The NSW Resources Regulator’s investigation unit reported Lee Peters, 28, was killed instantly before 10pm on September 6 when he used a shotcrete machine modified into a water cannon to unblock a draw point.

The Ridgeway mine operated by blasting ore and allowing it to cave naturally through stress and gravity into draw points, where the ore was collected and transported for crushing before being taken to the surface.

However, rock became lodged in the draw point to create a hang up and when Mr Peters tried to free it, the rock fell quickly and hit the cannon, pinning the Pybar Mining Services technician against the wall of the extraction level. 

Rock fall played pivotal role in Orange miner's death at Ridgeway: report

Mr Peters was found by another worker on the northern side of the machine in a vertical position but he was facing south, leading investigators to believe that he was travelling behind the water cannon to the south side when the incident occurred. 

The investigation was unable to confirm why Mr Peters was at the location, only narrowing the reason to three possibilities.

It anticipated he could have taken shelter behind the machine to avoid the rock or chosen to move to the southern side of the machine where the air was fresher.

It also posed the possibility the hang up failed to release and Mr Peters was in the process of leaving when it let go. 

Standard procedure would have required Mr Peters to remain on the north side and retreat further north to take cover.

But interviews established it was not unusual for some operators to move behind the water cannon to put themselves upwind of the dust cloud.

“Some supervisors knew this occurred,” the report said.

“A number of operators spoken to during the investigation admitted that they have been caught out by a collapsing hang up.”

There had been at least two previous incidents where rocks hit the front of water cannons and several where rocks entered the tunnel. 

Objects called bunds are built in front of draw points to protect workers from falling rock, but investigators found four different directives addressing their location and size.

“A number of critical policies and procedures that workers were required to comply with contained inconsistent, ambiguous and/or outdated advice,” the report said.

The report also said there was ambiguity in whether workers were required to wear dust masks.

The report pointed out Cadia Valley Operations (CVO) identified alternate machinery for the task, trialled remote control technology and banned workers from being near draw points on foot.

The report recommended CVO minimise worker exposure to pinch points and dust, construct bunds to consistent standards, undertake regular hazard management reviews and ensure appropriately trained personnel inspected draw points. 

CVO general manager Peter Sharpe said Mr Peters’ death was a tragedy and the company’s priority was ensuring a similar incident could not happen again.

“Newcrest co-operated with the investigation conducted by the Department of Industry Resources and Energy, and will work with the department to make improvements across all Newcrest operations,” he said.

“Since Lee’s death, Newcrest has implemented a group-wide safety transformation plan which aims to eliminate fatalities and life-changing injuries.”

Mr Sharpe said the plan was delivering improvements and CVO continued to offer support to Mr Peter’s family and colleagues.

A Pybar spokeswoman said safety was the contractor’s core value. 

“We are committed to working with our clients and regulators to ensure best practice and following the devastating loss of Lee, we have implemented a number of procedures to ensure the future safety and well-being of our employees.”