Coronial Investigation Case Number: 3314-01

Incident Circumstances
Mr F was a 33 year old man employed through an employment agency as a road roller operator on a construction site. Mr F did not have a motor vehicle licence nor a mobile plant operator’s licence.

On the second day after commencing the new job, Mr F was operating a vibrating road roller in reverse on the construction site and was seen to fall through the open cabin operator’s doorway. Mr F hit the earthen track and lay motionless until the (smooth) drum of the road roller passed over him causing crushing injuries, resulting in his death.

Coronial Investigation
Two days prior, Mr F commenced his first day of work at the construction site and was given an induction lasting approximately 30 minutes. He was not asked by his immediate supervisor or the site supervisor what his qualifications were or whether he held a motor vehicle licence. His allocated task at that time was to operate a vibrating road roller while towing a pad foot compactor.

At the end of Mr F’s second day in this job, he commented to his partner that:

“Something had gone wrong with the new roller and he had been required to drive a really old roller that you had to steer with your feet. He said that he had never driven anything like it, that he had told his boss this and that he had managed to drive it but it was very difficult and tiring”
The Coroner found on the day of the incident, Mr F was operating the vibrating road roller in reverse to roll an area of the construction site. During this operation, Mr F lost control of the vehicle, resulting in a jack-knife. The Coroner found that although the road roller was fitted with rear vision mirrors, it was unclear whether Mr F would have been able to see the pad foot roller in the mirrors.

The Coroner found that it was:

“more probable than not that he was standing and turning to his rear to observe the position of the pad foot roller as he struggled to regain control of his vehicle. In these circumstances and while unfamiliar with his working environment and the unusual motion of the vehicle, he fell through the door to the ground below from which position he was unable to move before he was struck by the jack-knifing roller.”

Finding & Recommendations
The Coroner found that there were several factors that may have contributed to this incident, they included:

• Inappropriate equipment coupling of the pad foot roller to the Cat CS 563D vibrating compactor;
• Inappropriate instruction of the operator to use a rope attached to an operational lever to control the pad foot roller;
• Non use of available operator restraint (seat belt);
• Possibility that the area was uneven and that the road roller ran over a ledge, causing (Mr F) to fall;
• Lack of adequate training & supervision; and
• Lack of job safety analysis, hazard identification and risk management.

Recommendations
The Coroner made three recommendations in this finding:

• The manufacturer of the vibrating roller should make clear in its’ Operation and Maintenance Manual its’ position in reference to the attachment of related heavy machinery.
• (Mr F’s) employer should undertake a risk management appraisal in respect of each earthmoving operation and instruct its employees appropriately.
• (Mr F’s) employer should ensure that all supervisory staff are qualified to provide operators employed in earthmoving works with the appropriate level of induction training. Such training should include both verbal and written instruction as well as ongoing on-the-job instruction. Managers also have an ongoing responsibility to supervise the work of heavy machinery operators. The fact that (Mr F) lost control of his rig to the extent that he was not able to prevent a jack-knife situation from occurring is strongly suggestive of a systems failure in regard to both training and supervision.