Peuckert, Bay Roxas - Non-inquest findings
Deceased
Bay Roxas Peuckert
Demographics
48y, female
Date of death
2011-09-01
Cause of death
Neck and chest injuries sustained in the incident with the cherry picker. Mechanism of death was multi-factorial: crush injury to the chest with pericardial tamponade due to lacerated right atrial appendage, multiple rib fractures with bruising of the lungs and fat embolism, and crush asphyxia.
AI-generated summary
Ms Peuckert, a 48-year-old farm worker with 12 years experience, died from crush injuries to her neck and chest while operating an Afron HAS-650 cherry picker on her employer's farm. She was directed to use the machine as a makeshift crane to lift a 590kg spray unit, despite the machine's 150kg load capacity and explicit manufacturer warnings against such use. The boom struck the shed roof, trapping her between the safety rail and roof beam as the machine became unstable and toppled. Critical failures included: no operator training provided; defective foot controls that stuck in raise position; inadequate clearance within the shed; and no personal protective equipment worn. The machine was fundamentally unsuitable for this purpose. Clinical lessons include recognition that workplace injuries causing crush asphyxia, pericardial tamponade, and multiple rib fractures require immediate advanced life support and emergency surgery—which was provided but could not overcome the severity of injuries. Prevention required proper equipment selection, operator training, load calculation, and workplace risk assessment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Cherry picker used as a makeshift crane contrary to manufacturer design and warnings
- Excessive load (590kg spray unit) far exceeding machine capacity (150kg)
- Machine instability due to overloading causing rear wheels to lift off ground
- Inadequate vertical clearance within shed entrance
- Defective foot controls that stuck in raise position, allowing uncontrolled platform elevation
- Operator struck shed roof beam, trapping her between safety rail and beam
- No operator training or induction provided
- No personal protective equipment worn (no body belt, harness, or hard hat)
- No daily pre-start safety checks performed
- Employer did not assess hazards or obstructions in work area
- Employer directed and approved unsafe work method
Coroner's recommendations
- Following the incident, WH&SQ released publications regarding appropriate maintenance, record keeping, safety and training requirements for elevating work platforms
- Prohibition Notice issued to cease use of the Afron HAS-650 cherry picker until repaired and inspected by competent person
- Improvement Notice requiring development and implementation of safe system of work for regular maintenance of plant per manufacturer specifications
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —