Finding into death of Nathan Lindsay Park
Deceased
Nathan Lindsay Park
Demographics
23y, male
Date of death
2004-09-03
Finding date
2011-08-24
Cause of death
Head injuries (skull base fractures and parenchymal brain injury sustained in formwork collapse)
AI-generated summary
Nathan Park, a 23-year-old carpenter, died on 3 September 2004 when formwork collapsed at a high-rise construction site in Melbourne. He was working on level 7 repairing formwork when a concrete pour commenced on level 8 above him. The formwork failed and collapsed, causing fatal head injuries. The coroner found the death preventable, resulting from multiple failures: inadequate propping (wooden beam instead of proper props), failure to check that level 7 was clear, inadequate barricading, lack of systematic safety procedures, and poor supervision. Workers were not removed from below, no alarm warned them, and supervision was ad hoc. Critical safety steps were skipped: no one checked level 7 before the pour, multiple workers were directed to the same task with unclear coordination, and barricades failed to prevent access. The coroner concluded that proper barricading, checking areas, clear safety responsibilities, and systematic procedures would have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Inadequate propping of formwork - wooden Truform beam used off-centre instead of Acrow props at mid-span
- Failure to check level 7 to ensure area was clear before concrete pour commenced
- Inadequate or absent barricading of the area below the concrete pour
- Lack of systematic safety procedures and enforcement at the construction site
- Multiple workers directed to perform the same task with poor coordination and no tracking
- Absence of documented formwork and propping plans
- No clear allocation of responsibility for worker safety during concrete pours
- No alarm or warning system to alert workers to evacuate below the pour
- Ad hoc approach to safety management rather than systematic procedures
- Supervisor's failure to follow up on worker Nathan Park after directing him to the job
Coroner's recommendations
- Minister for Planning to endorse and oversee review by Building Regulations Advisory Committee and Building Commission of compliance with building regulations, industry guidelines, and accepted practices in formwork
- Building Commission to review effectiveness of current means of monitoring compliance with Building Regulations 2006 and Occupational Health and Safety Regulations 2007 specific to formwork construction, in consultation with WorkSafe
- Enforcement of use of barriers and barricades on floor below during concrete pours
- Delegation of clear responsibility to a concrete pour crew member to check the floor below before the pour commences
- Use of barricading at the jump to prevent inadvertent entry during concrete pours
- Adoption of alarm or siren system to signal 'clear the area/floor' to reinforce that the floor below a pour is a no-go zone
- Conduct of JSA (Job Safety Analysis) meetings at the commencement of every floor in multi-storey complexes
Full text
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