At first, Rodney Redgen did not think anything of the 10-metre steel pipe rolling off the side of a truck's trailer.
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Then he noticed his "spotter" Billy-Joh Watts was no longer standing where he could see him.
He quickly located 36-year-old Mr Watts - underneath the pipe, which weighed up to 700 kilograms.
"I've killed him. I've killed him," Mr Redgen was heard saying as he sought help at the work yard northwest of Brisbane.
An inquest into the May 2017 death at Chinchilla heard Mr Watts was standing at the rear of the trailer when he gave Mr Redgen the thumbs up to unload the pipe with a front end loader.
About 30 seconds later the pipe fell off, killing Mr Watts instantly.
Mr Watts - who had been driving trucks for about two years for Neil Mansell Group (NMG) - was crushed after moving to the side of the trailer, apparently to load chains.
Coroner Donald MacKenzie said there were a few possible explanations for Mr Watts breaking a "golden rule" and entering an exclusion zone while the pipes were being unloaded from his truck.
One was complacency, with one co-worker telling the inquest that "it was a job they had done a hundred times before".
Mr MacKenzie also noted that Mr Watts was deaf in one ear, may have been distracted after losing a close friend in a car accident days earlier, and was potentially fatigued, telling colleagues he had recently worked 26 days straight.
The coroner said there was also an inadequate exclusion zone and an inherently unsafe loading manoeuvre used at the time.
"It is not possible to prefer any one of these six explanations over the other. It is probable that they each worked in combination," he said in his findings.
An Office of Industrial Relations (OIR) investigation into the death did not support criminal prosecution, he noted.
The coroner said measures that could have potentially avoided the fatality included well identified exclusion zone barriers, mandatory two-way radio use - rather than hand signals - and different mechanical devices for the unloading.
He said there were "gaps" in safety processes including flaws in the loading of the pipes, the trailer's placement, exclusion zone limitations, fatigue management, psychologic assistance and assessment of employees following trauma.
The coroner noted that NMG had formalised the use of exclusion zones to meet industry standards.
The inquest held in late 2022 was told by an OIR investigator that standards and guidelines were already available to prevent a similar death.
The coroner recommended that the OIR review its event management procedure to facilitate sharing information with other regulators where necessary to prevent public health and safety risks.
"It is without doubt that the transport industry can learn much from this tragedy," Mr MacKenzie said.
"Accordingly, it is hoped that the death of Billy-Joh Watts provides a template for safety in the trucking industry for many years to come."
Australian Associated Press
