Finding into death of Thomas Anthony Kelly
Deceased
Thomas Anthony Kelly
Demographics
46y, male
Date of death
2009-10-15
Finding date
2016-06-16
Cause of death
Head injury
AI-generated summary
Thomas Anthony Kelly, 46-year-old concreter, died from a head injury sustained when struck by a concrete pumping truck boom at the Pentridge Village building site on 15 October 2009. The truck, a 42.5-tonne unit with a 48-metre boom, tipped when its passenger-side outrigger stabiliser sank into inadequately compacted ground containing unknown buried pipes and uncontrolled fill. Contributing factors included: failure to assess ground bearing capacity or test site conditions; inadequate packing under outrigger pads (loose softwood timber instead of engineered bog mats); absence of a trained spotter near the pump; the operator being positioned remotely on the upper building level rather than proximate to the equipment; absence of traffic control for concrete trucks; and Kelly working under the boom in an exclusion zone. The coroner found multiple breaches of WorkSafe Industry Standards, Australian Standards AS2550.15, and the Sermac operator handbook. Despite WorkSafe withdrawing charges against West Homes and ICPS in August 2012, the evidence demonstrated significant systemic occupational health and safety failures. The coroner considered the death largely preventable and recommended legislative amendments to expressly incorporate requirements for appropriate staffing and trained spotters in heavy machinery operations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Failure to assess ground bearing capacity and ground conditions
- Failure to test soil conditions prior to establishing pump equipment
- Inadequate packing under outrigger/stabiliser pads - loose softwood timber instead of engineered bog mats
- Unknown and untested ground containing buried pipes and uncontrolled fill
- Absence of trained spotter proximate to concrete pumping truck
- Concrete pump operator positioned remotely on upper building level rather than at pump location
- Lack of visual monitoring of equipment stability by pump operator
- Absence of traffic controller for concrete delivery trucks
- Worker positioned under boom in exclusion zone
- Breaches of WorkSafe Industry Standard for Concrete Pumping (April 2004)
- Breaches of Australian Standard AS2550.15-1994 (Cranes - Safe Use - Concrete Placing Equipment)
- Breaches of Sermac operator handbook requirements
- Inadequate Job Safety Analysis by ICPS - failed to address site-specific risks
- Pressure to complete job after multiple cancellations
- Wet, muddy ground conditions from rainfall
Coroner's recommendations
- Recommended that the Minister for Finance (responsible for WorkSafe) consider the need for Parliament of Victoria to expressly incorporate the requirement of appropriate staffing or availability of a trained spotter to section 27 of the Occupational Health and Safety Act 2004, which addresses plant design information requirements
- Recommended that the Minister for Finance (responsible for WorkSafe) consider the need for Parliament of Victoria to expressly incorporate the requirement of appropriate staffing or availability of a trained spotter to section 29 of the Occupational Health and Safety Act 2004, which addresses plant manufacturing information requirements
- Recommended that the Minister for Finance (responsible for WorkSafe) consider the need for Parliament of Victoria to expressly incorporate the requirement of appropriate staffing or availability of a trained spotter to section 30 of the Occupational Health and Safety Act 2004, which addresses plant supply information requirements
- Recommended that WorkSafe issue Safety Alerts on a regular and periodic basis, not only in response to fatalities, on the dangers of operating concrete pumping trucks including recommendations that a spotter always be available
Full text
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