Greaves, Colin Arthur

Contributing factors

• Unsecured open hatch without barricades or protective barriers
• Absence of safety harnesses despite company policy requirement
• Excessive consecutive shift work (25-26 consecutive 12-hour shifts) resulting in significant fatigue
• Inadequate lighting on tank top at night with shadowy areas
• Supervisor failure to enforce Safe Hours of Work policy
• Lack of hard barricades around open voids
• Normalisation of risk by workers regarding open hatches
• Inadequate supervision of supervisor by management
• Hatch A illegally opened without proper management of change procedures
• Fatigue-induced loss of concentration and inattention to detail

Coroner's recommendations

1. Queensland Alumina Ltd perform regular and proactive monitoring of lighting on tanks with maintenance regime for optimum night lighting
2. Queensland Alumina Ltd consult with fatigue experts regarding safe shift lengths, rosters and consecutive shift limits, implementing appropriate Cardex system markers
3. Queensland Alumina Ltd implement formal policy for clearing scale and mud from Settler tank doors to maintain clear access
4. Queensland Alumina Ltd conduct thorough review of risk assessment procedures in emergency response, particularly confined space entry
5. Queensland Alumina Ltd ensure workers can efficiently enter items on hazard log with appropriate training
6. Transpacific Industrial Services review Safe Hours of Work and Fatigue Management policies with fatigue expert assistance
7. Industry Training Bodies develop or certify competency-based hydroblasting training course
8. Industry Training Bodies require managers implementing safety management systems to undertake competency-based training
9. Gladstone industry establish process to monitor contract workers' shifts across sites to ensure fatigue management compliance
10. Workplace Health and Safety Division review its role in coronial investigations with view to becoming primary investigators
11. State Coroner recommend amendments to Workplace Health and Safety Act 1995 and Coroners Act 2003 to formalise WPHS coronial investigation responsibilities
12. WPHS Division establish requirements for fatality investigations including investigation report content and provide inspector training
13. WPHS Division develop protocol for early communication with Coroner during investigation to identify investigation scope
14. WPHS Division provide training in safety management systems, risk management, and root cause analysis methods including ICAM
15. WPHS Division consider inspector experience in relevant industry when allocating investigations
16. WPHS Division ensure substantial communication of investigation issues to industry and encourage implementation of controls
17. WPHS Division and Queensland Police Service clarify Memorandum of Understanding to delineate coronial investigation responsibilities