Inquest into the Death of John Robert BORRADAILE
Deceased
John Robert BORRADAILE
Demographics
26y, male
Date of death
2013-02-04
Finding date
2018-04-30
Cause of death
Neck injury from falling glass crate
AI-generated summary
A 26-year-old labourer died from severe neck trauma when a 1.4-tonne glass crate fell on him during container unloading at a small glass import business. The crate became destabilized while being dragged from a sea container and toppled, striking his neck despite company policy prohibiting work in the fall zone. Critical failures included: no written protocols or Job Safety Analysis documents, inadequate task-specific training, lack of toolbox meetings before hazardous tasks, and failure to reinforce safety procedures despite a prior similar incident in 2011. The deceased, new to both the company and Australia, was not specifically allocated this task and lacked formal reminders of hazards. While individual judgment and common sense suggest avoiding the fall zone, the reality of workplace pressures caused safety awareness to lapse. The coroner emphasized that conscious reminders and formal risk assessments must precede each hazardous task, not rely on assumption of employee knowledge.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Absence of written protocols for container unloading
- Lack of Job Safety Analysis (JSA) documents
- No formal task-specific training or toolbox meetings
- Failure to reinforce fall zone hazards despite prior incident
- Employee positioned in fall zone during crate movement
- Crate became destabilized and toppled due to catching on container floor
- Limited space preventing safe escape from fall zone
- New employee not allocated task and lacked formal safety reminders
- Supervisor and experienced workers concentrated on their specific tasks and did not redirect employee away from hazard
- Company culture of routine task completion without reinforced risk assessment
Coroner's recommendations
- WorkSafe publish appropriate guidance materials on its website including NSW WorkCover Handling Glass Safely guidelines and NSW SafeWork NSW Guide for Unpacking Shipping Containers
Full text
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