Fatal tyre failure delivers a poignant lesson on risks to safety
A recent court case highlights how a company with a strong safety record can still be susceptible to shortcomings, with Centurion Transport’s example a timely reminder to industry operators to re-evaluate their risk-control measures.
Centurion expressed its grief at the death of a company employee after a tyre explosion and outlined the steps it has taken to reduce similar future hazards.
The Queensland Office of the Work Health and Safety Prosecutor (OWHSP) had earlier reported the company was sentenced at the Wynnum Magistrates Court on July 23 for breaching the Work Health and Safety Act relating to its primary health and safety duty.
Magistrate Sarra fined Centurion $200,000 but did not record a conviction.
Centurion told ATN the death of its employee at the Port of Brisbane was a tragedy that was felt deeply by his family and everyone at the company.
“He was highly experienced in performing his duties and, at the time of the incident, he was fitting and inflating a tyre on a heavy haulage low loader,” a company spokesperson said.
OWHSP outlined that, on September 4, 2019, the driver was due to drive a prime mover connected to a dolly trailer and a low loader, to transport mining equipment from the Port of Brisbane.
“At approximately 10:30am, the worker arrived at the Port of Brisbane and parked the prime mover,” OWHSP said.
“Shortly afterwards, the worker approached another driver to borrow a rattle gun and airline to ‘change a tyre’.
“Approximately 15 minutes later, a loud explosive noise was heard from the direction of the prime mover.
“The worker was found unresponsive underneath the dolly trailer.
“The worker suffered significant chest injuries and cardiac arrest and died at the scene.
“His injuries were consistent with exposure to significant percussive pressure.”
WHSQ issued an incident report shortly after the fatality
The investigation by Workplace Health and Safety Queensland (WHSQ) identified a tear of about 12.5cm in the wall of a tyre on the dolly trailer, and established that the worker had been attempting to inflate the tyre at the time of the incident.
“An expert determined the tear was caused by a ‘zipper failure’, describing a tear of all the components in the sidewall of the steel cord radial ply truck tyre,” OWHSP continued.
“A zipper failure causes the instantaneous release of stored energy.
“The expert found that the tyre’s steel body ply cords were contaminated during manufacturing, which led to corrosion and contributed to its failure.
“The investigation also determined the inflation equipment did not have a clip-on valve nozzle, which would have allowed the worker to inflate the tyre from a safe distance.
“The absence of that device, and the consequent proximity of the worker to the tyre, exposed the worker to a risk of death or serious injury when the tyre failed.”
Centurion asserted that the tyre, which was relatively new, having been in circulation for less than one year, “unexpectedly” failed during inflation.
“An independent expert engaged by Worksafe Queensland concluded that the tyre had a manufacturing defect which made the tyre susceptible to premature failure,” the spokesperson added.
“Shortly after the incident, Centurion received notice of a tyre exchange program for the same model of tyre, though concerning a different set of serial numbers to the tyre that had failed.”
WHSQ’s investigation pointed to a company safe-work method shortfall for inflating tyres.
“Although the defendant had a third-party service agreement to maintain the truck tyres, tyre pressures were only checked sporadically,” OWHSP said.
“Several workers attempted to inflate tyres using their own equipment, which the defendant failed to prohibit.”
Centurion accepted it had an arrangement with a service provider for tyre-fitting services, such as tyre inflation, so that its employees would not have to perform this work themselves.
“However, Centurion accepts that deficiencies arose in the implementation of its safety systems as well as clear directions to employees not to undertake their own tyre inflation,” the spokesperson added.
“Centurion’s position remains that all tyre repairs and inflation should not be undertaken by employees unless absolutely necessary.”
While Magistrate Sarra accepted the prosecution’s submission that the worker’s death could have been avoided if “inexpensive and only mildly inconvenient” procedures had been implemented, the company’s guilty plea and acceptance of responsibility, including implementing control measures to address the risks of tyre inflation, were also considered.
“Magistrate Sarra exercised his discretion not to record a conviction,” OWHSP noted.
“His Honour noted that, given the defendant company’s lack of prior offending and timeliness in implementing control measures, it was unlikely to reoffend.”
Centurion outlined to ATN its “significant steps to address any deficiencies in its safety systems and to mitigate the risk of any further tyre related incidents occurring”.
In particular:
- Shortly after the incident Centurion issued a company-wide directive to immediately cease all tyre inflation activities on the brand of tyre in question.
- Centurion completed a full recall of these tyres (more than 3,000) within one month of the incident and no longer procures the relevant brand of tyres for its heavy haulage fleet.
- Multiple Safe Work Procedures were developed to describe the necessary steps and controls to undertake changing and inflation of tyres across the business.
- All heavy haulage drivers and workers were trained in these Safe Work Procedures by a certified training assessor.
- All heavy haulage drivers are now provided with tyre inflation kits and protective equipment to aid in safety performing these tasks.
“These steps demonstrate Centurion’s approach to the safety of its employees, customers and the public,” the spokesperson said.