Coroner's Finding: Gleeson, Craig; Lucas, Alistair & Welsh, Michael

Contributing factors

• Use of unsecured, structurally inadequate King Billy pine timber platform
• Failure to wear correctly secured safety harnesses despite training
• Lack of proper engineering and design of work platform
• Failure to use skip bin as protective barrier
• Absence of supervision to ensure safety equipment compliance
• Inadequate procedure clarity and documentation (competing SOPs)
• Mud rush event from unstable draw point TD14 with inadequate instantaneous warning systems

Coroner's recommendations

1. No further use of temporary work platforms; only properly designed, engineered and constructed platforms to be used
2. All workers required to use appropriate fall arrest equipment (harnesses and lanyards) in all appropriate circumstances
3. All workers to be trained in use of fall arrest equipment
4. Regular auditing and supervision of adherence to fall arrest equipment use
5. Auditing of risk management tools and decision-making to be formalised and made consistent with NSW code of practice for inundation and inrush hazard management
6. WorkSafe Tasmania should avoid having records of interview conducted by retained expert witnesses during investigations