Wigg, Allan Thomas

Contributing factors

• Defective weld securing rear levelling pin due to welding of dissimilar materials (high tensile steel pin to mild steel clevis plate) causing cold cracking failure
• Russell Moyle performed welding outside his competency without specialist knowledge of the pin material properties
• Barry Duggan replaced original mild steel pins with high tensile steel pins in June 2004 without consulting manufacturer
• No maintenance logbook or record available to inform contractors of prior modifications and material specifications
• Loose fit (sloppy fit) of the replacement pin increased stress on the weld joint
• Parking brake non-functional at time of incident due to ongoing repairs by external contractor
• No safety harness fitted to restrain operator in basket despite Australian Standards requirement
• Hydraulic hoses repositioned to external routing during repairs, increasing complexity of control system
• Lack of documentation regarding modifications and their consequences
• Unclear communication about availability of return spring to improve brake function
• No risk assessment process undertaken for modifications

Coroner's recommendations

1. The Office of Workplace Health and Safety Queensland (OWHS) should facilitate the development and promotion of appropriate safety harnesses for use in banana bagging machines, with coordination of stakeholders to address current industry resistance and lack of agreed design
2. An urgent inspection of all banana bagging machines currently in use should be undertaken by a competent person to check the condition of welds and levelling joint security, particularly to identify instances where high tensile steel rods may have replaced mild steel rods
3. Manufacturers of banana bagging machines should include in their manuals clear warnings that any modification to the original design, including repairs and component substitution, requires notification to the manufacturer and consideration of design implications
4. The OWHS should recommend development of a system for systemic, regular independent inspection of high-risk farm machinery (similar to motor vehicle roadworthiness certification schemes) to ensure compliance with Australian Standards
5. A safety alert should be issued by the OWHS highlighting the critical importance of the security and integrity of levelling rods for elevated work platforms and that they must be designed and maintained in a professional manner
6. The OWHS should ensure investigators have access to and that coroners are routinely supplied with statistical data on the frequency of similar incidents to those being investigated, to better inform recommendations
7. The OWHS should adopt a process similar to Queensland Police Service whereby investigators consult with the coroner before returning seized machinery, to ensure the exhibit is no longer required and coronial continuity is preserved
8. There should be clarification of the delineation of areas of responsibility between Queensland Police Service and OWHS for initial scene investigation and handover procedures in workplace death investigations
9. Documentation provided with elevating work platform machines should include detailed information about all modifications, their consequences, and requirements for design compliance
10. Maintenance logbooks should be a mandatory requirement for all banana bagging machines and elevated work platforms, with details of repairs and modifications made readily available to contractors undertaking future work
11. Enhanced education and support should be provided to farmers and rural employers regarding workplace health and safety obligations, risk assessment processes, and the statutory implications of modifying or maintaining complex machinery
12. Contractors engaged for repairs or modifications to complex machinery should be educated regarding their statutory obligations as 'designers' when modifications are undertaken and the need to consult with original manufacturers
13. The OWHS should work to develop and disseminate simple, practical risk assessment models appropriate to rural and agricultural operations, with consideration of the practical constraints of rural areas including limited access to broadband and specialist expertise

Further listening

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