Coroner's Finding: Jones, Maxwell
Deceased
Maxwell Jones
Demographics
85y, male
Date of death
2022-03-21
Finding date
2024-07-23
Cause of death
head and neck injuries sustained when operating a bulldozer that rolled down a gully
AI-generated summary
An 85-year-old experienced heavy machinery operator died from head and neck injuries sustained when a Komatsu bulldozer he was operating rolled approximately 80 metres down a gully while reversing near the soft edge of a freshly constructed track on steep terrain (24-48 degrees gradient). The dozer was attempting to dislodge a large boulder obstructing the track. Clinical lessons include: workplace fatalities in older workers require rigorous safety protocols regardless of experience; the employer (the deceased's son) failed to implement a Safe Work Method Statement despite high-risk construction work; no seat belt or properly secured helmet were available; a potential pre-existing transmission defect preventing neutral engagement may have contributed but could not be definitively established. The employer's reliance on the worker's experience without documented safety systems, risk assessments, or work instructions fell short of legal obligations. Age-related deterioration of faculties may have affected judgement, though this could not be definitively proven.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- operator error - reversing dozer too close to soft edge of recently formed track
- steep terrain (24-48 degree gradient)
- inadequate soil strength at edge of track (>4.6m from inner cut)
- large obstructing boulder requiring removal
- possible pre-existing transmission defect preventing neutral disengagement
- lack of seat belt
- helmet not properly secured or not worn
- age-related potential deterioration of faculties
- failure to implement Safe Work Method Statement
- failure to maintain dozer logbook and service schedule
- lack of safety instructions or risk assessment discussion
Further listening
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