Inquest into the Death of Wayne ROSS

Contributing factors

• ambiguous supervisor instructions regarding task requirements
• deceased's misinterpretation of instructions
• inadequate risk assessment - operator assessed high-risk task as low-risk
• removal of bollard safety barriers without clear authorisation
• poor visibility in the drive due to dust from ventilation fan
• slight left-hand bend in the drive creating optical illusion about stope edge
• flat floor of stope making edge difficult to identify
• missing bolts on loader seat reducing restraint effectiveness
• operator unfamiliarity with CMS survey procedures from top level
• supervisor not present during the task execution
• reliance on lower-level operator risk assessments without quality control

Coroner's recommendations

1. Mine operators should manage the hazard of open holes by designing, constructing and locating physical hard barriers to prevent equipment from accessing the edge of open holes
2. Hard barriers should be used in conjunction with lower-level access control systems such as signage, demarcation and lockable barriers controlled by persons in authority
3. Formal, team-based risk assessments should be required where manned equipment is required to work near open holes
4. There should be no reliance solely on lower-level assessments made by operators
5. The assessment process should consider the use of alternative technology or techniques that remove the need for an operator to go near an open hole
6. Ongoing reinforcement in the use of lower-level risk assessment tools to ensure they are being used correctly