RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Christopher Webster, Coroner, having investigated the death of
Damien Leigh Woolley,
have decided not to hold a public inquest hearing into this suspected death because my investigations have sufficiently disclosed the identity, the believed time, place and cause of death, relevant circumstances concerning how the death is believed to have occurred and the particulars needed to register the deaths under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest hearing would elicit any information further to that disclosed by the investigations conducted by me.
Find :
(a) Damien Leigh Woolley (Mr Woolley) was born in Battery Point, Hobart, Tasmania on 21 February 1979;
(b) Mr Woolley died on 5 April 2008, at Hansen Orchards Pty Ltd, Conlanfs Road Orchard, Huonville;
(c) Mr Woolley died of neck and chest injuries received in an industrial accident with a hydraulic mat roller.
Circumstances:
Mr Woolley was a single man who lived alone at 2459 Huon Highway, Huonville. The residence is owned by Hansen Orchards Pty Ltd, for whom he had worked for the more than eight years. Three weeks prior to his death Mr Woolley had been promoted to the position of Orchard Manager.
Mr Woolley was a very conscientious worker and well regarded by his employers. He could be relied upon to ensure tasks were completed, even if it meant doing the work himself. It was not unusual for Mr Woolley to also work on Saturdays if required.
At ten o'clock on the morning of Saturday 5 April 2008 Mr Woolley was seen by a friend at Hansen's Orchard, on Baileys Lane at Huonville. Sometime after this he had gone to Hansen's Orchard on Conlans Road, where he has driven, and parked, a small green tractor at the end of a row of apple trees. Attached to the rear of the tractor was a hydraulically-driven net winder/spindle.
The winder was used to roll up the 'extenday' matting previously placed under the fruit trees. 'Extenday' matting is used in orchards to assist in colouring the bottom sides of apples for the export market. The spindle attached to the winder was a steel construction, approximately 3.5 metres in length, and had been modified from taking in and placing out cherry netting, to be capable of rolling up the 'extenday' matting . A 50mm PVC conduit sleeve had been placed over the spindle and the 'extenday' matting taped to the conduit.
Working alone, Mr Woolley commenced to operate the hydraulic winder and a small amount of the matting wound onto the spindle. He was standing near the end of the winding spindle when his clothing became entangled on a bolt that protruded at right angles from the conduit and used to keep the conduit in place on the spindle. The spindle continued to rotate and his clothing pulled him onto the spindle and twisted his body into an unnatural position. This caused his clothing to be drawn up from the lower part of his torso and wrap tight around his neck.
At about 3.25pm that afternoon, Ms Judith Mills (Ms Mills), Payroll Manager for Hansen Orchards, arrived at her office to catch up on paper work. Half an hour later she received a phone call at the office, from an unknown male, saying that he had come across a tractor, which was still running and there was a body of a blonde bloke. Ms Mill asked for directions and drove to the area after collecting another employee, Richard Longey (Mr Longey,) on the way.
Upon arrival at the Conlan Road Orchard they found the tractor and Mr Longey turned it off and Ms Mills recognised Mr Woolley and determined that he was deceased. Emergency services were contacted and arrived a short time latter. Work Place Standards were also advised and attended. A thorough investigation was conducted and it was determined that there were no suspicious circumstances in relation to Mr Woolley's death.
Forensic Pathologist, Dr Christopher Lawrence, performed an post mortem examination on Mr Woolley on 7 April 2008 and determined his death was caused by the neck and chest injuries received in the industrial accident with a hydraulic mat roller. Toxicology found cannabis present in Mr Woolley's blood which Dr Lawrence indicated may have contributed to Mr Woolley's awareness and therefore his clothing getting caught.
Carl Rupert Hansen (Mr Hansen) indicated that the company had been using the modified hydraulic rolling equipment to retrieve 'Extenday' mats for six years and that he aware that Mr Woolley had used the equipment on previous occasions. He also indicated that the equipment was always to be operated by two people and he could not understand why Mr Woolley attempted to operate the equipment by himself.
A thorough investigation was conducted by Work Place Standards. The investigation determined that Mr Woolley was operating a machine alone when it normally required two people to operate. The investigation further determined that the modification to the machinery resulted in an unguarded bolt being positioned on the rotating shaft and it was this unguarded bolt that became entangled in Mr Woolley's clothing. The fact that cannabis was found in Mr Woolley's system may have been a contributing factor to his awareness around the machinery.
Work place Standards determined the primary cause of Mr Woolley's death was Hansen Orchards Pty Ltd failing to provide a piece of plant machinery in a safe working condition. It recommended that the unguarded bolt be removed and replaced with a collar and grub screw.
Hansen Orchards Pty Ltd and Howard Carl Hansen (Director of Hansen Orchards Pty Ltd) were charged with failing to maintain plant in a safe condition contrary to section 9 subsection (1) of the Workplace Health and Safety Act. The matter was heard by His Honour, Mr Glenn Hay and, in his decision on 22 December 2009, he determined that there were a number of unpredictable events which could not have been practicably foreseen and guarded against and the matter was dismissed.
Findings & Comments:
I find that a thorough investigation has been carried out by the Tasmanian Police and Workplace Standards and that there are no suspicious circumstances surrounding Mr Woolley's death.
I am satisfied that Mr Woolley was a enthusiastic, trusted and valued employee, who was working by himself to complete duties at the orchard. Unfortunately, while working alone, Mr Woolley's clothing has became entangled on a unguarded bolt located at the end of a spindle which was winding up 'Extenday' matting. With no one else present to stop the operation of the machine Mr Woolley was unable to free himself and the spindle continued to rotate, pulling him onto it and twisting his clothing up and around his neck. This caused severe neck and chest injuries which resulted in his death.
This was a terrible industrial accident that was unable to be foreseen by Hansen Orchards Pty Ltd.
I conclude this matter by conveying my sincere condolences to Mr Woolley's family.
DATED: 12 March 2013 at Hobart in Tasmania.