Inquest into the Death of David Stanley William Poole

Contributing factors

• Improperly positioned packing timbers on crane carrier deck creating trip hazard
• Attempted correction of hazard using foot while standing on elevated platform
• Loss of balance and foot catching on angle iron lip
• Pelvic fracture resulting in immobilisation
• Development of deep vein thrombosis secondary to immobilisation
• Pulmonary embolism and cardiac arrest
• Severe hypoxic encephalopathy

Coroner's recommendations

1. Where possible, maintenance and non-operational tasks on mobile cranes should be performed from the ground
2. Where ground-level performance is not possible, such tasks should be performed from suitable work platforms with appropriate fall arrest equipment if practicable
3. Housekeeping issues in relation to mobile cranes should be addressed appropriately in hazard identification and risk management methods such as job safety analysis by employers and employees
4. Employees should be adequately trained in performing maintenance and non-operational tasks on mobile cranes
5. Employers and employees must ensure housekeeping standards for mobile cranes are maintained at the highest practicable standard at all times
6. Emphasis on continuous compliance with existing Australian Standards (AS2550.1-1993 and AS1418.5-1995) relating to safe operation and maintenance of mobile cranes