Gear, Christopher James; Sayer, Steven Frank - Non-inquest findings
Deceased
Christopher James Gear and Steven Frank Sayer
Demographics
male
Date of death
2008-06-21
Finding date
2015-08-27
Cause of death
Multiple injuries sustained as a result of a fall from height caused by swing stage scaffold failure
AI-generated summary
Two construction workers died when a swing stage scaffold failed during external concrete patching work on a multi-storey building. The scaffold had been installed by Allscaff Systems in a manner deviating significantly from the manufacturer's design, with the counterweight secured using friction couplers rather than as a positive connection. Critical failures included: inadequate design certification, reliance on properly-tensioned couplers (which could not be verified by visual inspection), deviation from Australian Standards, lack of documented procedures, incomplete worker induction, and absence of adequate checking systems. The incident led to successful prosecutions and subsequent industry reforms including mandatory engineer certification, specialized training requirements, and compliance packs for swing stage scaffolding.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Swing stage scaffold installed in manner deviating from manufacturer's engineer drawings
- Counterweight box secured with friction couplers rather than positive connection
- Lack of engineering certification for alternative construction method
- Couplers not adequately tightened to predetermined torque
- Method relied on specialized equipment verification rather than visual inspection
- Breach of AS/NZS 4576-1996 and AS/NZS 1576.4-1991 scaffolding guidelines
- No documented procedures for erection in accordance with manufacturer specifications
- No adequate checking and monitoring system for swing stages on site
- Scaffold log books not up to date
- Steven Frank Sayer had not been inducted in use of swing stages
- No system in place to prevent unqualified workers from accessing scaffold
Coroner's recommendations
- Industry adoption of load testing of suspended scaffolds to ensure safety for use
- All aspects of design of suspended scaffold systems and inspection of initial installation to be carried out by suitably qualified engineer
- Implementation of compliance pack containing documentation for design, testing, inspection of swing stage scaffolds
- Ongoing active review and auditing of swing stage operators by WHSQ
- Enhanced inspector training for identification of non-compliance with operation and erection of swing stage scaffolding
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