MAGISTRATES COURT of TASMANIA CORONIAL DIVISIONIN THE MATTER OF THECORONERS ACT 1995ANDIN THE MATTER OF AN INQUESTTOUCHING THE DEATH OFLARRY PAUL KNIGHTSUMMARY OF FINDINGS / CONCLUSIONS of Coroner Rod Chandler following an inquest held in Launceston on 22 July to 25 September and 11 November 2008.26 February 2009 SUMMARY OF FINDINGS/CONCLUSIONS1.A BRIEF FACTUAL CHRONOLGY1.1.On 25 April 2006 Mr Knight was working underground in the Beaconsfield goldmine on level 925. His work colleagues were Mr Todd Russell and Mr Brant Webb. Together they were erecting a mesh wall above a bund of waste rock. For that task Mr Knight was operating a telehandler which was fitted with an open metal cage. Mr Russell and Mr Webb were both working from the cage. Mr Knight collected tools and materials for them when required. 1.2.At 9.23 pm a local magnitude 2.3 seismic event occurred at the Beaconsfield Mine. On level 925 it caused several falls of ground. The largest, comprising about 800 tonnes, engulfed the telehandler and entrapped Mr Russell and Mr Webb. Mr Knight was buried in a separate fall of ground which had occurred immediately to the rear of the telehandler. It is estimated that this smaller fall of ground contained 120 tonnes of rock. 1.3.The 2.3 seismic event was not a natural phenomenon but rather was induced by the mining activities being undertaken at the mine. 1.4.It is apparent that since 2003 Beaconsfield Gold (BG) had been aware that seismic activity was being generated by mining, particularly as it descended to lower levels. This led to BG, during 2003 and 2004 seeking consulting advice upon seismic activity, its effect upon its mining operation and its management.1.5.I am satisfied that by late 2004 it was known by BG that because of the fragmented nature of the rock mass there was a risk of rock falls due to shake down and hence a need for it to have in place strategies to manage the risk including suitable ground support. 1.6.On 9 October 2005 a 350 tonne fall of ground occurred on Level 925. It involved a local magnitude 0.8 seismic event and had followed a production blast. On 26 October there was a local magnitude 2.1 seismic event which occurred well beyond any production blasting. It caused major falls of ground upon both levels 915 and 925. 1.7.BG's response to the 26 October fall of ground was to cease mining and to initiate a risk management strategy. That strategy included seeking the advice of independent consultants. 1.8.Sometime in January 2006 BG took the decision to resume mining in the 940 level stoping block. That block included levels 915 and 925. This decision was taken on the basis that:"There had been an upgrading of ground support in areas identified by an audit,"The ground support system would continue to be based upon the compressive arch,"That initially mining would retreat west from the H/W shear and east from the offset fault, "That otherwise the mining sequencing method would change from the modified Avoca method to a checkerboard system. 1.9.The fall of ground on Anzac Day which caused Mr Knight's death led to the immediate closure of the mine and an investigation of its cause. 1.10.Mining at Beaconsfield resumed in 2007 after a case for safety which had been commissioned by BG was approved by WST. It was a principal recommendation of the case for safety that mining in those areas of the mine affected by seismicity only proceed by the utilisation of footwall drives. This mining method eliminates the need for workers to work in the ore drives during ore extraction and thus eliminates the risk of a recurrence of the Anzac Day tragedy.1.11.It is accepted by all stakeholders that the current method of ore extraction represents "best practice." This makes it unnecessary for me to make any further comment or recommendation upon the mine's present mining practices. 2.ISSUES ARISING2.1.The Cause of the Anzac Day Event2.1.1.I find that the Anzac Day rockfalls on level 925 were the result of seismic shakedown following the 2.3 seismic event. I further find that the seismic event was generated by a slip on an unmined section of the Tasmania shear in the hanging wall of the mine workings, [ie. on the C-shear]. This slip was located perhaps as near as 10 to 20 metres from where Mr Knight and his colleagues were working. 2.1.2.The 2.3 event was induced by mining activity at the mine, primarily in the 940 block which caused an unclamping of the structures within the reef enabling them to slip. 2.1.3.I am satisfied that by Anzac Day 2006 mining activity within the 940 block had caused the reef rocks, because of their friable nature, to degrade. This allowed the rapid propagation of the depth of failure within the pillar on 925 level thereby decreasing the anchorage capacity of the friction bolts within the ground support system. In this state the ground support system was unable to resist the very high straining effects of the 2.3 event and thus failed. 2.1.4.I am satisfied that BG could not have reasonably predicted that the 2.3 magnitude seismic event would occur on Anzac Day. I am also satisfied that BG could not have reasonably predicted that the C-shear would be the source location of that event. However, it is my opinion that neither of these matters is of critical importance in terms of worker safety at the mine. 2.1.5.Of greater importance in my opinion is whether BG was managing its mine in a manner which adequately allowed for the real likelihood that it could on any day, including Anzac Day 2006, experience a seismic event potentially as large as 2.5 in magnitude. Critical to this issue was the suitability and sufficieny of the ground support system, particularly having regard to the known fragmented nature of the rockmass. 2.2.The Ground Support Regime.2.2.1.The compressive arch was the underlying foundation for BG's ground support regime. As at Anzac Day 2006 the arch was maintained on level 925 with a combination of 1.8m and 2.4m splitsets at 1.5m spacing with straps and mesh plus 2.4m Posimix threadbars spaced 1.5m apart in rows. This ground support was inspected and approved by Mr Turner when he undertook an audit on 28 and 29 March 2006. 2.2.2.Of all the consultants who proffered an opinion upon the suitability of the compressive arch only Mr Turner was firmly of the view that it was suited to the ground conditions at Beaconsfield although from his evidence it may be inferred that Dr Mikula was also supportive of it. Of the others Dr Sharrock had serious concerns about it, Dr Fuller dismissed it and Professor Kaiser and Mr Marisset fell well short of embracing it. 2.2.3.In my view Dr Fuller's evidence upon the compressive arch was particularly compelling. I accept it and find that the compressive arch was unsuited as the basis for the mine's ground support system, at least within the 940 block and upon the lower levels. 2.2.4.It is my further opinion that the unsuitability of the compressive arch, or in the very least questions as to its suitability, should have become apparent to BG following the October 2005 rockfalls. 2.3.Risk Assessment.2.3.1.This issue was considered in the context of BG's response to the October 2005 rockfalls. 2.3.2.The fall of ground on 26 October in particular was a clear warning to BG that seismicity within its mine was not being managed in a controlled manner. It also served to give BG notice that it could expect a further seismic event of a 2.1 or greater magnitude at some undeterminable time in the future. These circumstances created a very real risk for worker safety and required BG to put in place and follow a systematic, comprehensive, rigorous and properly documented risk assessment process before it permitted mining to resume. It is my opinion that this did not occur. 2.3.3.As part of its risk assessment strategy BG, quite properly, sought assistance and advice from a range of suitable consultants. These advices, when received, logical risk assessment process where advices on specific issues were separated, differences of opinion on those issues identified and a strict process followed in the analysis, resolution and management of those issues. All of this required documenting. Regrettably, this process was not followed. 2.3.4.The risk assessment process was particularly deficient in that it failed to ensure that a comprehensive and independent re-assessment of the ground support system was undertaken. 2.3.5.In a memorandum of 1 November 2005 Mr Gill properly identified the need for the then existing ground support standards to be re-assessed. It was insufficient, in my view, for BG to commission Mr Turner to audit his own work and for a general overview to be undertaken by Dr Mikula. The mine's rockfall history up to and including October 2005 made it glaringly obvious that a ground support system based upon the compressive arch was not performing satisfactorily and that the entire system required a comprehensive and independent re-assessment. The need for that re-assessment should have been reinforced by the concerns expressed by Dr Sharrock upon the ground support. Why BG made the decision to resume mining without that re-assessment has not, in my opinion, been satisfactorily explained. 2.3.6.I am unable to positively find that Mr Knight's death would have been avoided if BG had undertaken a thorough and systematic risk assessment following the October falls of ground. Nevertheless, it is my view that the likelihood of Mr Knight's death occurring would have been reduced, perhaps significantly, if BG had undertaken such an assessment. This is particularly so, in my, view because a thorough and systematic risk assessment would have, in all likelihood, identified the inadequacy of the ground support system and led, either to a variation to that system or to the mining method being changed before mining resumed. 2.3.7.A lesson to be learned from Mr Knight's tragic death is the critical importance of proper risk management practices to worker safety, particularly in the mining industry. 2.4.Production in April 2006.2.4.1.I accept that in the early part of April 2006 production had been slow and that by 20 April the mine was approximately 3000 tonnes behind its monthly production target. I also accept that production was accelerated in the five day period ending at night shift on 24 April so that by this date the production deficit had been all but eliminated. However, there is not any evidence to show that this acceleration in production was undertaken at the expense of worker safety nor particularly was this acceleration in production a factor which contributed to Mr Knight's death. 2.5.BGM's Financial State and the Influence of Macquarie Bank.2.5.1.The Allstate Group held a majority interest in BG. Since June 2001 it had been in administration. Its financier was Macquarie Bank which had provided a loan of $21m. Also, the Allstate Group had in place a hedging arrangement with the Bank with a negative value of $13m. Further, in about March 2004 Mr Ryan in his capacity as administrator had negotiated the sale to Macquarie Bank of inter company loans within the Allstate Group. They totalled approximately $77m. The sale price was $300,000. By this arrangement Macquarie Bank became entitled to recover what it could of the inter-company loans as an unsecured creditor. These circumstances have given rise to two broad issues, firstly whether Allstate Group's level of indebtedness and the fact of its administration were matters which impacted upon BG's decision making to the detriment of worker safety and secondly, whether Macquarie Bank sought, for its commercial advantage, to influence BG's decision making so that worker safety was compromised. 2.5.2.I am able to specifically find that there is not any evidence that any of the decisions taken by BG relating to its mining operations and production were to any extent affected by the Allstate Group's financial status or the involvement of the Macquarie Bank so that worker safety was compromised. I find that these were matters which did not play any part in Mr Knight's death. 2.6.Workplace Standards Tasmania (WST) and related matters.2.6.1.I find that for at least one year prior to Anzac Day and almost certainly longer the level of staffing at WST's inspectorate was grossly inadequate and that it was incapable of carrying out its core function of inspecting and enforcing best safety practices within the mining industry. 2.6.2.I find that WST was content to permit BG to manage the investigation of the October 2005 rockfalls and to devise the plan forward with virtually no active involvement on its part. I am satisfied that this non-involvement was a consequence of its lack of resources, most particularly the availability of inspectorate personnel with mine engineering experience. 2.6.3.It is my opinion that the inspectorate's non-participation in the investigation of the October rockfalls and the matters relating to it constituted an abrogation of its statutory duty to inspect, monitor and enforce safe work practices at the Beaconsfield mine. As such it denied Mr Knight that layer of protection that he was entitled to expect from a properly functioning inspectorate. However, I am unable to find upon the evidence that the greater involvement by WST in the events post October would have led to either the Anzac Day rockfalls being avoided or the prospect of their occurrence being markedly reduced. It therefore follows that there cannot be a finding that this non-action by WST was a factor which directly contributed Mr Knight's death. 2.6.4.Since Mr Knight's death a dedicated mines inspectorate has been created within WST. It is known as the Office of the Chief Inspector of Mines. The evidence indicates that this Office is now adequately manned. There is also evidence that the Tasmanian Government has committed sufficient funds to it to enable it to properly carry out its statutory functions. However, there has not been sufficient time to make an assessment of the effectiveness of this Office in its new format and the adequacy of its funding. It is thus my recommendation that an audit of the Office be undertaken each 12 months to ensure that it is properly fulfilling its statutory duties. 2.6.5.It is plain that the current legislation, such as it is, is incapable of providing the mining industry with a proper occupational, health and safety framework within which to operate. In my opinion it is in need of immediate review and reform. On this subject I agree with and support the recent findings made by Coroner Jones concerning the deaths of three miners at Renison. The legislative reform should be specific to the mining industry but its precise form and detail is ultimately a matter for the State Government, properly advised and after consultation with the industry and worker representatives. I agree that it is desirable, as far as is reasonably possible, for the Tasmanian legislation to be consistent with national guidelines. 2.6.6.It appears from the evidence of the current management at WST that the Tasmanian Government now accepts the need for fundamental legislative reform. I urge the authorities to remain committed to such reform and to ensure that it is promptly implemented. It is long overdue. 3.FORMAL FINDINGS PER S.28(1)(A) - (F) OF CORONERS ACT 19953.1.I find that Mr Larry Paul Knight died on 25 April 2006 on level 925 of the Beaconsfield Gold Mine at Beaconsfield. Mr Knight was aged 44 years. He resided at Relbia with his partner and family. 3.2.I find, accepting the opinion of the State Forensic Pathologist, that Mr Knight died from multiple injuries sustained in a rock fall. It was mooted in the early stages of the investigation that Mr Knight may have survived the rock fall but died from injuries suffered in the course of the recovery operation. I specifically reject that notion. 3.3.The evidence does not permit me to make a positive finding that any person, corporation or other entity, by their conduct, directly contributed to Mr Knight's death. Dated : Thursday, 26 February 2009 at Launceston in the State of Tasmania.Rod Chandler CORONER