Kolomaka inquest findings
Deceased
Setaleki Kolomaka
Demographics
male
Date of death
2008-05-22
Finding date
2012-06-20
Cause of death
Traumatic injuries to the left chest wall, left lung and heart due to high pressure water jet
AI-generated summary
Setaleki Kolomaka died on 22 May 2008 at Port Kembla steelworks when a high-pressure water jetting lance struck him fatally in the chest and heart. The inquest found multiple systemic failures: the lance lacked handles or trigger for direct shutoff, he had no direct control of water flow (another worker operated the foot pedal), and management selected a larger nozzle without proper risk assessment, increasing dangerous reaction forces. Supervisors and staff were inadequately trained on reaction force calculations and Australian Standard requirements. No comprehensive job risk assessment was conducted. Management-level safety personnel, including the Chief Safety Officer, failed to enforce compliance with written safety procedures. The coroner found this entirely avoidable death resulted from systemic failures within the company. Recommendations were made to Safe Work Australia and Standards Australia for a Code of Practice and review of the water jetting standard.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Absence of handles or adequate means of control on the lance
- Absence of a shutoff device or trigger on the lance
- Operator lacked direct control of water supply - another worker operated the foot pedal
- Excessive reaction force from use of larger nozzle tip
- Lack of proper risk assessment when nozzle was changed
- Inadequate personal protective equipment
- Absence of comprehensive job safety risk assessment
- Inadequate training of supervisors and workers
- Non-compliance with Australian Standard and company safe operating procedures
Coroner's recommendations
- Copy of findings and expert reports forwarded to Director of Safe Work Australia for consideration in establishing a Code of Practice for Water Jetting
- Copy of findings and expert reports forwarded to Director of Standards Australia for review of the Australian Standard concerning High Pressure Water Jetting
- Consideration by Standards Australia committee of three recommendations: (a) all lances have at least 1 handle, at least 1 hold to open device and at least 2 shutoff devices operated by 2 people; (b) caution regarding mandating liquid resistant suits as they may in some cases increase risks; (c) establishment of a National training course
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