Coroner's Finding: Gorrie, Kurt Joshua
Deceased
Kurt Joshua Gorrie
Demographics
28y, male
Date of death
2014-12-08
Finding date
2018-08-03
Cause of death
multiple traumatic head injuries sustained in a fall from height
AI-generated summary
Kurt Gorrie, a 28-year-old experienced roof plumber, died from multiple traumatic head injuries after falling approximately 6 metres from an unmeshed roof section onto a concrete slab while working on an airport extension in King Island, Tasmania. The fall was entirely preventable. Safety mesh had not been installed in the area where he was working, and he was not wearing a safety harness despite them being available and required by the Safe Work Method Statement. The coroner found that Mr Winwood, the De Jong site supervisor, failed to provide safety oversight despite knowing the roof was not fully meshed and work was proceeding. Critically, basic fall prevention devices (mesh and harnesses) were not utilised. The coroner identified poor safety culture, inadequate SWMS understanding and implementation, and insufficient supervision as contributing factors. De Jong had failed to ensure adequate mesh supply before work commenced and did not provide safety instructions when the workers returned to site on the day of the fatal fall.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure to install safety mesh on entire roof before work commenced
- absence of safety harnesses during work on unmeshed roof section
- inadequate supervision by site foreman Mr Winwood
- failure of site supervisor to provide safety briefing or instructions when workers returned to site
- poor safety culture and understanding of Safe Work Method Statements
- inadequate provision of safety mesh materials to the site
- failure to address how work would be completed safely given incompletely meshed roof
- inattention by deceased when stepping onto batten in unsupported area
- batten failure under worker's weight
Coroner's recommendations
- De Jong should implement a proactive approach to safety amongst its workers and contractors on any sites for which it has responsibility
- Consideration should be given to the apparent lack of prosecution of apparent breaches of Work Health and Safety Act by regulatory authorities and the importance of maintaining deterrent effect of workplace safety legislation
- A review should be undertaken in relation to the adequacy of training and instruction delivered within construction industry apprenticeship schemes for Safe Work Method Statements, particularly for working at heights
- Persons involved in work involving reasonable risk of death from falls from heights should be required to undertake regular refresher training regarding SWMS preparation, compliance and enforcement, consistent with continuing education practices in other occupations
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