Vearncombe, Muraka Jenny
Deceased
Muraka Jenny Vearncombe
Demographics
42y, female
Date of death
2010-03-03
Finding date
2013-03-28
Cause of death
Head injury due to ejection of a section of steel pipe from slasher
AI-generated summary
A pedestrian was fatally struck by a metal pipe ejected from a slasher operating on a vacant urban block. The coroner found that while the incident occurred in an urban setting with foreseeable pedestrian presence, critical safety control measures were not implemented. The employer and operator possessed a manufacturer's manual detailing risks of projectile ejection and control measures (exclusion zones, higher cut heights, directional positioning) but did not consult it. The WHS investigation was inadequate—inspectors failed to obtain or review manufacturer's documentation, did not apply systematic risk management principles, and concluded the operator exercised proper diligence based solely on a flashing light and alleged walk-through. The coroner identified missed opportunities for better safety management and a systemic failure in the WHS investigation process, with recommendations for safety alerts emphasizing manufacturer guidance and risk assessment application.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Failure to obtain and review manufacturer's safety manual
- Inadequate risk assessment for slashing in urban setting with pedestrian presence
- Absence of exclusion zones or pedestrian traffic management
- Limited understanding of projectile ejection risk and distance
- Reliance on personal experience rather than evidence-based safety procedures
- Inadequate walk-through of overgrown block to identify debris hazards
- Slasher orientation during maneuvering directed discharge toward pedestrian area
- Gap in chain guard allowing projectile discharge
- WHS investigation failed to apply systematic risk management process
- WHS inspectors did not consult manufacturer documentation
Coroner's recommendations
- WHS consider issuing a safety alert targeting contractors and organisations engaged in slashing operations to raise awareness about: the limits of personal experience however extensive; availability of collective industry knowledge in publications such as NSW WorkCover guidelines on slashing; the need to use manufacturer's safety information in developing and implementing operating procedures; and the application of basic risk management process in determining necessary control measures
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