‘Grossly deficient’: CQ mine death findings revealed
A CORONER has found critical failures in record keeping at a Central Queensland underground mine directly contributed to Paul McGuire's death.
The father of two and experienced electrician was completing the routine task of calibrating gas sensors at Anglo's Grasstree mine when he was wrongly directed to a goaf area and died within seconds after inhaling toxic air.
Today Central Coroner David O'Connell, in releasing his findings into the May 6, 2014 fatality, referred former Grasstree outbye electrical co-ordinator Anthony Johns to the Department of Natural Resources Mining and Energy's chief executive for further investigation and possible action.
"I have no hesitation in saying, and I find, that the mine's record keeping, particularly the updating or acting upon received information which required change, was grossly deficient," Mr O'Connell said.
Barely one month before the 34 year old's death another electrician, Dean Archer, was tasked a similar job at the same location and noted a "very clear" handwritten correction that the sensor was no longer there.
The gas sensor had been relocated in January 2014, but the system was never updated. As a result, Mr McGuire was given a job card with inaccurate information.
"I am convinced beyond any doubt that Mr McGuire was simply following that information printed on his job card which told (where) the sensor was," Mr O'Connell said.
"The evidence was that at the end of Mr Archer's shift his job card should have been checked by a supervisor and the information he gave should have been checked by a supervisor and the information updated in the system.
"What is abundantly clear is that the poor checking or failure of adequate checking of the completed job cards … with inaction to update the system, was the head of where the process broke down and directly led to Mr McGuire's death."
A coronial inquest heard unchallenged evidence that the outbye electrical co-ordinator should have checked the completed job card and updated the system.
But the court heard job cards were reviewed by "merely looking at the front page" rather than the relevant details contained within.
Mr McGuire's body was found partly inside a hatch to the partly sealed goaf area that was held shut with only one nut and bolt.
"What is apparent … there were no warning signs or markings on the door to indicate the danger which lay beyond it, which danger was unable to be seen, heard or felt," Mr O'Connell said.
"I am left perplexed as to why such a dangerous location could not have simple warning signs attached on the face of the stopping man door and then on the sealed hatch."
In 2016 Anglo American was fined $137,000 over Mr McGuire's death and a conviction was not recorded after the Commissioner for Mine Safety and Health accepted a plea deal.
Mr O'Connell noted a letter to the Commissioner from Anglo's lawyers "said to be persuasive" in the decision to drop three of the four charges linked to the death had "perplexed" him.
The letter highlighted the risks of prosecution without detailing any deficiency in the prosecution case, a possible adverse costs order and the appropriate use of court and prosecution time.
"Some may even take the view that if the defence cannot point to any particular deficiency in the evidence then perhaps there is no deficiency at all," Mr O'Connell said.
"I only cover these matters because it highlights to me that there are benefits in having a specialist prosecutor deal with the court aspects of prosecution, with input from the Mines Commissioner as to mining practices."
Since Mr McGuire's death, hatch seal design has changed to a padlock and key system as well as warning sign installation.
Mr O'Connell said while he could recommend DNRME establish a guideline for an appropriate hatch design, it was up to each mine "under the law" to take the appropriate steps to protect coalmine workers".
"There should be widely promoted … as to what are appropriate, or acceptable, minimum design requirements for a hatch seal which should include those things identified in the changes made by Grasstree mine," he said.