McGuire, Paul Thomas
Deceased
Paul Thomas McGuire
Demographics
male
Date of death
2014-05-06
Finding date
2020-05-22
Cause of death
Asphyxia, caused by the inhalation of severely oxygen-depleted air
AI-generated summary
Paul McGuire, an experienced mine electrician, died from asphyxiation after opening a partially sealed hatch door to a GOAF (worked-out coal area) containing severely oxygen-depleted air. The critical failure was the mine's grossly deficient record-keeping system: job cards contained outdated sensor location information that was never updated despite multiple workers noting corrections. A sensor relocation in January 2014 was never reflected in the job card generation system. McGuire's card directed him to an incorrect location where he encountered an inadequately sealed hatch with no warning signs. The hatch was secured by only one bolt and lacked barrier tape or other physical deterrents. Systemic failures included: inadequate checking of completed job cards, failure to update the source system, absence of warning signage on the dangerous door, and insufficient physical barriers. The coroner found the mine's record-keeping was the most significant contributing factor. Recommendations included developing hatch seal design guidelines, improving signage and access controls, and allowing workers to request accompaniment by ventilation officers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Failure to maintain accurate and up-to-date job card information regarding sensor locations
- Inadequate checking of completed job cards at end of shift
- Failure to update mine's source system for job card generation despite known sensor relocations
- Lack of warning signs or markings on hatch seal door
- Inadequate physical barriers (tape or fencing) preventing access to sealed hatch
- Hatch seal secured by only one bolt rather than full permanent sealing
- Poor lighting in the sealed area except for worker's headlamp
- Absence of signage indicating GOAF dangers and 'no entry' warning
Coroner's recommendations
- Department should establish a guideline (guidance note) regarding appropriate design standards for hatch seals, particularly for interim versus final seals, recognising that mine operators must assess individual circumstances and cannot abrogate their duty to workers
- Mine operators should prepare risk assessments for preventing ingress to GOAF areas during sealing operations, with consequential regulation refinements
- Hatch seals should include minimum design requirements: padlocked with key retained by ventilation officers, clearly marked with warnings about dangerous GOAF gases and prohibition of entry, and physical barriers (temporary fencing and/or 'No Road' tape) to prevent access
- Coal workers should be permitted to request accompaniment by a ventilation officer or deputy when working in return air areas where dangerous gases are concentrated, rather than making this mandatory
- Widely promote and communicate acceptable design standards for hatch seals to all mines
- Improve signage and warning systems for sealed areas containing irrespirable atmospheres
- Implement more robust procedures for checking and updating job cards at the end of shifts to ensure source system information remains current
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Source and disclaimer
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