Finding into death of Noel Imbrogno
Deceased
Noel Ian Imbrogno
Demographics
43y, male
Date of death
2013-07-01
Finding date
2013
Cause of death
Multiple injuries sustained in a motor vehicle incident (passenger)
AI-generated summary
A 43-year-old man died from multiple injuries sustained when the truck he was a passenger in collided with a power pole. The driver lost control after the driver's seat collapsed due to pre-existing mechanical failures in the seat base. The seat had been reported as faulty months earlier but was never properly repaired. Expert investigation identified that the seat failure was sudden and unexpected, causing the driver to jerk the steering wheel. The collision was entirely preventable had the employer implemented effective vehicle maintenance, inspection, and defect reporting systems. Key lessons: establish robust written defect reporting procedures, ensure timely repair of identified vehicle faults, conduct regular safety inspections, and maintain clear communication between drivers, supervisors, and maintenance providers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Faulty driver's seat with cracked base and broken welds in seat mechanism
- Failure to repair known defect in driver's seat despite previous reports
- Inadequate vehicle maintenance and inspection system
- Weak defect reporting and rectification procedures relying on verbal communication
- Failure of scissor mechanism components due to fatigue cracks
- Sudden and unexpected seat collapse causing driver to lose steering control
Coroner's recommendations
- Startrack undertake periodic review of system of work relating to reporting and rectification of vehicle faults, periodic and routine maintenance and servicing of heavy vehicles, and general safety of vehicle fleet
- Startrack undertake periodic review of system of work relating to induction of new employees and regular training of workforce, including regularly employed subcontractors, in procedures relating to inspection and reporting of vehicle faults to management
- VicRoads review publications and information distribution to heavy vehicle operators to promote awareness of importance of periodic and routine maintenance and servicing, safe systems of work for defect reporting and repair, and inherent dangers of failure to do so
- WorkSafe review publications and information distribution to heavy vehicle operators to promote awareness of importance of periodic and routine maintenance and servicing, safe systems of work for defect reporting and repair, and inherent dangers of failure to do so
- National Heavy Vehicle Regulator review publications and information distribution to heavy vehicle operators to promote awareness of importance of periodic and routine maintenance and servicing, safe systems of work for defect reporting and repair, and inherent dangers of failure to do so
- Insurance Council of Australia review Code of Practice, publications and information distribution to heavy vehicle operators to encourage awareness of importance of periodic and routine maintenance and servicing, safe systems of work for defect reporting and repair, and inherent dangers of failure to do so
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