Non-inquest findings into the death of Pedro Miguel Ventura Enes

Contributing factors

• Rock lodged in dual tyres of heavy vehicle
• Inadequate inspection of dual tyres for debris before highway operation
• Tyre deflection and pressure changes from rain and acceleration dislodging rock
• Insufficient wheel arch guard design to prevent rock ejection
• High-velocity impact with inadequate windscreen structural integrity after initial impact
• Lack of legislative requirement for pre-trip dual tyre inspections on heavy vehicles

Coroner's recommendations

1. Form an intersectoral working group between NHVR, Department of Infrastructure/Transport/Regional Development/Communications/Sports and the Arts, and industry stakeholders to address rock ejection risk mitigation
2. Develop design improvements to wheel arch guards on earthmoving and forestry trucks to reduce probability of rock ejection from dual axles
3. Consider legislative requirements for heavy vehicle operators to conduct pre-trip inspections of dual tyres for lodged objects/rocks
4. Produce safety alerts and educational materials by NHVR regarding the risk of rocks becoming stuck between dual tyres
5. Mandate dash cameras (front, side, and rear) on all heavy vehicles with tamper-proof recording to improve accountability and evidence collection
6. Review and potentially strengthen windscreen design standards for laminated glass to better withstand penetration after initial impact
7. Assess industry codes of practice regarding dual tyre inspections, particularly on quarry and forestry operations, and consider broader legislative application
8. Develop risk mitigation strategies for construction and industrial sites to prevent rocks entering vehicle tyres before heavy vehicles enter public carriageways
9. Undertake research into design improvements applicable to high-suspension earthmoving/forestry vehicles that operate off-road
10. Consider occupational health and safety regulatory improvements to address site-specific hazard management