Coronial
NTother

Inquest into the death of Jade Lange-Loades, Rory Lange-Loades and Nathaniel Rose

Deceased

Jade Marie Lange-Loades, Rory Duncan Lange-Loades, Nathaniel Jake Rose

Demographics

8y, male

Date of death

2003-01-22

Finding date

2004-10-01

Cause of death

Drowning as the result of a motor vehicle accident

AI-generated summary

Three children drowned following a motor vehicle accident on the Stuart Highway after a grouser plate fell from an inadequately restrained load on a road train, puncturing their vehicle's tyre and causing loss of control. The pallet was hastily repacked by a two-week apprentice with minimal supervision, using insufficient banding and no interlocking of lugs, contrary to industry best practice. The load was not properly secured and the truck driver failed to check the load during a long journey from Darwin. Systemic deficiencies in load restraint training and procedures existed at both Hastings Deering and Shaw's Transport. Clinical and operational lessons include: proper supervision and training are essential for safety-critical tasks; cursory inspections are insufficient for hazard assessment; and formal, documented procedures with competency-based training should replace informal knowledge transfer.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Error types

proceduralsystemcommunicationdelay

Contributing factors

  • Inadequately restrained load on road train
  • Grouser plate fell from load and punctured vehicle tyre
  • Insufficient banding and restraint of pallets
  • Plates not interlocked as per best practice
  • Inadequate supervision of apprentice restacking task
  • Cursory inspections rather than thorough examination
  • Truck driver failed to check load between Darwin and stopping point
  • Lack of formal training on load restraint requirements
  • Lack of knowledge about stable stacking methods
  • Use of damaged/rotting pallet as part of load
  • No wire cages or alternative securing methods used
  • Extended approach guard railing not present at bridge

Coroner's recommendations

  1. Hastings Deering continue to develop and offer training on loading particular materials on pallets
  2. Shaw's provide to staff formal training on load restraint methods and develop and document procedures for loading trucks in accordance with the load restraint guide
  3. NT Police continue to provide the Accident Investigation Unit staff with investigation and interview training as well as other matters raised in the letter of Assistant Commissioner Kelly to the Territory Coroner on 17 August 2004, in an endeavour to improve the quality and timeliness of coronial investigations
  4. A protocol be developed between the NT Police and NT WorkSafe in relation to the reporting and investigation of work related motor vehicle accidents
  5. NT WorkSafe work with the trucking industry and related industries to provide information on standards and procedures in the industry in regard to use of pallets, banding of pallets and the development of formal training materials on the requirements of the load restraint guide

Further listening

Coronial podcast — Episode 62

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