DODUNSKI, Gareth Leo
Deceased
Gareth Leo Dodunski
Demographics
21y, male
Coroner
MacKenzie
Date of death
2013-06-23
Finding date
2023-08-31
Cause of death
Gross cerebral trauma due to multiple comminuted depressed fractures of skull due to trauma from rig machinery (ST-80 Iron Roughneck tool)
AI-generated summary
Gareth Dodunski, a 21-year-old floorhand, was fatally struck by an ST-80 Iron Roughneck tool on 23 June 2013 while setting a dog collar on a drill string. The driller, Jacob Kilby, activated the ST-80 in a moment of inadvertence while Gareth was positioned in the danger zone between the tool and the drill string. Kilby attempted to stop the equipment but pressed the wrong button on the confusing HMI screen. Systemic failures contributed: inadequate engineering controls (no emergency stop on the driller's screen, reliance on E-Stop as routine isolation rather than emergency measure), insufficient administrative controls (work instructions failed to address ST-80 hazards), and minimal formal training on emergency procedures despite a similar incident two months prior on Rig 188. The crew was competent but relatively inexperienced. While Kilby's momentary error was immediate cause, comprehensive safety system deficiencies enabled the fatality. Substantial improvements have since been implemented including dual push-to-run controls, isolation valves, audible/visual alarms, and formalised job safety analyses.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Contributing factors
- Driller activated ST-80 in moment of inadvertence while worker positioned in danger zone
- Confusing HMI control screens without emergency stop function
- Driller pressed wrong button in attempt to stop equipment
- Lack of formal training on emergency procedures for ST-80
- E-Stop used as routine isolation measure rather than emergency control
- No physical barriers to prevent worker access to danger zone
- No audible or visual warning alarms before ST-80 activation
- Informal practice of E-Stop isolation not formalised in safety documents
- Work instructions and JSA documents did not adequately address ST-80 hazards
- Similar incident on Rig 188 two months prior (28 April 2013) not adequately addressed
- Crew included relatively inexperienced workers still completing competency training
- No formal Job Safety Analysis conducted on day of incident due to time constraints
- Inadequate engineering controls in equipment design and installation
- Inadequate isolation mechanisms for ST-80 energy source
Coroner's recommendations
- Queensland Government amend P&G Act to include provisions similar to sections 139-141 of Coal Mining Safety and Health Act 1999, authorising investigators of serious incidents to require relevant persons to give information or answer questions where such answers might tend to incriminate them, with statutory assurance such information cannot be used against them in proceedings
- Queensland Government rationalise and harmonise various Work Health and Safety Acts (Coal Mining Safety and Health Act 1999, Petroleum and Gas (Production and Safety) Act, Work Health and Safety Act 2001, Mining and Quarrying Safety and Health Act 1999) into one unified body of legislation to address inconsistent offence descriptions, time limitations for prosecutions, appeal avenues, and definitions of breaches
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. Some material may have been redacted or restricted by court order or privacy requirements. 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 — report an inaccuracy here.