Adam Douglas Forster, a 34-year-old sales and marketing manager at a small mineral processing company, died from a torn aorta sustained in a crushing accident involving an unguarded rotating ball mill. Despite not being employed to work with the machinery, he had unrestricted and unsupervised access to the mill room. While sweeping spillage alone, he became ensnared by protruding bolts on the rotating cylinder and was dragged underneath. The exact mechanism of entrapment could not be determined. The coroner identified inadequate workplace health and safety measures in very small businesses as a systemic issue, with no guards, barriers, or restricted access to dangerous machinery. Key clinical findings included a trace level of THC that had no adverse effect. The death was not preventable as an individual clinical event but highlighted systemic workplace safety failures in small business operations lacking oversight.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
Unrestricted and unsupervised access to operating ball mill
Absence of guards, barriers or apparatus restricting access to machinery
Unguarded rotating machinery with protruding bolts
Inadequate workplace health and safety measures in small business
Lack of operator training or safety briefing for employee with operational area access
Coroner's recommendations
Copy of findings to be forwarded to Attorney-General and Minister for Justice
Copy of findings to be forwarded to Chief Executive, Workplace Health and Safety Queensland
Policy makers and advisors of WHSQ to consider circumstances and determine what else may reasonably be done to educate very small business operators to foster a culture of workplace health and safety in their operations
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