Inquest into the death of Brandoli POU
Deceased
Brandoli Pou
Demographics
29y, male
Date of death
2013-11-04
Finding date
2017-03-16
Cause of death
severe chest injuries sustained when struck by a magnetic lifter attached to an overhead crane
AI-generated summary
29-year-old Brandoli Pou, a leading hand at a steel processing facility, was fatally struck in the chest by a magnetic lifter suspended from an overhead crane operated by colleague Mariousz Cyrta. Cyrta experienced a sudden left-hand cramp while operating the remote control. Although evidence suggests Cyrta continued manipulating the crane for at least 6 seconds after the cramp onset and did not visually track the lifter during the incident, he adequately received formal accredited training in crane operation. The death resulted from crane operation not complying with established safety procedures: the magnetic lifter was travelled at unsafe height (1.2m) over a populated work area, and the operator failed to keep the load in constant view. While mechanical failure and design defects were excluded, three process improvements were recommended: explicitly requiring operators to keep loads constantly in sight, mandating crane shutdown if operators become incapacitated during operation, and clarifying that safety procedures apply to unloaded lifting equipment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- operator loss of control of crane remote control due to left hand cramp
- magnetic lifter travelled at unsafe height of 1.2 metres over populated work area
- operator did not maintain visual sight of the magnetic lifter during movement
- continued operation of crane for extended period (at least 6 seconds) after onset of incapacitation
- non-compliance with safe operating procedures regarding load visibility and travel height
- operator did not immediately cease crane operation or activate emergency stop button upon becoming incapacitated
Coroner's recommendations
- Southern Steel Group Pty Ltd should include in its Work Instruction 'Safe Operating Procedure for Overhead Cranes' an explicit requirement that the load/hook shall be constantly in view of the operator when being moved, consistent with Australian Standard AS 2550.1-2011
- Southern Steel Group Pty Ltd should include in its 'Safe Operating Procedure for Overhead Cranes' and 'Do's and Don'ts of Steel Handling' documents the requirement that if an operator becomes incapacitated through injury or illness whilst operating a crane and unable to continue crane-operating duties, the crane must be stopped and the matter reported to a supervisor
- Southern Steel Group Pty Ltd should clarify in its 'Safe Operating Procedure' and 'Do's and Don'ts of Steel Handling' documents that the term 'load' includes any item suspended from overhead cranes, including all crane accessories and lifting equipment
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