An investigation into how Mr Green came to be pinned revaled that the had moved the truck forward through the open gate and exited to close the gate. On closing the gate, Mr Green was standing at the back of the truck when it moved backward on slightly sloping ground and pinned him to the gate.
Mechanical and other inspections and testing of the truck revealed, amongst other things, ineffective park and service brake system.
Mr Green died due to a severe crush injury to the chest.
Recommendations
The Mines Inspectorate identified a greater need to ensure those responsible for safety on sites, Site Senior Executives, understand their statutory obligations and how to satisfy them in a practical sense. It was recommended that teh legislatve requirements be considered about requiring a legislation exam for Site Senior Executives.
A further recommendation was that teh Inspectorate advance and promotes the development and implementation of effective Safety and Health Management Systems for exploration activities.
The Inspectorate also responded with a statewide "Brake Blitz" in the form of a comprhensive audit of maintenance systems, aided with a hand held infra-red brake assessment tool which gies and immediate assessment of brake capability.