Coroner's Finding: COPPINS Trevor Wayne

Contributing factors

• brake booster diaphragm rupture with loss of vacuum function
• gearbox jumping out of gear due to worn engagement dogs on third gear
• inadequate post-repair testing of gearbox repair
• failure to immediately remove faulty equipment from service after second fault occurrence
• absence of fail-safe or back-up braking system
• steep terrain unsuitable for operation without functioning brakes
• inadequate communication of safety procedures to contracted workers

Coroner's recommendations

1. The Minister of Transport should consider compulsory requirements for all heavy vehicles, earth-moving and road-building machinery to be fitted with fail-safe or back-up braking systems
2. Boral Asphalt should provide further training of employees, particularly supervisory staff, to ensure understanding of the importance of utilising maintenance reporting systems when machinery faults are detected
3. Boral Asphalt should improve its systems for providing safety information to employees, including contract employees, with documented receipt verification
4. Boral Asphalt should ensure that all repairs to machinery are checked and tested thoroughly before return to active service