Coroner's Finding: Shayne Hamilton McMahon

Contributing factors

• Unlicensed apprentice working unsupervised
• Inadequate training—prior experience only with dead-end lines, not ring mains requiring two clamps
• Lack of proper safety equipment (no full overalls, gloves, safety glasses, gas detection equipment)
• Job Safety Analysis not completed
• No gas network map provided or available
• Inadequate isolation valve at work site
• Employer failed to supervise critical work
• Resort's inadequate gas distribution system management
• Incomplete aboveground work before attempting main line connection
• Use of unsuitable clamp not compliant with Australian Standards

Coroner's recommendations

1. WorkCover Authority to issue Safety Alert advising industry that butane in LPG can induce fatal cardiac arrhythmia, ventricular fibrillation or asystole
2. WorkCover Authority to issue Safety Alert that Material Safety Data Sheets for LPG should include toxicological data and warnings about butane cardiac risks
3. Minister for Commerce and Fair Trading to notify all gas fitting contractors under Home Building Act of butane dangers in LPG
4. Minister for Education and Training to direct TAFE NSW to incorporate warning about butane in Certificate III Plumbing course and related programmes
5. LPG Australia to notify members (manufacturers and suppliers) about butane cardiac risks in LPG and promote improved Material Safety Data Sheets
6. Ministers and WorkCover CEO to urgently refer regulation of private gas distribution networks to Standards Australia for development of standards
7. Fire and Rescue NSW to review procedures for electronic recording and retention of gas detection data from incidents involving serious injury or death