Short, James Leon

Contributing factors

• Driver had limited visibility when reversing due to trailer configuration; Mr Short was obscured by approximately 900mm from driver's mirror view
• Inadequate audible warning device: squawker fitted to truck only (not trailer) and was suppressed by trailer configuration, providing virtually no warning to person standing at rear of vehicle in site noise conditions
• Lack of designated spotter during reversing manoeuvre
• Failure to implement and enforce workplace system of work separating pedestrians from reversing trucks
• Inadequate worker induction on vehicle movement hazards and parking procedures
• Inconsistent enforcement of parking procedures; only 90% of drivers complied
• No safe zones or pedestrian-only areas defined at facility
• No line markings or identifying markers for parking bays or walkways
• Company switched from traditional beeper alarms to quieter squawker alarms for tunnel night work, compromising daytime effectiveness at facility
• Lack of direct communication between driver and other workers regarding reversing procedure

Coroner's recommendations

1. Forward findings to relevant industry organisations and unions as reminder of dangers of reversing large vehicles without appropriate precautions
2. Forward findings to SVSEG for consideration of amending Australian Design Rules to require reversing lights on all trailers
3. Forward findings to SVSEG for consideration of requiring all vehicles (including trailers) over a particular size or used in a particular industry to have some form of audible reverse warning alarm appropriate for the operating environment
4. Recommend that WH&S in consultation with the Department consult with relevant industry manufacturers and representatives to conduct analysis on whether smart alarms (using universal beeping noise with adaptive volume) represent a cost-effective solution for work sites
5. Forward findings to CVIAQ and TIC suggesting enquiries with members about implementation of smart alarms
6. Recommend that WH&S liaise with relevant industry organisations, associations and unions to encourage them to publish Transport and Storage Industry Sector Standing Committee Guidelines and Plant Code of Practice to enable ready member access