Inquest into the Death of Robert Stephan Hamiora SERJEANT
Deceased
Robert Stephan Hamiora SERJEANT
Demographics
25y, male
Date of death
2011-07-13
Finding date
2017-04-18
Cause of death
Multiple injuries from concrete soakwell lid falling on deceased
AI-generated summary
An experienced crane operator/rigger was fatally crushed when an 800 kg concrete soakwell lid fell during a lifting operation. The lid was attached using 2.5 tonne lifting clutches on 1.3 tonne anchor pins (the wrong size), causing the clutches to slip when the inherently unstable load (only two lifting points) tipped during crane slewing. Multiple preventable errors were identified: inappropriate equipment design and manufacturing tolerances allowing mismatching of clutches and pins, unstable lift configuration (only two lifting points instead of three or four), and the worker remaining in the drop zone. The coroner found no current regulatory framework applied to precast concrete elements in civil construction, unlike building construction which had standards. The case demonstrates the need for extending AS 3850:2015 safety requirements to civil works.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Mismatched lifting equipment - 2.5 tonne clutches used with 1.3 tonne anchor pins
- Poor manufacturing tolerances allowing clutch/pin mismatching
- Inherently unstable load design with only two lifting points
- Worker positioned in drop zone during lifting
- Absence of regulatory framework for civil construction precast elements
Coroner's recommendations
- That the Western Australian Commission for Occupational Safety and Health and the Minister of Commerce consider and, if appropriate, implement as soon as possible amendments to the Occupational Safety and Health Regulations 1984 to apply the requirements of AS 3850:2015 to civil construction works.
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