Blee, Jason George Elliott

Contributing factors

• unexpected breakdown of continuous miner altering normal work sequence
• narrow heading width (4.8 metres) constraining safe positioning of personnel
• shuttle car positioned inappropriately in heading prior to incident
• lack of clear extraction procedures for persons trapped by machinery
• soft administrative control (no-go zones) inadequate to prevent incident
• absence of hard physical barriers between pedestrians and mobile equipment
• low-speed manoeuvrability limitations of shuttle car not suited to fine directional control
• inadequate emergency response training for crush syndrome management
• lack of proximity detection systems on shuttle cars

Coroner's recommendations

1. Department to resolve outstanding issue of notification to next-of-kin with Queensland Police Service; develop protocol for fatality notifications with priority treatment; coal mine operators to adopt guiding principles for next-of-kin notification including maintenance of registers and trained notification staff
2. Minister to consider amendment of Coal Mining Safety and Health Act to provide for tripartite investigations involving employer, Department and ISHR into serious accidents and fatal incidents, with privilege protection for investigation materials
3. All coal mines to include in Alcohol and Other Drug Policies requirement for all workers involved in fatal incidents or serious bodily injury to be tested; results provided to Department and QPS; mining inspectorate manual and QPS procedures to be updated accordingly
4. Underground coal mines to review pedestrian-machinery interaction arrangements and revise No Go and Restricted Zones following risk assessment; pictorial representations to be displayed in crib rooms; training to be provided to workers
5. Coal mining operations to equip underground districts with airbags of sufficient capacity to move heaviest equipment; conduct risk assessment for trauma types; ensure personnel trained in trauma care and crush injury management; QMRS to develop training for machinery extrication
6. All coal mining operations to urgently audit and if necessary develop management of change standards
7. Department to move quickly with manufacturers to develop, test and approve proximity detection devices for pedestrian detection on shuttle cars
8. Department to ensure any uncertainty in legislation regarding single safety and health management system at coal mines be removed
9. Working party comprising Department, coal mine operators, workers, union representatives and manufacturers to review and discuss shuttle car design to improve ergonomic and safety factors
10. Manufacturers and stakeholder groups to investigate whether regulatory bodies are unnecessarily prohibiting or delaying machinery design modifications
11. Department to liaise with emergency service providers to establish ongoing familiarisation program for mining operations; mining companies to assist implementation
12. Coal mining industry to adopt system providing workers with copy of competencies, tickets and authorisations on departure; documents to be placed on record at subsequent operations
13. Memorandum of Understanding to be established between Queensland Mines Inspectorate and Queensland Police Service incorporating forensic science facilities and assistance for mining deaths
14. Department to review and reissue Safety Alert MDA 148/06 in light of this incident
15. Minister to consider amendment to require coal mine operators to submit Safety and Health Management System electronically to District Inspector annually with updates as requested
16. Standards Review Committee to thoroughly review place change mining system and establish best practice guidelines and Recognised Standard
17. Department to make SIMTARS simulation available as training tool
18. In all industrial deaths, particularly mining deaths, autopsy to be conducted by Forensic Pathologist including full internal and external examination, photographs, x-rays and other tests as warranted to fully understand circumstances of death