Coroner's Finding: Trevor Drayton and Edgar Orgo
Deceased
Trevor Drayton and Edgar Orgo
Demographics
male
Date of death
2008-01-17
Finding date
2011-07-13
Cause of death
Blast injuries and multiple injuries from explosion caused by ethanol vapours igniting when heated during welding operations on Tank 104
AI-generated summary
Trevor Drayton (52, winemaker) and Edgar Orgo, an experienced welder, died on 17 January 2008 in an explosion at Draytons Winery, Pokolbin NSW. The explosion originated in Tank 104 containing 9000 litres of SVR (spiritus vinous rectificatus – ethanol), triggered by welding operations. Mr Orgo, working from a forklift-elevated platform, unknowingly welded on the tank containing flammable liquid. Heat from welding created a spot exceeding 700°C on the tank's interior, igniting ethanol vapours. Multiple safety system failures cascaded: Tank 104 lacked warning labels, Mr Orgo was not informed of contents, Job Safety Assessment was treated as routine paperwork rather than genuine risk evaluation, and dangerous goods were not segregated or specially stored. The coroner applied the 'Swiss Cheese' model of accident causation, identifying latent conditions (poor safety culture, compliance-focused approach) and active failures (communication gaps, inadequate hazard assessment). Key recommendations: develop notification systems for dangerous goods consignees and conduct safety awareness campaigns in wine and metal fabrication industries.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- SVR (ethanol) stored in Tank 104 within the wine production area without segregation
- Tank 104 not labeled, marked, or distinctly identified as containing dangerous goods
- Failure to communicate tank contents to welder (Edgar Orgo)
- Job Safety Assessment not updated when circumstances changed (SVR added 9 days after initial JSA)
- Job Safety Assessment treated as routine paperwork rather than genuine safety assessment
- No hot work permit issued or required
- No verification that tank was empty before welding commenced
- Tank cap removed when filled and not replaced, creating ambiguity about tank contents
- No segregated or clearly delineated storage area for SVR
- Poor hazard communication – only whiteboard note in laboratory indicating tank contents
- Perfab's reliance on clients to identify hot work permit requirements rather than welders independently assessing risk
- Inadequate safety culture – compliance mentality rather than risk mindfulness at both Draytons and Perfab
- No briefing of welders about winery contents and hazards
- No independent verification by welders of tank contents before commencing work
Coroner's recommendations
- WorkCover Authority of NSW should develop a simple and practical method of bringing the Notification of Dangerous Goods requirement to the attention of consignees of Dangerous Goods
- WorkCover Authority of NSW should conduct a one-off publicity campaign within the wine industry reminding wineries of the risks associated with the storage and use of ethanol
- Similar safety awareness campaign should be considered for the metal fabrication industry
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