Realising he had activated heavy machinery near co-worker Gareth Leo Dodunski, driller Jacob Kilby tried to shut it down.
Tragically, he pressed the wrong button.
Within seconds, Mr Dodunski was crushed to death at the Fairwell Mining Camp's drill rig west of Brisbane in June 2013.
Ten years later, the 21-year-old's parents believe their long fight for the "truth to be told" has been in vain after the coroner revealed his findings into their son's death on Thursday.
Mr Dodunski succumbed to "catastrophic head injuries" after being hit by an ST-80 iron roughneck, hydraulic equipment used to move large piping.
The death was a consequence of Mr Kilby's "momentary inattention" at the drill rig operated by Saxon Energy Services Australia and contracted by Santos, coroner Donald MacKenzie said.
"Tragically Mr Kilby engaged the ST-80 while Gareth was still in the danger zone," he said.
A 2014 Petroleum & Gas Inspectorate incident report outlined 10 contributing failures, the court heard.
It said Mr Kilby attempted to stop the ST-80 by pressing an incorrect button on his touch screen and "did not attempt an emergency stop of the ST-80 using the other hardwired button".
It also said Saxon, Santos and Mr Dodunski's crew did not formally action risk concerns about the ST-80 following a similar incident in South Australia.
The Industrial Court of Queensland overturned convictions of Mr Kilby and Saxon on appeal in 2020, Mr MacKenzie noted.
"Not only did that cause substantial delays but it also caused a misguided assumption by some that the coroner would act as a Court of Appeal and effectively reinstate the convictions," he said.
"That is not the role of Coroners Court. It is ... looking for causes and potential preventions, not blame and liability."
The 10 contributing failures have since been addressed in some way by Santos, Saxon and Resources Safety & Health Queensland (RSHQ), the coroner said.
Mr MacKenzie on Thursday recommended the Queensland government consider amending the Petroleum and Gas Act to authorise investigators to compel witnesses to answer questions and they are protected from prosecution.
He also recommended that the state government combine various work health and safety acts into one body of legislation.
Mr MacKenzie acknowledged the tenacity of Mr Dodunski's parents, saying they had "relentlessly sought answers".
However, the parents said more must be done to police multinational companies' workplace safety in the resource sector.
"These companies in our opinion are complete cowboys and they get away with it every time," mother Michelle Dodunski said outside court.
"These companies need to stop putting profit and production over workers' safety.
"We stopped counting at nine fatalities after Gareth in the resources sector - what is going on?"
Asked what coroner's recommendation they were hoping for, she said: "RSHQ needs to be doing unannounced inspections ... on these multinational companies.
"They are the sheriff of the industry - get out there and do your job."
Father Philip Dodunski felt their hard work had all been in vain after listening to the coroner's findings.
"Definitely ... it can't go anywhere now, can it?" he said.
Asked what they would do now, Michelle Dodunski said: "Probably try to start grieving our beautiful son."
