Coroner's Finding: Marshall, Eric Craig
Deceased
Eric Craig Marshall
Demographics
19y, male
Date of death
2014-10-02
Finding date
2020-11-05
Cause of death
Chest and abdominal injuries sustained when a forklift rolled over and trapped him underneath
AI-generated summary
A 19-year-old farm worker with intellectual disability died when a forklift he was operating rolled over on a gravel laneway, trapping him beneath the roll cage. Mr. Marshall had received informal training in August 2014 and was told to operate the forklift only under supervision, wear a seatbelt, and use designated areas. On the day of death, he operated the forklift unsupervised without a seatbelt, drove it at excessive speed with swerving movements, attempted a sharp right-hand turn, and lost control. The primary cause was inappropriate driving by an inexperienced operator. Key preventable factors included: the farm manager's failure to formally communicate supervisory arrangements to all employees before his extended absence, inadequate documentation of the scope of authorised work, and the employee's known habit of not wearing a seatbelt which was not adequately enforced. The employers pleaded guilty to failing to ensure proper licensing/supervision, though this breach was not directly causative of death. Better formalization of supervision protocols, documented safe work procedures, and stronger seatbelt enforcement could potentially have prevented this tragedy.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Inexperienced operator driving forklift at excessive speed
- Operator swerving forklift across gravel laneway
- Sharp right-hand turn executed by operator
- Operator not wearing seatbelt despite instruction and repeated reminders
- Operator working unsupervised contrary to training instructions
- Operator performing unauthorised task (moving tractor tyre) outside designated work areas
- Inadequate formalization of supervisory arrangements during farm manager's absence
- Absence of formal meeting with all employees to communicate chain of command during manager's absence
- Presence of unauthorized family members on property, influencing operator behaviour
- Forklift rear-wheel steering on uneven gravel surface with momentum
Full text
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