Garyjamescook 001509 part2
Deceased
Cook
Demographics
male
Date of death
2008-12-30
Finding date
2012-10-11
Cause of death
Electrocution from contact with energised low voltage overhead electrical conductors
AI-generated summary
Mr Cook, a high voltage electrician at Thales Australia's Mulwala facility, died from electrocution on 30 December 2008 while maintaining overhead power lines from an elevated work platform. Despite being suitably qualified, critical systemic failures preceded the incident: switching instructions required by Thales procedures were absent, electrical access permits failed to clarify which power lines were de-energised, and work proceeded near energised low voltage conductors without protective insulating mats. The coroner could not determine if Mr Cook knew the wires were live but concluded he should have treated them as energised. No evidence of personal error by Mr Cook was found, but deficient safety protocols and documentation were identified. Thales subsequently implemented improvements including insulated cable replacement and revised procedures. Recommendations addressed mandatory electrical safety standards requiring protective measures, consideration of alternative work methods, and improved documentation of switching instructions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Absence of switching instructions as required by Thales procedures
- Inadequate documentation of which power lines were de-energised in electrical access permits
- Work conducted in close proximity to energised low voltage conductors without protective measures
- Earthing sticks placed within insulated elevated work platform, removing its insulating capacity
- Lack of insulating mats to cover low voltage conductors
- Deficient safety protocols and guidelines in electrical maintenance procedures
Coroner's recommendations
- Energy Safe Victoria and national authorities should review electrical safety legislation and standards to mandate that work in close proximity to live conductors only be undertaken when no viable alternative is available
- Mandate that insulating mats or other sufficiently protective methods be used to prevent contact with live conductors when work is conducted in close proximity
- Require switching instructions to be incorporated into the same document as Electrical Access Permits when work is to be conducted in proximity to high or low voltage lines
- Mandate that documentation of consideration of all possible work alternatives be included in the Electrical Access Permit
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