Coronial
QLDother

Non-Inquest findings into the deaths of Ashley Pangana Morris and Humbereto Ferreira Leite

Deceased

Ashley Pangana Morris, Humberto Ferreira Leite

Demographics

male

Date of death

2016-10-06

Finding date

2025-12-01

Cause of death

Multiple injuries due to or as a consequence of concrete wall collapse

AI-generated summary

Two workers, Ashley Morris (34) and Humberto Leite (55), were fatally crushed by collapsing concrete wall panels on 6 October 2016 while installing foul water settling tanks at Eagle Farm Racecourse. The work system designed and directed by Claudio D'Alessandro violated fundamental safety principles. Workers were positioned inside an excavation pit with no escape route, inadequate diagonal bracing (one per panel instead of the required two), no lateral restraint at panel bases, and uneven gravel flooring instead of concrete pads. The fourth panel's installation applied lateral forces that catastrophically failed the bracing system. Compliance with the Tilt-up and Pre-cast Construction Code of Practice 2003 would have prevented the incident. D'Alessandro was charged with manslaughter but proceedings were discontinued after he suffered a stroke in 2019. The principal contractor, Criscon, was successfully prosecuted and fined $625,000.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

occupational and environmental health

Error types

proceduralsystemcommunication

Procedures

precast concrete panel installationmobile crane lifting operationtemporary bracing system

Contributing factors

  • Failure to comply with Tilt-up and Pre-cast Construction Code of Practice 2003
  • No escape route for workers in the excavation pit
  • Structurally inadequate diagonal bracing (one per panel instead of minimum two required)
  • Inadequate lateral restraint at bottom edges of panels
  • Uneven gravel flooring instead of level concrete pads
  • Protruding reinforcement steel creating installation difficulties
  • Lateral forces applied by suspended fourth panel exceeding bracing capacity
  • Lack of engineer-certified design and temporary support system documentation
  • No lift plan or exclusion zones established around mobile crane
  • Workers required to place packing under panel edges in high-risk zone
  • Panels not firmly seated on unstable gravel surface
  • Mobile crane overloaded by approximately 15 percent (though negligible contribution to incident)

Coroner's recommendations

  1. Compliance with the Tilt-up and Pre-cast Construction Code of Practice 2003 is essential for safe installation of precast concrete panels
  2. A minimum of two engineer-designed braces per panel must be used
  3. Effective lateral restraint and safe means of support must be provided at bottom edges of panels
  4. Workers must not be positioned in excavation pits during panel installation; external bracing systems should be used
  5. Concrete footings (deadmen) should be established outside pits for external bracing attachment
  6. Level concrete slabs or strip footings must be provided as panel support surfaces
  7. Professional engineer certification is required for panel temporary support systems and erection loads
  8. Documented lift plans including crane setup locations and exclusion zones must be established
  9. Edge lifters should be used to ensure vertical panel hanging and reduce installation forces
  10. All safety work method statements must be prepared in accordance with codes of practice and strictly followed on site
  11. Principal contractors must audit subcontractor compliance with safety work method statements
  12. No 'live props' or cost-cutting safety measures are acceptable
Full text
Official source Archived copy

Related cases

SA2026-04-23

Coroner's Finding: Nash, Russell

Male·suicide

Russell Peter Nash, a serving South Australian Police officer and Bandmaster, died by suicide in 2021. Before his death, he complained of bullying and harassment by his Chief Inspector. His former supervisor subsequently…

occupational and environmental healthpsychiatrysystemcommunication
TAS2026-06-03

Coroner's Finding: Brown, Nicholas, Wiki, Toni, Winwood, Matthew and Kemp, Belinda

Male, female, male, female·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …

Joint inquest into four deaths of individuals prescribed opioid replacement therapy by Dr J. between September 2016 and August 2017: Nicholas Shane Brown (35), Toni Lee Wiki (38), Matthew Wayne Winwood (47), and Belinda …

addiction medicinegeneral practicediagnosticmedicationmethadone
NSWcommunity2026-01-16

Inquest into the death of Jerwin Royupa

21y · Male·Complications of multiple blunt force injuries sustained when voluntarily exitin…

Jerwin Royupa, a 21-year-old Filipino agricultural graduate, died on 15 March 2019 from injuries sustained when he exited a moving vehicle. He had arrived in Australia on a Subclass 407 training visa, sponsored by an agr…

occupational and environmental healthforensic medicinesystemprocedural

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 —