Coroner's Finding: GOROSTIAGA Jessica

Contributing factors

• Sudden whirlwind with wind speed estimated at 100-120 km/hr
• Inadequate anchorage system design by manufacturer
• Soft anchor pins supplied by manufacturer unsuitable for hard ground
• Operator modification using car axle half-shafts with rope attachment to compensate for manufacturer-supplied pins
• Rope attachment to webbing caused webbing failure through 'choking' mechanism
• Poor engineering design process lacking proper safety margins and wind-loading analysis
• No dynamic loading or gust wind evaluation in design calculations
• Inflatable structure lifting off ground when anchorage webbing failed

Coroner's recommendations

1. Review Australian Standard AS3533 to establish expected wind conditions including sudden changes that inflatable structures must withstand with appropriate safety margins
2. Require design of anchorage systems proven capable of withstanding established wind conditions with appropriate safety margin before structures are approved
3. Require Workplace Services to refuse registration of inflatable structures for commercial use unless they comply with revised standards
4. Implement wind-velocity testing to establish whether particular systems will cope with required conditions before approval
5. Establish proper engineering design process that first determines operating conditions, then designs equipment to cope with those conditions multiplied by reasonable safety factor