Non-inquest findings into the death of Pedro Miguel Ventura Enes
Deceased
Pedro Miguel Ventura Enes
Demographics
54y, male
Date of death
2025-02-05
Finding date
2026-02-24
Cause of death
Blunt force head injury due to hit by rock while driving
AI-generated summary
A 54-year-old Portuguese tourist driving a rental car on the Bruce Highway was struck by a rock that penetrated the windscreen while overtaking a heavy vehicle. The rock, approximately 190mm x 160mm, had become lodged between dual tyres on an earthmoving truck and was ejected at high velocity during acceleration, causing catastrophic traumatic brain injury with unsurvivable injuries including complex fractures, intracranial haemorrhages, and vascular dissections. The patient died three days later. This case highlights a rare but lethal hazard involving debris ejection from heavy vehicle dual tyres. Key preventive measures identified include: mandatory pre-trip inspections of dual tyres for wedged rocks; improved wheel arch guard design to reduce ejection; mandatory dash cameras on heavy vehicles for accountability; and coordinated industry-wide risk mitigation strategies involving vehicle design standards, occupational safety protocols, and construction site preparation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
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
- 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
- Develop design improvements to wheel arch guards on earthmoving and forestry trucks to reduce probability of rock ejection from dual axles
- Consider legislative requirements for heavy vehicle operators to conduct pre-trip inspections of dual tyres for lodged objects/rocks
- Produce safety alerts and educational materials by NHVR regarding the risk of rocks becoming stuck between dual tyres
- Mandate dash cameras (front, side, and rear) on all heavy vehicles with tamper-proof recording to improve accountability and evidence collection
- Review and potentially strengthen windscreen design standards for laminated glass to better withstand penetration after initial impact
- Assess industry codes of practice regarding dual tyre inspections, particularly on quarry and forestry operations, and consider broader legislative application
- Develop risk mitigation strategies for construction and industrial sites to prevent rocks entering vehicle tyres before heavy vehicles enter public carriageways
- Undertake research into design improvements applicable to high-suspension earthmoving/forestry vehicles that operate off-road
- Consider occupational health and safety regulatory improvements to address site-specific hazard management
Full text
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