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It was early morning on a Lynfield construction site when a concrete mixer became stuck after reversing too far down a ramp.

Graeme Brett Rabbits hopped into a large JCB telehandler lifting machine, and moved it so he could help tow the mixer out.

He parked it up the slope, while another worker came over to help him attach a rope.

The 36-year-old Auckland man was crouching down, facing away from the telehandler, which remained in place for a minute and 20 seconds.

Then it began to roll.

The other worker was standing up, and facing the telehandler, and was able to get out of the way.

But despite Rabbits’ attempt to move, his crouched position left him unable to move in time, and he was trapped between the telehandler and the concrete mixer.

He died from the “severe traumatic injuries” at the site.

Coroner Erin Woolley has now issued strong warnings about the type of brakes that were being used in the telehandler on January 9, 2018.

Roll-away incidents have caused at least six deaths since 2010

In her findings, which were released this afternoon, the coroner concluded there was nothing to signal to Rabbits that the cardan shaft brakes (CSBs) would fail that day.

CSBs operate by applying a single brake mechanism to the transmission/driveshaft, rather than at the wheels.

Coroner Woolley said they are an inexpensive braking mechanism because one small transmission brake can provide more park brake force than two larger wheel brakes can.

But they’ve been associated with safety issues for several years.

The coroner said roll-away accidents caused by CSBs releasing or failing, without warning, are known to have caused at least six deaths in New Zealand since 2010.

The evidence presented during the inquest highlighted that many factors can cause CSBs to release, but it commonly happens when the vehicle is parked on a slope, and the load changes.

She noted tragedy could have been avoided if wheel chocks, a wedge or block of material placed against a vehicle’s wheels, had been available on site that day.

While not suggesting it had been Rabbits’ fault, as he’d had no reason to suspect the CSBs would not hold, she said CSBs are “very dangerous” if not used in conjunction with a secondary braking or safety mechanism. Wheel chocks should be available on all sites where CSBs are in use.

The inquest findings were lengthy and detailed aspects of inquest evidence from expert advisor Dr Tim Stevenson, police vehicle safety experts, and representatives from the New Zealand Transport Agency and WorkSafe.

Near-miss involving school bus ‘could have had tragic consequences’

Another person who provided a large amount of work and expertise in the inquiry was Rabbits’ father, Selwyn Rabbits.

He owned the company his son Graeme was working for at the time of his death, New Zealand Crane Specialists Ltd.

Graeme Rabbits.

Graeme Rabbits is described in the findings as a “careful person who took safety seriously”, and was “experienced, and qualified, for [his] role”.

As part of the inquest, his father produced, with input from Stevenson, a table that summarised 26 roll-away incidents involving vehicles with CSBs.

A particularly alarming incident, referred to by Coroner Woolley, involved a Puhoi school bus.

The bus was parked on the school driveway and, after 14 children had boarded, thereby changing the weight, the bus rolled down the driveway.

It was only by good luck that the bus did not collide with a passing vehicle or end up in a nearby stream.

The coroner said while evidence about the cause of this incident was not determinative, she acknowledged it was concerning, “could have had tragic consequences”, and had “common features with other CSB roll-away incidents”.

Details of earlier warnings were also included in the findings, including some made by now-Chief Coroner Anna Tutton, who in 2018 considered the death of Phillip Loving, who was hit by a liquid waste truck when its CSB did not hold.

Coroner Tutton identified issues with a test used to assess the functioning of CSBs, and recommended NZTA review it.

Since 2022, there has been a new type of brake test – the roller brake machine (RBM) test – which is considered a more rigorous test than what was previously used.

But another issue highlighted was the way telehandlers were registered, and that this could impact whether their brakes were tested regularly.

The coroner noted that the CSB in the telehandler in use on January 9 was not up to standard, but because the vehicle had been registered as an “agricultural” vehicle, it was exempt from the Certificate of Fitness process.

NZTA urged to acknowledge CSBs ‘inherently dangerous’ when used as sole park mechanism

Now Coroner Woolley has issued further directions.

She has “strongly encouraged” NZTA to “acknowledge that relying on a CSB as the sole park mechanism in a vehicle/machine is inherently dangerous, because even a well-maintained CSB can fail, without warning”.

Coroner Erin Woolley.

Stevenson, in his evidence, had observed that there seemed to be a “general reluctance” from NZTA, and industry representatives, not only to acknowledge the dangers of CSBs, but to be “open-minded and consider options or dealing with these issues during the inquest, on the basis that not all risk can be eliminated from the transport system”.

The coroner encouraged NZTA to “adopt a more positive attitude and be more willing to consider what more can be done to address the safety issues with CSBs in the future so that no further deaths occur”.

Coroner Woolley’s recommendations also called on NZTA, WorkSafe, and the police to work together to gather data to assess CSBs’ effectiveness, and improved record-keeping of any incidents involving vehicles fitted with CSBs.

Without that data, she noted it would be difficult to assess the effectiveness of NZTA’s efforts to remediate CSB issues.

Other recommendations were focused on technical aspects of rules and regulations, and industry operations, including stopping owners from registering telehandlers as agricultural vehicles, when that is not their intended use.

She also called for safety campaigns targeted at the owners and operators of heavy vehicles with CSBs.

Coroner Woolley also issued a message to the public, highlighting again that vehicles with cardan brake shafts have been involved in several incidents where the brake has failed, and the vehicle has rolled away causing injury and, in some cases, death.

She told vehicle owners to ensure CSBs are serviced regularly, and adjusted properly, to maintain proper performance of the brake.

But she said anyone operating a vehicle with that type of brake should avoid parking the vehicle on any kind of slope, unless there is a secondary means of holding the vehicle still.

If parking on a slope can’t be avoided, wheel chocks should be used.

She also urged operators to understand the limitations of CSBs, including that they shouldn’t be used to slow a moving vehicle, and should only be used as a park brake when the vehicle is stopped.

Operators should be aware that once stopped, a CSB can “let go without warning”.

NZTA Waka Kotahi deputy director of land transport Mike Hargreaves said he extended his sincere condolences to those affected.

He said NZTA had taken a “range of actions on cardan shaft park brakes [CSPB] since 2020″ to reduce the safety risks associated with their maintenance and operation.

“This includes raising awareness of the correct use, testing and maintenance of CSPB among industry, requiring mandatory warning labels in the cabs of vehicles fitted with CSPB, providing free CSPB servicing training and introducing more rigorous roller brake machine testing of CPSB during Certificate of Fitness [CoF] inspections from December 2022.”

He said a recent NZTA review has found marked improvements in fleet compliance and industry awareness since these measures were introduced.

NZTA also highlighted an independent review, done in 2023, of the measures it had taken and said they were sound, pointing to the new type brake testing, the frequency of testing, and increased education of owners and operators.

However, they are now carefully reviewing the coronial recommendations to consider if any additional measures are needed.

Hannah Bartlett is a Tauranga-based Open Justice reporter at ��һ�ǿ�����. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at ��һ�ǿ�����talk ZB.