Coroner Crerar heard evidence about Mr Voorkamp's death at an inquest in September.
Mr Voorkamp's widow, doctor and various colleagues were heard along with police who attended and investigated the fatal incident and the pathologist that carried out a post mortem.
WHAT THE WITNESSES SAW:
Nathan Meikle and Joseph Pearce saw Mr Voorkamp pull over and thinking something unusual was happening they went over to the grader.
"The saw Garry Voorkamp lying on the ground near the rear wheels of the grader. (Mr) Pearce investigated and saw the head of (Mr) Voorkamp was between the two rear wheels of the grader. He had suffered a serious head injury," the Coroner's findings stated.
Mr Pearce told the inquest that earlier in the day Mr Voorkamp had told his road crew he was feeling unwell.
"He had trouble with his eyes. This may have been due to his leaving a contact lens in his eye overnight," Coroner Crerar reported.
"(Mr) Voorkamp took a 'migraine pill' but said this was not helping."
Mr Voorkamp was asked if he wanted to go home for the day but declined and carried on working.
THE INVESTIGATIONS:
Police told the Coroner that there was "no evidence to present that any third party caused or contributed to the incident".
Mr Voorkamp's employer told the inquest that there was no pressure on him to rush or finish his work that day and the team dynamic between the drivers was "positive and friendly".
He said Mr Voorkamp was considered by his peers and supervisor, to be "methodical and safety conscious". He was licenced to operate the grader and was fully inducted into safety procedures.
After Mr Voorkamp's death the grader was examined and found to be "of an appropriately high standard".
The death was also investigated by WorkSafe.
"The... investigation into this event has not identified any evidence to support a breach of Health and Safety in Employment Act by wither South Roads Limited or (Mr) Voorkamp," it concluded.
A WIDOW'S QUESTIONS:
Mr Voorkamp's wife Katherine suggested that her husband did not go home when offered on the day he died because he "did not want to put anyone out". She also suggested whether South Roads should consider providing non-slip surfaces in the cabs of their graders in future.
Coroner Crerar asked his employer to provide a submission on both issues Mrs Voorkamp raised and said the company had, since the death, strengthened protocols around the treatment of staff who become unwell at work.
Parking brake and safety alarm systems had also been installed in company vehicles.
THE CORONER'S FINDING:
Coroner Crerar found said he was satisfied that Mr Voorkamp had vomited and then tried to exit the cab while the grader was still moving. He could not establish why the man had not stopped the grader before doing so.
"Garry Voorkamp has slipped or fallen from the cab... and fell under the rear wheels of the grader which, still being under power, ran over his head."