Coroner's Finding: Reaney, Leigh Anthony
Deceased
Leigh Anthony Reaney
Demographics
20y, male
Date of death
2012-08-07
Finding date
2018-02-13
Cause of death
Blunt trauma to the head sustained in a fall from gutter boards at a height of approximately 4.7 metres
AI-generated summary
Leigh Anthony Reaney, 20-year-old roofer, died from head injuries sustained in a 4.7-metre fall through an unfixed sump on gutter boards during roofing work. Death was entirely preventable. The approved Safe Work Method Statement (SWMS) was abandoned when roofing iron packs were placed on the roof, forcing workers to use gutter boards as platforms rather than scissor lifts. The deceased wore a harness but failed to attach it—a predictable lapse given the cumbersome manual tying-off system. Critical failures by employer Sherwoods included: rejecting a delivery delay, accepting unsafe working conditions without objection, failing to implement a static tether line, not covering unfixed sumps, and not formally notifying the principal contractor of SWMS abandonment. No secondary review of compliance occurred. Had the approved SWMS been followed or a better harness system (static line) implemented, the death would have been prevented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Abandonment of approved Safe Work Method Statement despite non-compliance with work site conditions
- Placement of roofing iron sheet packs on roof purlins, necessitating use of gutter boards as work platforms instead of scissor lifts
- Employer's failure to reject or delay roofing material delivery despite acknowledged unsuitability of site conditions
- Inadequate fall protection system: cumbersome manual harness tying-off procedure over parapet wall creating predictable non-compliance
- Absence of static tether line for harness attachment along gutter line
- Lack of covering or identification of unfixed sumps on gutter boards
- Failure to formally notify principal contractor Fairbrothers of SWMS abandonment
- No secondary review of SWMS compliance before the accident
- Unsystematic, piecemeal, reactive approach to work methods rather than formal adoption of alternative safe system
- Deceased failed to attach harness safety line—a predictable lapse given system design and worker behaviour patterns
Coroner's recommendations
- Industry must recognize Safe Work Method Statements as central to safe work practices, not merely bureaucratic formalities
- Employers and principal contractors must ensure comprehensive dissemination and understanding of obligations under Work Health and Safety Act 2012, particularly Regulations 299–303 regarding high-risk construction work
- Static tether lines should be standard on roofing and elevated gutter work rather than relying on complex manual harness attachment procedures
- Unfixed sumps and gutter components must be covered or marked with simple systems such as plywood sheets
- Principal contractors must conduct regular compliance reviews of approved SWMS early in high-risk work schedules, not deferred to later phases
- Any substantial departure from an approved SWMS must be formally documented, reassessed, and communicated to all supervising personnel before work continues
- Workers must receive training on the predictable human factors affecting compliance with fall protection systems, particularly regarding harness use on extended gutter work
- When site conditions (material deliveries, slab curing status, equipment availability) make an approved SWMS unworkable, work methods must be formally redesigned and approved before proceeding, rather than adopting ad hoc approaches
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