Deceased
Dwayne Charles Robertson
Demographics
37y, male
Coroner
Coroner Peter White
Date of death
2010-11-16
Finding date
2012-12-06
Cause of death
Hypoxic brain injury from low-voltage electrocution
AI-generated summary
A licensed electrical worker died from hypoxic brain injury three days after receiving a low-voltage electrocution. While installing new rising mains at an office building, he threaded an earth conductor through a live current transformer chamber, despite being informed the bus bars were energised. He came into contact with live parts and received a prolonged electric shock. The incident was attributed to inadequate risk assessment, failure to isolate supply despite safer alternatives being available, and lack of appropriate protective equipment and precautions as required by electrical safety standards and the Code of Practice. Proper isolation, risk assessment, and protective measures could have prevented this fatality.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Error types
Court Reference: COR 2010 4401
Form 37 Rule 60(1) Section 67 of the Coroners Act 2008
Inquest into the Death of: DWAYNE ROBERTSON
Delivered On: 6 December 2012 ._. —- _
Delivered At: Level 11, 222 Exhibition Street Melbourne 3000
Hearing Dates: 6 December 2012.
Findings of: PETER WHITE, CORONER
Representation: Mt S. Russell on behalf of Westwoods
Mr R. Ray, QC with Mr S. Stafford on behalf of Citipower Mr J. Murphy on behalf of Energy Safe Victoria
_ Ms E, Watson on behalf of WorkSafe Mt R. O’Neill for Christopher Elliot
Police Coronial Support Unit Senior Constable Kelly Ramsey, assisting the Coroner
1 of 2
I, PETER WHITE, Coroner having investigated the death of DWAYNE ROBERTSON
AND having held an inquest in relation to this death on 6 December 2012 at MELBOURNE find that the identity of the deceased was DWAYNE CHARLES ROBERTSON bom on12 June 1973 and the death occurred on 16 November 2010 at 158 City Road, Southbank 3006 from: .
1(a) HYPOXIC BRAIN INJURY 1(b) ELECTROCUTION (LOW VOLTAGE)
in the following circumstances:
Alfred Hospital, 55 Commercial Road, Melbourne, from 1(a) an oxy brain injury, and 1(b), an
electrocution as a result of a low voltage shock which was sustained some three days earlier,
that is on 13 November at Hanover House, 158 City Road, Southbank.
Johnson (attached) save the reference at paragraph 8 of that report to the suggestion that he
was given access to the chamber by Citipower to run the earth conductor.
3, Thave no further comments to make and I have no further recommendations to make and I
thank counsel for their assistance. I am sure I speak for all present when I extend to Mr
Robertson our sincere condolences for your loss.
I direct that a copy of this finding be provided to the following: Mr David Robertson, next of kin
Senior Constable Mary White, Major Crime Investigation Unit, inwestigatine™ Member
Interested Parties
Signature:
\
Date: 6 December 2012 ; a
2 of 2
energysafe
Report
of
Fatality — electrocution
158 CITY Road
SOUTHBANK 3006 VIC Incident Date — 13/11/2010
Investigation Date — 13/11/2010
| This report contains confidential information and is subjected to a duty of confidentiality. The information may only be disclosed to other persons with express written consent of Energy Safe Victoria, The information may only be used for a lawful purpose which is directly related 10 your functions and activities. Where information from this report is incorporated in documents other than ESV documents, which are subject to
freedom of information requests, such requests may be transferred to ESV in accordance with the Freedom of information Act 1982.
TO: Director of Energy Safety FROM: Greg Johnson- Enforcement Officer . RE: Contact - Shock VICTIM: Dwayne Charles Robertson LOCATION: 158 CITY Road
Synopsis.
_| On or about 10:42 hours on Saturday 13" of November 2010 Energy Safe Victoria was informed of an Incident at 10:00 involving an licensed electrical worker receiving an electric shock.
Energy Safe Victoria attended the scene at Hanover House, 158 City Road, Southbank.
The incident involved an electrical worker installing new unmetered sub mains from the main switchboard on the mezzanine floor to take off boxes on each of the six floors. The works also included the removal of existing mineral insulated metallic sheathed cables.
While installing the new earth conductor in the main switchboard the victim installed the earth conductor through the current transformer chamber. The supply to the chamber had not been isolated and there was access to live parts, During the course of this work the victim came into contact with live parts. He remained connected until a fellow employee removed him from
supply.
The electrical supply was isolated by jamming the aluminum top plate of a 1.2m fiberglass ladder between the victim and the live parts. This ruptured the protection fuses in the substation isolating supply.
On the 16” of November 2010 the victim died of what is believed to have been complications of the electric shock.
———
At 10:42 AM on Saturday the 13" of November 2010, Energy Safe Victoria received notification from the National Response Centre (NRC) that the Metropolitan Fire Brigade (MFB) had reported an electrical incident at the abovementioned address. MFB advised NRC that an electrical worker had been electrocuted.
At 11:30 AM, I arrived on site and introduced myself to Constable Timothy Brannigan (37002) of Victoria Police. Also in attendance at this time was Daryl Taylor, Compliance Officer (Energy Safe Victoria) Damian Harris (CitiPower), Craig Westwood of Westwoods Electrical and Property Services Pty. Ltd., the MFB crew and several workers from Westwoods. Constable Brannigan informed me that there had been a work place incident that involved a worker that was installing new cables. He also informed me that the injured person was Dwayne Charles Robertson, (DOB 12/06/1973) a licensed electrical worker (A40694), an employee of Westwoods Electrical and Property Services and that he had been transported to the Alfred
Hospital in a serious condition.
Information provided was that Christopher Archibald Elliot a fourth year electrical apprentice with Westwoods was a witness to the incident and that he had attempted to free the victim and
raise the alarm.
Discussions on site determined that WorkSafe Victoria would be the lead agency for this incident.
After leaving site I assisted WorkSafe with the taking of Terry Long’s statement at Energy Safe Victoria’s Southbank office. Terry Long’s statement indicated that he had discussion with Dwayne Robertson on what he required to be isolated. He also discussed the installation of the earth conductor, opened the CT chamber and what the safety issues would be if Dwayne chose to use this area to install the earth conductor as the bus bar in the CT chamber would be live. The
CT chamber was left closed.
The incident occurred in the Main Switchboard Room, located at the rear of the mezzanine floor of Hanover House, a six story office building.
On arrival at scene, Daryl Taylor and I were shown the location where the incident occurred by Station Officer David May (MFB). The scene consisted of a switch room approximately 3m deep and 2m wide. The switchboard was located on the north wall.
The center compartment, (current transformer chamber) was opened and had tools located in front of it.
A closer examination of the area, it was noticed that a 70mm sq insulated earth conductor was installed from a penetration through the west wall and the entering the switchboard via the top of the left cable way, it then entered the left side of the CT chamber and exited via the right side to the compartment locating the earth bar. Excess earth conductor was laying on the floor and out the access door. (refer photo 1)
An associated active conductor (185mm sq XLPE) was installed in the same manner but was in the unmetered riser main switch connection compartment located on the left side of the switchboard, The two other active and one neutral conductor where installed through the wall penetration and placed in the south west comer of the room.
I then inspected the unmetered riser main switch and noted that it had a distribution company lock on it and it was in the off position (Photo 5). No danger tags were located on the main
switch.
Daryl Taylor and I then conducted a close inspection of the CT chamber and noted that Red and Yellow bar from the existing CT fuses had arc marks on them (refer photo 3). The Red, Yellow ~ and Blue incoming supply bars had arc marks located on the connection bolts that connected the cables to the bars. There was also an arc mark on the right hand side of the CT chamber. (refer photo 2) The CT chamber was not isolated by the unmetered main switch that was locked off
(refer photo 5).
A small 1.2m. fiberglass step ladder located outside the room had are marks on the aluminum top cap. The arc marks on the top cap were consistent with distance between the marks on the right hand side of the CT chamber and the connection bolts. Christopher Elliot’s statement to Police
' confirmed that the ladder was used to remove Dwayne Robertson from the electrical supply by jamming it between the bus bars and the victim (refer photo 2 and 4).
The victim had already been taken to hospital before ESV attended and there was no evidence of any protective clothing or eauinment.
Located at the front of the CT chamber was a spanner roll, a cordless drill with a 32mm hole saw -
and numerous hand tools. Located under the connection bolts of the unmetered main switch was a inch drive ratchet and socket.
Within the main switch room were electrical drawings that identified the installation being installed in the late 1970’s. The electrical contractor, Westwoods Electrical and Property Services were replacing the original rising mains when the incident occurred.
An inspection of the substation it was noted that all 3, 4(00amp HRC fuses supplying the main
Compliance officers observed that there were3 a number of options to get the earth conductor to the earth bar without running it in the CT chamber. The earthing conductor could have been run on the cable tray located on top of the switchboard and down the cable riser located on the right
hand side of the board.
Photos taken by Daryl Taylor.
The installation is from a CitiPower indoor substation located on the ground floor via 3 x 400amp HRC fused installed in JW 4 holders. The substation was accessed via the car park.
The substation was directly. below the main switch room.
The main switchboard is located at the north end of the mezzanine floor. This supplies a number of main switches including the lift, public light and power and an unmetered rising main to take off boxes located on each floor. These then supply individual tenancies on that floor. The CT chamber would normally be sealed with a distribution company seal. The seal had been removed and the CT chamber door was in the open position. :
There was no evidence of and protective equipment such as rubber mats, face shields or LV gloves.
From the observations made on site, it appears that the electrical installation work was being done was in accordance with the requirements of AS/NZS 3000:2007 known as “Wiring Rules” but failed to comply with Section 43(4) of the Electrica] Safety Act 1998 which states,
Section 43 (4) , A person carrying out electrical installation work must insure that adequate precautions are taken to prevent electric shock or other injury in the handling of electrical circuits or electrical
equipment in the course of that work.”
The electrical contractor requested an isolation from CitiPower for the unmetered riser. This was done by CitiPower Customer Technical Assistant Terry Long at 8:00 that moming. Terry Long discussed with the victim the installation of the earth wire and running it through the CT chamber. Terry Long explained that the bus bar in the CT chamber was live.
There were a number of options to get the earth conductor to the earth bar without running in the CT chamber, The earth conductor could have been installed along a cable tray that was located on top of the switch board and down the cable riser at the right hand side of the board.
The victim was given access to the CT chamber by CitiPower to run the earth conductor. The evidence on site did not show that appropriate protective equipment and procedures as described in section 15 of the Code of Practice for Safe Electrical Work, Low Voltage electrical Installation and AS/NZS 4836. 2001, Safe work on Low-voltage electrical installation had been
followed.
General - Rescheduling the work to a time when power can be isolated must be considered first.
Working on live electrical equipment must only be considered as a last resort and when an adequate risk process has been undertaken, Suitable safety apparel must be wom and only tools and equipment appropriate for the work to be carried out must be used,
15.1. Assessment - An assessment of the associated risks prior to commencing any work on live electrical equipment must be made.
15.2. Assistance - Where in the judgment of the person doing the work that it cannot be carried out safely without assistance or a safety observer, then that person must be
provided with that assistance, or the work delayed until isolation can be arranged.
15.3, Competeney - Any persons undertaking work on live electrical equipment must be skilled and competent in the work to be carried out.
15.4. Precautions - The person responsible for authorising work to be caried out live must specify any particular precautions to be taken to eliminate hazards and to prevent injury.
When work is to be carried out on or near live low voltage equipment, preceutions must
be taken fo prevent the likelihood of simultaneous contact with conductors or conducting objects at different potentials. .
15.5. Safety Apparel - Electrical workers and their assistants must wear appropriate protective clothing suitable for the task when working on, or in close proximity to, live (energised) electrical equipment. Protective clothing wom by personnel must be of
correct fit and in good condition. Refer to section 12 - Safety Apparel.
15.6. Earthing - When working on live electrical equipment having earthed metal, precautions must be taken to ensure earthing continuity is maintained to any component part of the equipment af all times. Bonding conductors may be required to be installed when
removing electrical equipment from earthed metal, e.g. live component part seperated
from its connected earthing medium. Bonding conductors must be rated fo withstand the
Yet through’ energy of the primary protection without failing. —
15.7, Neutral Connections - Particular care should be taken when removing neutral connections as tests may have indicated a de-energised situation. However, when these connections are removed, a voliage may be present befween conductors or between conductors and earth.
15.8. Barriers & Insulation Mediums - Only conductors at one potential should be worked on at any one time and insulated bamiers should be utilised in the work area between conductors of different phases or volfage potentials. Insulating mats or barriers should
be used between electrical workers and conductors and between electrical workers and earth including building structures such as concrete and steel which may be earthed.
The male victim received an electric shock when he came in contact with live parts of the electrical installation while installing an earth conductor for a new rising main system. .
This prolonged exposure to the electrical current is likely to have caused serious injury.
As the current was limited due to the resistance of the body of the victim and other influences, the characteristics of the HRC fuses would not have been expected to have operated and opened.
€g Johnson Enforcement Officer 09/05/11
INCIDENT DETAILS Victim: Street Name: Location:
(Police/C¥A, Ete)
Name: Title: Organisation:
Contact Telephomes
Name: ‘Titles Organisation:
Contact Telephone:
ESV INVESTIGATOR DETAILS Name: Titles
Contact Telephomes
Dwayne Charles Robertson
158 CITY Road
10:00
Peter Collins Senior Investigator Work Safe
1 Yarra Street
Mary White
Detective Senior Constable Victoria Police
637 Flinders Street
03 9247 5413
Greg Johnson Enforcement Officer
03 9271 5446
Photo 2. This image shows the Earth conductor passing though the CT chamber and the arc marks on bus bars and frame of CT chamber and earth conductor that was installed.
Red arrows indicate location of arc marks and green arrow indicates earth conductor.
Photo 3. This image shows are marks on bus bar supplying CT fuses. Red arrows indicate location of arc marks and green arrow indicates earth conductor,
Photo 4. This image shows the arc marks on the aluminum ‘op cap of the ladders, — Red arrows indicate location of arc marks.
Photo 5. This image shows the locked off main switch (bottom left). Blue arrow show locked mainswitch,
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