No one is to blame for the death of miner Larry Knight in the Beaconsfield disaster, coroner Rod Chandler says.
“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,” Mr Chandler told a court in Launceston on Thursday.
Mr Chandler found the mine should have been aware that its ground support system in place at the time of the fatal rock fall was unsuitable after two earlier rock falls in October 2005.
He also said the mine\’s risk assessment process following the October rock falls – and that led to the recommencement of mining – was deficient.
“The risk assessment process was particularly deficient in that it failed to ensure that a comprehensive and independent reassessment of the ground support system was undertaken,” Mr Chandler told the court.
“… (However) I am unable to positively find that Mr Knight\’s death would have been avoided if (the mine) 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 (the mine) had undertaken such an assessment.
“This is particularly so because a thorough and systematic risk assessment would have, in all likelihood, identified the inadequacy of the ground support and led, either to a variation to that system or to the mining method being changed before mining resumed.
“A lesson to be learned from Mr Knight\’s tragic death is the critical importance of proper risk management practises to worker safety, particularly in the mining industry.”