13 February 2008 Ronald Shores Death Leads to Safety Reforms His Honour found that: Ronald Shores died on the 29 July 2004 in the MTVI (East) Ventilation Tunnel, Darling Harbour, in the State of New South Wales, from multiple injuries, sustained there and then, when a section of the tunnel roof dislodged. Recommendations The Coroner also made the following recommendations as suggested by WorkCover 1. That the industry’s attention be drawn to the existence of the “Tunnels Under Construction Code of Practice, 2006” and the re-enforcement of the matters contained therein. In particular that the interdependence of design, the chosen construction methods, and the ground and environmental conditions are critical and need constant monitoring. Continuity in engineering practices at the stages of planning, investigation, design and construction are desirable. 2. That roof support or anticipated roof support indicated on drawings (Issued for Construction – IFC) be treated as mandatory minimum roof support during all phases of construction unless formally varied in writing by the designer. 3. That IFC drawings, which depict roof support or anticipated roof support carry a direction that the roof support indicated thereon cannot be reduced without written consent of the designer. 4. That each excavation team have available to it at the face of each excavation, a copy of the latest design drawing indicating applicable roof support annotated in accordance with recommendations 2 and 3 together with a copy of any variation in roof support authorised by the designer. 5. That in respect of each support type indicated on the IFC, whether as anticipated support or otherwise, there be a dedicated Construction Sequence indicating the “unsupported face distance” or “maximum cut out distance” between previously installed support and the face. This construction sequence should be specific to each tunnel under construction. In the absence of such a construction sequence tunnelling is not to commence or to continue. 6. Reliance upon self support, or random bolting for any length of chainage either as temporary or permanent support should only be permitted when a representative of the designer authorises the same in writing after written authorisation by a suitably qualified and experienced engineering geologist or geotechnical engineer and following an inspection of the as found ground conditions.