
10. Include contractor control position in mine management structure as senior position with specified role and responsibilities
11. All coal mines establish a system to ensure next of kin can be expeditiously contacted and informed during serious or fatal accidents
12. Establish protocols for next of kin notification with details of contact, who should inform them, and how to keep them informed
13. Review protocol between Inspectorate and Queensland Police Service for effective and timely communications during investigations
14. Inspectorate liaise with other departments, industry and professional bodies to disseminate safety message regarding uncontrolled release of stored energy from tyres and training needs