Finding into death of Dwayne Robertson
Deceased
Dwayne Charles Robertson
Demographics
37y, male
Date of death
2010-11-16
Finding date
2012-12-06
Cause of death
Hypoxic brain injury from low-voltage electrocution
AI-generated summary
A licensed electrical worker died from hypoxic brain injury three days after receiving a low-voltage electrocution. While installing new rising mains at an office building, he threaded an earth conductor through a live current transformer chamber, despite being informed the bus bars were energised. He came into contact with live parts and received a prolonged electric shock. The incident was attributed to inadequate risk assessment, failure to isolate supply despite safer alternatives being available, and lack of appropriate protective equipment and precautions as required by electrical safety standards and the Code of Practice. Proper isolation, risk assessment, and protective measures could have prevented this fatality.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Failure to isolate electrical supply despite technical capability to do so
- Installation of earth conductor through live current transformer chamber
- Lack of appropriate protective equipment (no rubber mats, face shields, or low voltage gloves)
- Failure to follow Code of Practice for Safe Electrical Work and AS/NZS 4836:2001
- Inadequate risk assessment for work on live electrical equipment
- Failure to implement alternative routing options (cable tray on top of switchboard)
- Absence of safety observer or assistance requirements for live electrical work
- Distribution company seal on CT chamber removed, chamber left accessible
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