Inquest into the Death of Daren Cheng Lim Tan
Deceased
Daren Cheng Lim Tan
Demographics
23y, male
Date of death
2000-01-19
Finding date
2002-07-23
Cause of death
Thermal injury in association with electrocution
AI-generated summary
Daren Cheng Lim Tan, a 23-year-old graduate electrical engineer in Western Power's training program, died on 19 January 2000 from thermal injury and electrocution at the Coolgardie substation in Western Australia. While undertaking a routine familiarisation visit with a field service officer (Ron Pike), the deceased entered a transformer substation enclosure without authorisation to assist with removing vegetation near a transformer. The substation contained live high-voltage equipment with exposed bushings at dangerously low heights (1.4 metres) that did not comply with Australian Standard AS2067-1984 (which required 2.44 metres minimum clearance). The deceased received approximately 19,000 volts AC and sustained severe burns (80% of body surface) after contact or proximity to a live arcing horn. The coroner found multiple contributing factors: the substation's non-compliance with safety standards, the deceased's inexperience, lack of proper safety clothing, inadequate signage, and the failure to follow the mandatory permit system for substation entry. The coroner made critical findings about Western Power's systems, particularly concerning the widespread distribution of NK6 access keys, lack of documentation regarding the substation's hazardous status, and the absence of warning signs regarding the specific dangers of this installation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Substation did not comply with minimum safety clearances required by AS2067-1984 (exposed live equipment at 1.4 metres instead of required 2.44 metres minimum)
- Failure to follow mandatory permit system for substation access
- NK6 access key system allowed unauthorised entry to operational areas
- Deceased was inexperienced in operational electrical work and did not appreciate the dangers
- Deceased was not wearing appropriate safety clothing or equipment (no helmet, safety glasses, or suitable materials)
- Inadequate signage regarding restricted access and specific hazards of the substation
- Vegetation growth at substation enabled fire to ignite and sustain after initial electrical contact
- Deceased was not aware of lower transformer bushings and associated heightened risk
- Lack of documentation of substation's failure to comply with safety standards
- Field service officer (Ron Pike) did not follow permit procedures and did not advise deceased of specific dangers
Coroner's recommendations
- Western Power should review all operational areas to identify areas that do not meet required safety standards and ensure work is planned as high priority to bring them into compliance
- Implement signage and warning placards in addition to training to remind employees of hazards and ensure only authorised personnel access restricted areas
- Provide all personnel with sufficient information, instruction, training and supervision including refresher training for existing employees
- Implement a permit system ensuring only authorised persons can access operational areas
- Accelerate identification and location of distribution open high voltage bushing ground-mounted substations and issue work parcels to remove, replace, raise or install barriers to comply with AS2067 standard
- Before entering any high voltage aerial bushing transformer compound, an authorised switching operator must carry out appropriate isolation and issue an electrical access permit
- Include comprehensive training on identifying regulated areas and permit procedures in all field employee inductions including engineers and project officers
- Include regulated area and permit procedure awareness in all employee inductions in Network Services Division with well-documented and sustainable record system
- Accelerate review and implementation of multi-tiered master key system to other operational areas and equipment types
- Develop an authorised access and tiered signage plan complementing the new keying system
- Carry out comprehensive public and employee safety risk assessment on all distribution equipment types and build into sustainable ongoing assessment process
- Develop risk mitigation strategies for all identified risks and include in works programmes
- Office of Energy should be given appropriate powers to proactively check and verify compliance with safety standards rather than being confined to reactive involvement after incidents
Full text
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