Coroner's Finding: COPPINS Trevor Wayne
Deceased
Trevor Wayne Coppins
Demographics
41y, male
Date of death
1998-02-25
Finding date
2000-08-04
Cause of death
closed chest injuries (ruptured hemi-diaphragm with displacement of abdominal contents)
AI-generated summary
Trevor Coppins, a 41-year-old plant operator, died from closed chest injuries sustained when a road roller he was operating failed to brake while reversing down a steep hill and overturned. Investigation revealed the brake booster diaphragm had ruptured, rendering the braking system non-functional. The gearbox also had chronic wear affecting gear engagement. Clinical lessons include the importance of prompt emergency response—trauma team intervention was appropriate but futile given the severity of injuries. The preventable aspects relate to machinery maintenance: inadequate post-repair testing, failure to promptly remove faulty equipment from service, and absence of fail-safe braking systems on heavy equipment. Better maintenance protocols, employee training on reporting procedures, and mandatory fail-safe braking systems could have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
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
- 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
- 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
- Boral Asphalt should improve its systems for providing safety information to employees, including contract employees, with documented receipt verification
- Boral Asphalt should ensure that all repairs to machinery are checked and tested thoroughly before return to active service
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