Coroner's Finding: ORGAN Kelly

Contributing factors

• inadequate welding of post baseplate joint (only 50% of design thickness)
• failure to install reinforcing gussets to all support posts after previous failure
• substandard metal fabrication and welding quality
• structural design that did not account for foreseeable misuse and climbing access
• insufficient clearance between play equipment and sail structure
• placement of hard pine log border directly below fall zone instead of under entire sail area
• lack of maintenance inspection and retensioning of sails after warranty period
• failure to seek engineering advice despite known misuse of structures
• no guy wires for lateral support due to aesthetic considerations and perceived child safety concerns

Coroner's recommendations

1. Development of an Australian Standard for shade sail structures covering: design and construction standards (footings, metal fabrication, welding standards, rust-proofing, material strength); tensioning standards including recommended methods and checking procedures; formulae for stress calculation accounting for wind and storm variables; maintenance frequency standards including retensioning; minimum height standards above play equipment to prevent access to sail surfaces; materials standards; design standards for play equipment layout and placement of ground-level hazards such as borders; and warning signage levels
2. Any future design of shade structures should take into account the possibility that someone may fall from the sail structure when considering placement of hazards below
3. Consideration should be given to discontinuing shade sail structures if access to the sails cannot be prevented