Turnbull, John

Contributing factors

• Brake system severely de-adjusted and non-functional
• Safety padlock not engaged on gear range lever, allowing unintended gear changes
• Steep driveway slope (12 degrees) exceeded safe operating conditions for the roller design
• Lack of formal site risk assessment and safety briefing
• No site supervisor or coordination of work activities
• Informal volunteer arrangement with no clear safety responsibilities
• Reliance on assumed competence without verification or supervision
• Inherent design weakness: roller primarily designed for flat surfaces with inadequate braking for slopes
• Hydraulic system design: application of non-functional brake disengages hydraulics, eliminating gear holding mechanism

Coroner's recommendations

1. Refer to relevant Minister issues regarding responsibility for safety where independent contractors are involved, highlighting gaps in current legislative scheme
2. Support and continue proactive Workplace Health and Safety efforts to assist small workplaces understand importance of assessing risk and establishing safe work practices
3. Commend to legislature a system requiring certification that transferred plant is fit for purpose and safe to operate, similar to motor vehicle roadworthiness requirements
4. Review and standardise mechanisms for operation of emergency brakes across plant, particularly addressing variation in design, and refer to Australian standards if necessary
5. Increase public profile of safety and preventative work performed by Workplace Health and Safety through media publication of information
6. Consider legislative review to establish ongoing competence requirements for plant operators, distinct from initial certificate requirements
7. Evaluate by Workplace Health and Safety whether safe operational practices for rollers on sloping sites should be reviewed and clarified, with consideration of independent expert review and industry education