Coroner's Finding: CASTILLO-RIFFO Jorge Alberto

Contributing factors

• absence of Safe Work Method Statement (SWMS) for scissor lift patching work
• unsafe work method with extremely limited workspace (360mm×620mm)
• emergency lowering lever positioned flush against safety fence, making it inaccessible and difficult to locate during rescue
• lack of ground spotter
• inadequate supervision and HSE resource allocation
• choice of scissor lift instead of boom lift for task
• no direct supervision of worker
• worker expressed concerns about scissor lift method but did not formally report them

Coroner's recommendations

1. Distribute Elevating Work Platforms information document annually in electronic and hard copy to all building industry participants in South Australia; display on SafeWork SA website with current links; update minimum standard training to include clear lines of sight references
2. Pursue standardisation of scissor lift controls at State and National level; elevate to Council of Australian Governments (COAG) for commissioning of standardisation project
3. Until scissor lift control standardisation implemented, require ground spotters available at all times to activate emergency lowering mechanism
4. SafeWork SA to consider whether WHS Act balance between risk assessment and mandatory rules should shift toward express mandatory rules; raise with SafeWork Australia
5. SafeWork SA to investigate and report on world best practice engineering solutions to protect workers against crushing from overhead surfaces, including secondary protective systems and operator protective alarms; consider reform requiring all scissor lifts in South Australia have secondary protection system
6. Fund representation of worker families at coronial inquests and assign caseworker as single point of contact; consider funding from Victims of Crime fund