Coronial
QLD2013-08-15

Morris, Daniel Paul

23y · Male·Electrocution

Daniel Paul Morris, 23, died from electrocution while welding at Ridley Agriproducts in March 2011. He was sitting on a metal hopper (workpiece) with dangling legs in …

systemcommunication
SA2000-11-09

Coroner's Finding: ORGAN Kelly

18y · Female·hypoxic encephalopathy due to raised intracranial pressure caused by severe clos…

…limbing on the sail with friends after consuming minimal alcohol, a support post failed due to inadequate welding at the base. She fell approximately 2.5 metres onto a pine log border, sustaining a fractured skull and m…

proceduraldesign
VICcommunity2010-12-16

Finding into death of Graeme George Watts

67y · Male·Injuries sustained in motor vehicle collision (driver)

…. The vehicle had been improperly converted from a prime mover to a tipper truck in 2002 with substandard welding modifications to the chassis. Critical failures included: brakes that were severely maladjusted (only 2 o…

systemprocedural
NSW2011-07-13

Coroner's Finding: Trevor Drayton and Edgar Orgo

Male·Blast injuries and multiple injuries from explosion caused by ethanol vapours ig…

…iginated in Tank 104 containing 9000 litres of SVR (spiritus vinous rectificatus – ethanol), triggered by welding operations. Mr Orgo, working from a forklift-elevated platform, unknowingly welded on the tank containing…

communicationsystem
QLDPodcast2008-01-16

Wigg, Allan Thomas

44y · Male·Massive brain damage due to multiple skull fractures from crush injuries sustain…

…m causing fatal crush injuries. Critical failures included: (1) Russell Moyle, a hydraulic fitter without welding expertise, welded the pins without realising they were high tensile steel (not mild steel as he assumed),…

occupational and environmental healthproceduralsystem
VICcommunity2013-08-13

Finding into death of Graeme Andrew Dunn

52y · Male·Chest injuries involving massive left haemothorax, right pneumothorax, multiple …

… cracking. Investigation revealed the axle had been repaired after the 1989-90 rollover with non-standard welding and an additional plate, which altered stress distribution and contributed to progressive cracking over 1…

diagnosticsystem
WAcommunity2015-08-18

Inquest into the Deaths of Debra Alexandra TILL and Craig Allan RAABE

Ms Till: head injury with probable crush asphyxia; Mr Raabe: head injury

…A specification. Had proper Wind Region C standards been applied with appropriate tie-downs and certified welding, the dongas would have withstood the cyclone. The preventable deaths highlight systemic failures in const…

diagnosticsystem
VIC2015-07-27

Finding into death of Michael John Jonson

48y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

Michael Jonson, age 48, died from multiple injuries sustained in a motor vehicle collision on the Melba Highway near Vasey Houghton Bridge when a trailer being towed by another vehicle detached and crossed into his path.…

forensic medicinetrauma surgerysystemprocedural
SA2000-07-07

Coroner's Finding: BAULDERSTONE Andrew Grant

37y · Male·Multiple injuries including lung lacerations and contusions, multiple rib fractu…

…51 hooks lacked specified 5mm radius bend, reducing fatigue life 2.5-fold); inadequate quality control of welding; and structural stress from major kiln design changes made without proper engineering analysis. The ancho…

occupational and environmental healthforensic medicinesystemprocedural
QLD2017-07-11

Hooper, Troy Ronald - Non-inquest findings

24y · Male·Penetrating head injury due to industrial accident involving explosion and eject…

Troy Ronald Hooper, a 24-year-old labourer, died from a penetrating head injury caused by an exploding gas strut during removal of a prototype boat rack at his workplace. The incident occurred because the boat rack was p…

diagnosticprocedural
VIChome2004-06-18

RAWSON Donald

67y · Male·Malignant mesothelioma

Donald Rawson, aged 67, died of malignant mesothelioma in May 2003. Investigation traced multiple possible sources of asbestos exposure across his working life and domestic context: probable exposure at Benny Teare Pty L…

TAS2025-02-05

Coroner's Finding: Explosion, Glenorchy

Explosion caused by ignition and deflagration of acetylene leak from a cylinder …

…r should have been stored externally in open air according to manufacturer safety warnings. Luke Campbell Welding failed to ensure correct storage procedures despite clear safety labelling on cylinders warning against e…

proceduralsystem
VIC1996-09-02

GALLAGHER GREEN Kevin

39y · Male·neck injuries from being crushed between a hydraulic ram and hydraulically opera…

Kevin Gallagher-Green, 39, died from neck injuries when crushed between hydraulic machinery at BHP Western Port Steel Works while attempting to adjust a tilt table height. The coroner identified multiple system failures:…

proceduralsystem
NSWcommunity2024-03

Inquests and Inquiries into the 2019/2020 NSW Bushfire Season - Volume 1

Unknown·Thermal injury and burns from bushfire exposure; smoke inhalation

…onditions, and seven firefighters killed in action. Fire causes included lightning strikes and accidental welding ignition. The Coroner made 28 major recommendations targeting the NSW Rural Fire Service, NSW Police, and…

systemdelay

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