MacDonald, Wayne
Deceased
Wayne Robert MacDonald
Demographics
53y, male
Date of death
2010-12-18
Finding date
2014-09-09
Cause of death
Multiple injuries due to blast injury from catastrophic tyre failure (zipper failure) releasing a percussive shockwave of compressed air
AI-generated summary
Wayne MacDonald, a 53-year-old truck driver, died from catastrophic tyre failure when a burst truck tyre released a powerful air blast while he lay on the ground between dual wheels during a tyre change at a coal mine. The failed tyre (marked 'slow leak/OK') suffered a 'zipper failure' due to previous under-inflation and inadequate integrity testing. Clinical examination revealed blast injuries (cerebral contusions, pulmonary collapse, pulmonary lacerations, fractured ribs) with no physical trauma. Key preventable factors included: positioning in confined space close to tyre, inadequate pre-service tyre pressure testing, confusion regarding correct tyre pressure specifications, lack of remote pressure monitoring, and poor communication of tyre operating parameters. Critical improvements needed include requiring 20-minute pressure integrity testing at 120% operational pressure before use, implementing remote tyre pressure monitoring systems, ensuring equipment allows operators to remain distant from tyres during maintenance, embossing specific operating parameters on tyre sidewalls, and establishing Australian standards for large-diameter tyres.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Tyre operated outside design parameters due to previous under-inflation history
- Inadequate pre-service integrity testing of tyre
- Operator positioned in confined space between dual wheels in close proximity to tyre failure source
- Confusion regarding correct tyre operating pressure specification (125 psi marked on sidewall versus required 130-140 psi minimum)
- Dispensation for special operating parameters communicated only via PowerPoint presentation rather than formal written communication
- Lack of remote tyre pressure monitoring system
- Use of manual jack requiring operator to enter confined space
- No visible warning signs of impending zipper failure
Coroner's recommendations
- Management of mine sites and contractors review all tyre management practices to ensure tyres operated within design parameters; review within three months then annually
- Any jack used by operator must have handle of sufficient length to allow safe use without operator being in, under, or in close proximity to vehicle's tyres
- Industry investigate and implement within two years remote or wireless tyre pressure sensing equipment to allow operators to monitor pressures from cabin
- Until remote tyre pressure sensing equipment introduced, discontinue practice of tyre tapping and use accurate, calibrated pressure gauges when checking inflation
- Investigate, create, and implement within two years an Australian Standard for up to 24 inch diameter truck tyres, or if not created within two years, implement Recognised Standard under Part 5 of Coal Mining Safety and Health Act 1999 within one year
- Whenever tyre supplier grants dispensation from designed operating parameters, provide and receive written acknowledgement of formal information package clearly specifying approved operating conditions
- When tyre supplier grants dispensation used by mine site operator, incorporate specific details into written training and operating procedures
- When tyre manufacturer grants dispensation, permanently emboss variations on tyre sidewall in non-removable legible method throughout serviceable life
- Every tyre (new or repaired) undergo integrity testing by inflation in suitable cage to 120% of recommended minimum cold operational pressure for 20 minutes, then reduce to recommended minimum operating pressure before fitting for use
Full text
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —