On 26 May 2000, Mr Michael Morris received fatal injuries while working on night shift at Oaky No 1 Mine. The incident occurred at 28 cut-through Main Gate 19 when Mr Morris was trapped by a roof fall at 3.40 am.
1. The reviewers endorse the recommendations of inspector Caffery's report, and of the manager's recommendations implemented since the event.
2. Mines should review Strata Control Action Response Plans to ensure they provide a reliable method of determining if trigger levels have been exceeded.
3. Mines should ensure that personnel who are exposed to strata hazards are competent to identify and respond to changing conditions in accordance with pre-defined trigger levels.
4. Mines should ensure that trigger levels in the Strata Control Action Response Plan are adequately resourced in the event of an uncontrolled roof fall. The response time should consider the need to recover people entrapped in roof falls.
5. Risk management techniques should be used to determine the level of strata support required and appropriate monitoring in relation to mine design - which includes when mining adjacent to and/or parallel to major geological structures.
6. The findings of this investigation and inquiry should be placed on the DME incident database.
7. All risks assessment data and core data used to develop the safety management plans and associated procedures should be retained at the mine and used in reviews of the plans until it is no longer current, including a system to report and record relevant information pertaining to the strata each shift as mining progresses for the use in future mine plan decision making.