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Event- Tractor Roll-over (Equipment (Kubota M4800 tractor (Not maintained,…
Event- Tractor Roll-over
Equipment
Kubota M4800 tractor
Not maintained
Overdue servicing
No maintenance records
No pre-start checks
Uneven tyre pressures
Maintained
Dump truck
Attachable tractor trailer
People
Management/Owner
Joanne Hansy
Also employed elsewhere
John Hansy
Tractor driver
Potentially Intox
Bundy Rum can found by scene
Employees
Janelle (family)
Environment
Weather
Poor weather
Day of event
Overcast, no rain
Prior to event
Rain leading up to day of event
Storms
Optimal weather
Terrain
Optimal
Poor
Uneven
Hill, transverse slope
Soft
Wet
Weather prior to day of event
Organisation
OH&S
Management
Generic risk assessment
No consideration of slope
Poor risk management
Fatigue
Excessive work without a break
Product safety
Poor tractor maintenance
Process
Qualifications
John Hansy
Unlicensed
License expired
Joanne Hansy
License status unknown
OH&S
Basic procedures
No maintenance records
Overdue servicing
No pre-start checks
Did not follow product recommendations
Slope greater that Kubota OEM recommendations
Excessive work without a break