SafetyInsights.org

Another coroners investigation that may interest you. This involved the deaths of two track workers after being struck by a reversing track machine.

The coroner noted that:

·     Technology that was relied on wasn’t able to provide the info people needed, when they need it, such as via a dirty reversing camera as it wasn’t covered by the wipers

·     An extensive pre-start checklist was supposed to be in place – but this was time consuming (and didn’t consider the camera as a safety asset anyway)

·     Because of how onerous the checklist was, they would perform “cursory checks” and then mark the entire checklist as performed

·     Hence, this was a “tick and flick” process that “eroded the [intended] assurance”

·     Beliefs around what ‘safe working’ meant boiled down largely to looking out for your mates rather than specific worksite protections

·     Thus “The axiom ‘look out for your mates’ may have been well intended but the reality was that no individual person was in control of track protection within [this] worksite”

·     Reliance on the horn to alert workers was also inappropriate, since the horn activated in the forward facing direction only. Moreover, the track workers had no practical means to communicate with the plant operators other than visual

·     Hence, safety arrangements didn’t meet local work requirements

·     The coroner said “A blame culture existed within the Trackside Systems and Resurfacing local Districts at the time of the collision, which contributed to a reduction in the level of safety reporting”

·     And a whole host of other issues were present, including production pressures, inadequate risk assessment and safety communication, cumbersome incident reporting processes, lack of spot audits/inspections which masked inadequate track protection, and problems with the inspectorate

Ref: Coroners Court (2016). Non-inquest findings into the deaths of Jamie Christopher ADAMS and Gary Robert WATKINS

Report link: https://www.courts.qld.gov.au/__data/assets/pdf_file/0007/457558/cif-watkins-gr-adams-jc-20160119.pdf

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