Finding into death of Gaylee Antillia Kati
Deceased
Gaylee Antillia Kati
Demographics
40y, female
Date of death
2004-06-28
Finding date
2013-01-21
Cause of death
Crush injury to the chest
AI-generated summary
Gaylee Kati, a 40-year-old waste collection driver, was crushed against a power pole by the side loader arm of her truck on 28 June 2004. She had used cannabis after leaving the depot and before her death. She exited her vehicle without engaging the handbrake or putting it into neutral, allowing the truck to roll forward and crush her chest. Toxicology detected delta-9-tetrahydrocannabinol at 19ng/mL, consistent with use 1-2 hours before death. Contributing factors included inadequate mobile supervision, lack of driver intoxication awareness among supervisors, equipment design limitations, Ms Kati's inconsistent work history reporting, and her cannabis use during work. The coroner found that implementation of an automatic "Maxi brake" would have prevented her death. Recommendations focused on enhanced supervision, supervisor education on drug effects, automatic brake systems, external emergency stops, and regulatory amendments to include vehicle-mounted equipment in occupational health and safety plant regulations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Cannabis use during work hours
- Failure to engage handbrake before exiting vehicle
- Failure to put truck into neutral before exiting vehicle
- Inadequate mobile supervision of waste collection driver
- Supervisor unfamiliar with recognising drug-affected individuals
- Equipment design lacking automatic emergency braking
- Inconsistent reporting of driving accidents and work history by employee
- New equipment in routine operation for only 2 months
- Employee only 4 weeks into role with new equipment
Coroner's recommendations
- Cleanaway appoint a full-time supervisor to provide greater supervision of waste collection driver/operators performing recyclable waste collection tasks
- Cleanaway better educate operational supervisors to increase their awareness of the effect of cannabis on skilled performance and risk and ensure appropriate responses to suspicions that cannabis is an issue in the workplace
- Cleanaway continue to fit all their domestic side loader vehicles with a 'Maxi brake' that engages if the driver exits the cabin while operating it in left hand drive without engaging the handbrake
- Cleanaway ensure that there is an emergency stop button on their domestic side loader vehicles which is accessible from outside the cabin
- The Government of Victoria amend the definition of 'plant' in the Occupational Health & Safety (Plant) Regulations 2007 to ensure that equipment mounted on a vehicle used primarily as a means of transport on a public road is not excluded from the provisions that impose duties on the designers of that equipment
Full text
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