Finding into death of IL Gambero Restaurant Fire
Date of death
2009-08-19
Finding date
2015-11-23
Cause of death
Fire, origin either within a multi-outlet power board or an appliance connected to the power board
AI-generated summary
A fire occurred at Il Gambero restaurant in Carlton, Victoria on 19 August 2009. The coroner investigated the origin and cause of the fire and found it likely originated from either a multi-outlet power board or an appliance connected to it, located on a shelf behind the service counter. The power board had been covered (cocooned) with paper and plastic items. The coroner examined risks associated with power board misuse including overloading, cocooning, piggy-backing, and contamination. Testing of new power boards showed temperature exceedances when cocooned. The coroner found that age and wear of power boards may exacerbate electrical degradation and increase fire risk. Key clinical/safety lessons: power boards are frequently misused and pose fire hazards; public awareness of misuse risks is critical; testing of aged power boards is needed; Standards may require review based on evidence of misuse patterns. Recommendations include joint public awareness campaigns and testing of used power boards.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Multi-outlet power board overloading
- Power board cocooning with paper and plastic items
- Possible piggy-backing of power boards
- Contamination of power board outlets
- Age and wear of electrical equipment
- Lack of public awareness regarding power board misuse
- Use of power boards as permanent rather than temporary fixtures
Coroner's recommendations
- ESV and MFB jointly fund a public awareness campaign to inform the public about the importance of power board safety
- Public awareness campaign to inform the public that power boards are for temporary use and not permanent installation
- Public awareness campaign to inform about power board misuse including overloading, cocooning, piggy-backing, contamination, outdoor use of indoor boards, DIY repair, use of pre-1984 boards, and wear and tear
- Public awareness campaign to inform about possible risks associated with power board misuse
- Public awareness campaign to inform the public how to identify when a power board should be discarded
- ESV in consultation with MFB undertake testing of a range of used and old power boards to determine if cocooning, contamination, wear and tear, overloading, piggy-backing and age causes electrical degradation or safety issues
- Results of testing should be compared against most recent AS/NZS 3105 Standard
- If evidence of electrical degradation or safety issues is found, Standards Australia should review AS/NZS 3105 in light of new information provided by ESV
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —