Finding into death of Ivica Andrijasevic
Deceased
Ivica Andrijasevic
Demographics
54y, male
Date of death
2016-10-26
Finding date
2022-03-24
Cause of death
neck compression
AI-generated summary
Ivica Andrijasevic, a 54-year-old boilermaker, died from neck compression after being crushed by a malfunctioning Mobile Elevated Work Platform (MEWP) at a construction site. The MEWP's jib switch was defective and failed to return to neutral position, causing uncontrolled upward movement. He was working alone without a safety spotter. Investigation identified multiple systemic failures: inadequate pre-start checks that failed to detect the faulty switch (which had intermittent defects), poor maintenance procedures with inadequate logbook oversight, lack of supervisory controls, and absence of administrative safety measures despite prior similar incidents. The coroner found the death was preventable had adequate safety controls, regular equipment inspections, spotters, and proper supervisor oversight been implemented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- faulty jib lift switch that failed to return to neutral position
- intermittent mechanical defect in toggle switch due to wear and tear
- lack of detection of switch malfunction during pre-start checks
- operator working alone without a safety spotter
- inadequate supervisory oversight of pre-start checks and logbook entries
- poor maintenance procedures and lack of checks and balances
- inadequate Safe Work Method Statements that did not specifically address crushing risks
- failure to implement secondary guarding or alternative work methods
- prior similar incident on 31 March 2016 with defective switch not adequately addressed
Coroner's recommendations
- The Victorian WorkCover Authority should revise Part 6 of its Industry Standard for the Safe Use of Elevating Work Platforms to require mandatory pre-start operational checks of MEWPs
- The Victorian WorkCover Authority should review Part 6 of the Industry Standard to consider which elements of MEWP inspection should be undertaken more regularly than only before the start of each shift or first daily use, specifically testing of directional switch controls should occur throughout the day whenever there is a new episode of MEWP operation
- The Victorian WorkCover Authority should review Part 6 of the Industry Standard to consider the role of the supervisor in the inspection process, including the need for supervisors to countersign logbook entries completed by operators and conduct weekly audits of logbooks to ensure maintenance of complete and accurate records
- The Victorian WorkCover Authority should review Part 2.1 of the Industry Standard to consider recommendations about ongoing training and the regular reinforcement of safety messages regarding crushing risks
- Standards Australia should engage appropriate experts to review AS 2550.10-2006 to consider the circumstances of Ivica Andrijasevic's death and the coroner's findings regarding his preventable death
Full text
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