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Blee was working as a continuous miner operator for Walter Mining and while the presented evidence varied on the circumstances of what transpired, his death was caused by a severe pelvic crush injury.

“This was not a case of workers participating in aberrant behaviour but rather of an adverse incident occurring in a situation where coal mine workers have followed existing procedures and requirements,” Coroner Annette Hennessy said in her formal findings.

She said there was significant controversy about what had happened in this incident.

“It is difficult to determine from the direct and reliable evidence, with any certainty, what movements of the shuttle car took place and when during those movements the fatal injury to Jason Blee occurred.

“What is clear is that Blee was injured as he was trapped between the shuttle car and the rib after initially being pinned by the shoulders as the shuttle car moved to leave the heading as directed.

“It is not clear what movements of the shuttle car were made in what sequence and which of the movements inflicted the fatal injuries. The precise sequence of events remains unknown.”

The coroner referred to expert forensic pathology analysis of the injuries to give a possible explanation of the movements made by the shuttle car.

“Shuttle cars are large, heavy machines which are designed to be manoeuvrable at speed and providing for heavy loads. They are not designed for fine directional control at low speed such that would have been required to free Blee from the initial pinning. There is no evidence that the design of the shuttle car itself was causative of the death.”

Blee was not in a no-go zone at the time of the incident, but was in a restricted zone over which he had authority.

Before the incident, track for the continuous miner was damaged.

Hennessy said Blee acted in accordance to procedure when he left his work area to communicate to the shuttle car driver.

Blee also gave an appropriate command for the shuttle car driver to move out of the heading so repairs could be made.

Importantly, Hennessy determined that the width of the heading was not extraordinary in the context and the floor conditions did not appear to have contributed to the incident.

While no party was blamed for the accident, the first set of coroner’s recommendations related to the notification of next of kin. Rachel Blee was not informed about her husband’s death until five hours after the accident occurred.

Key recommendations touched on safety issues involving vehicles, which manufacturers are trying to address by developing proximity detection and collision avoidance technology.

One recommendation was for underground coal mines to review arrangements on pedestrian and vehicle interaction and to revise the no-go zones and restricted zones.

Another was for coal operations and government to move quickly with manufacturers and other appropriate bodies to develop, test and approve proximity detection devices for use in underground coal mines.

Hennessy recommended a working party, consisting of government representatives, coal mine operators, workers, union officials and other interested organisations, meet with manufacturers of shuttle cars to review and discuss improving the design of the vehicles.

She also recommended the prepared Simtars simulation be used as a training tool and for the Coal Mining Safety and Health Advisory Council to thoroughly review the “place change” system of mining.

The 97-page Findings of Inquest document is available on the Queensland Courts website.