Finding into death of Keith Phillip Dickman
Deceased
Keith Phillip Dickman
Demographics
56y, male
Date of death
2009-03-05
Finding date
2012-02-29
Cause of death
Head injuries sustained in a fall from a height
AI-generated summary
Keith Dickman, a 56-year-old experienced plumber, died from severe head injury sustained in a fall from a 2-metre 'A' frame ladder while installing air conditioning ducting at height in a ceiling cavity. Working on the fourth or fifth rung, he was using both hands to align and secure builders' strap with an explosive power tool (Hilti gun) when the defective ladder, which had missing rivets and non-standard replacement bolts, shifted and destabilized beneath him. He fell approximately 2.7 metres to concrete, striking his head. The coroner found the ladder was deficient, the work method inadequate, personal protective equipment (helmet and safety glasses) was not worn or enforced, and the Safe Work Method Statement was superficial and failed to identify foreseeable risks. The work should have used stable platforms or been redesigned; alternative methods existed but were not properly assessed or offered to workers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Defective A frame ladder with missing rivets and non-standard replacement bolts causing instability
- Performance of complex two-handed task (air conditioning duct installation) from an A frame ladder
- Use of explosive power tool (Hilti gun) requiring two-handed operation from ladder at height
- Inadequate and incomplete Safe Work Method Statement failing to identify risk of falls
- Failure to provide stable work platform or alternative access method
- Lack of personal protective equipment (safety helmet and glasses) and inadequate supervision of PPE compliance
- Failure to foot the ladder despite complex overhead work
- Relocation of worker to unfamiliar task (spiro ducting) without proper assessment
- Ceiling grid installation prior to ducting work preventing use of safer work platforms
- Work method choice (builders' strap vs allthread) left to individual workers without specification in SWMS
Coroner's recommendations
- Victorian Workcover Authority and WorkSafe Victoria should immediately advise building and construction contractors to cease using A frame ladders for installation of air conditioning ducting and utilise methods providing stable work platforms. A safety alert should be published to this effect.
- Victorian Workcover Authority and WorkSafe Victoria should abolish the distinction between working at height above or below two metres in publications and guidelines to industry in relation to falls protection.
- Victorian Workcover Authority and WorkSafe Victoria should restate in publications the risk of death and serious injuries from falls from any height and that working from ladders is a particular risk.
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