Adrian Hayes died at the age of 32 when a falling piece of rock struck him on the head while he was attaching hoses on a continuous miner in the Blackwood No 3 Fingal bord and pillar coal mine in October 2000.

But Tasmanian Coroner Rod Chandler in his 30-page report cites failures by Hayes’ employer Cornwall Coal and the inaction of safety authorities in preventing the accident.

A series of similar accidents in previous weeks that were not properly investigated by managers at Cornwall Coal indicate that in the weeks leading up to the accident other miners had been injured in six separate rockfalls, four of them near to where Hayes died, according to the report.

Chandler said the incidents were not investigated and the miner may not have been killed had the managers acknowledged the area was unsafe.

“All the incidents causing injury were notified to Cornwall Coal, either in the shift reports and/or by notice of injury, but there is not any evidence that any one of them was the subject of investigation. Critically, none generated a risk assessment,” the report states.

“The incidents occurring after 23 August demonstrated a deterioration in mining conditions associated with an identifiable area of mudstone, yet there is not any evidence that Cornwall Coal gave any consideration to this when drawing the sequencing plan dated 11 October 2000.

“It is pertinent to observe that s47 of the Workplace Health & Safety Act 1995 obligates a person having control or management of a workplace by the quickest available means to notify an inspector if a person is killed or suffers serious bodily injury or illness at a workplace or if a dangerous incident occurs as a result of which a person could have been killed or could have suffered serious bodily injury or illness.

“Cornwall Coal did not report any of the above incidents to Workplace Standards (WST). Had it done so, it was the evidence of Mr Sears, the Chief Inspector of Mines, that he may have directed an inspector to attend the mine to investigate.”

Safety regulator WST was also singled out for criticism over the accident.

"By its inaction, WST permitted Cornwall Coal's mining operations to proceed unchecked and without review when its risk management practices were deficient," he said.

"Mr Hayes was denied that level of protection to which he was entitled from a properly functioning safety regulator."

Tasmania’s workplace relations minister David O'Byrne said new legislation regarding mine safety in coming weeks is being considered and there are now five mining inspectors in Tasmania, three more than at the time of Hayes' death.