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This resulted from the roller, for whatever reason, bumping out of gear and then freewheeling down a sloping driveway.

I’ve skipped a lot of the technical factors in this case and focused on a few items.

The coroner observed:

·     Prior experience of the workers meant they relied on each others’ competencies and experience

·     No formal assessment of risk was undertaken for this task – indeed, the business owner relied on expertise of the operators and subsequently, a formal risk assessment “seemed an entirely novel suggestion”

·     The business owner believed so much in relying on the expertise of his crew that he “found it hard to articulate a need to assess put into place protective measures”

·     However, this perspective “relied on everyone else to have the same inbuilt appreciation of risks and he assumed that others would in fact be as skilled and careful as he considered himself to be”

·     When asked whether there’s standard operating procedures or safety activities prior to work, or even things like a toolbox, the owner said “Not really, because they’re all trained. They know what they’re doing”

·     The braking and gear system had a problematic design. An emergency brake was the only braking mechanism on the roller (and more used for parking), besides hydrostatic operation of the machine itself when in gear. Being in gear would counter freewheeling

·     The roller came out of gear during operation, falling into neutral, while the operator was traversing the slope, resulting in no hydrostatic counterforce to freewheeling

·     Most people were also confused about how the roller braking system operated – including technical witnesses who maintained the roller

·     The roller was fitted by the OEM with a padlock to secure the gearing in high/low range, but this was removed by the business owner. Rough terrain could cause the gear to fall into neutral, thereby resulting in no hydrostatic counterforce

·     The “potential for disaster” with this machine’s lack of braking due to falling out of gear wasn’t apparent when the machine was operated on relatively flat ground. But due to the driveway slope, “the potential for danger was tragically transformed from a risk, into a moving machine incapable of being stopped in its implacable course”

This example reminds me a little of the Buncefield oil storage accident. A tank had a high-level switch to shut off flow if the tank was overfilled. The switch needed a padlock to keep its check lever in the working position, but the supplier didn’t communicate the criticality of the lock to the installer, maintainers, or operators. The lock therefore wasn’t fitted.

People didn’t know that they didn’t know.

Coroner’s Court Qld. Inquest into the death of John Turnbull. COR 659/04(5)

Report link: https://www.courts.qld.gov.au/__data/assets/pdf_file/0007/86668/cif-turnbull-j-20070313.pdf

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