In reading through the Queensland Coroner’s investigation into the deaths of three insulation installers, one is struck by how a series of cascading mistakes led to tragic consequences.
Differing circumstances of the deaths
Firstly, what has been missed in much of the reportage is that the circumstances of each death were quite different.
While it makes for great television having a grieving family on the 7.30 Report say they want Kevin Rudd to disappear, if we are to avoid such mistakes in the future we need to look a lot deeper than simply blaming Rudd.
Two of the people who died, Matthew Fuller and Mitchell Sweeney, were electrocuted as a result of putting a metal staple through an electrical cable, which then made the foil insulation they were working on electrically live. However there were major differences surrounding these two deaths.
Matthew had barely commenced working, had not received any real training, and was not being supervised by anyone at the time of his death. His employers were well aware of the danger that staples could pierce electrical cables leading to electrocution and death.
He may have been warned to avoid putting staples through electrical cables. But it seems likely the fatal consequences of doing this were not adequately explained and little was done to minimise the risks of this occurring (for example by not using metal staples as a bare minimum).
Considering the inadequate training and supervision, his death was a mistake waiting to happen.
Mitchell’s death took place after Matthew’s.
Mitchell had completed insulation installation training and had been installing insulation for some time. As a consequence of Matthew’s death, Mitchell had been told to not use metal staples by his employer, and had also been provided with a plastic fixings stapler, which he was instructed to use. He was also instructed about switching off power to the house.
In spite of this Mitchell chose to use metal staples and did not attempt to switch off the power supply.
The third person who died was Rueben Barnes, who was installing insulation batts, not foil. According to the Coroner, Rueben Barnes, like Matthew, had inadequate training. Also the Coroner felt the level of supervision provided was “lax”, even though the supervisor was at least on site.
Yet according to the Coroner’s report:
“It is unlikely these inadequacies directly contributed to Rueben’s death. He was killed by a hidden trap created by another tradesman [who had pieced an electrical wire with a metal screw which had electrified a metal batten in the roof].. before the job in which Rueben was engaged.”
The supervisor of Rueben had checked the power board and assumed a circuit breaker would flick-off to prevent an electrocution. Unfortunately the electrical wire that was pierced was not connected to the circuit breaker.
So what can be learnt from this?
The stand-out lesson is never assume that other people will do the right thing and to design around this reality of life.
While you’d think firms would take their responsibility for safety extremely seriously, sometimes money and laziness can overwhelm commonsense.
Foil insulation should not have been used in the first place
Firstly, retrofitting foil insulation to homes is a risky endeavour. Metal foil conducts electricity and a lot of Australian roofs contain poorly installed and unsafe electrical wiring.
Even if the wiring is fine, it can still pose dangers in the cramped and dark spaces of ceiling cavities. This was well known to a wide range of people in the insulation sector and the electrical trades.
Insulation manufacturers should not have been pushing foil insulation for retrofits, certainly with inexperienced insulation installers. Plus installer firms should have recognised the dangers of foil and refused to use it.
But commercial interests overwhelmed safety concerns. Indeed some companies even tried to suggest to customers and employees that their version of foil insulation didn’t pose risks of electrocution when it plainly did.
Foil should not have been eligible for the government rebate.
Some firms will cut corners on safety where quick bucks are on offer and regulators have trouble keeping up
State laws involve severe penalties for firms that fail to ensure a safe workplace for their employees. But the case of Matthew Fuller illustrates that some firms don’t take this seriously enough.
Also it seems that the responsible state government regulators were not on top of their job.
The Coroner concluded:
“I am of the view the two Queensland safety agencies did not react with sufficient urgency or decisiveness to information and activity that should have alerted them to the real likelihood that the risk of death or injury in home insulation activity would significantly increase with the commencement and implementation of the HIP.”
Unfortunately the federal government wasn’t alert to these state government inadequacies. The Coroner’s report states:
“Mr Carter [a federal government public servant] accepted nothing proactive was done from DEWHA’s [department in charge of insulation program] perspective and that it was simply an assumption that the states would be able to regulate the HIP.”
Is the federal government primarily responsible for the deaths of Matthew Fuller, Mitchell Sweeney and Rueben Barnes, as well as the house fires associated with the insulation program?
An honest examination of the evidence would have to acknowledge there were other equally important factors involved. In particular there were latent dangers already in place prior to the insulation program commencing, which still remain to be fixed:
-- Poor standards of electrical safety across the Australian building stock (lack of safety switches, poorly installed halogen lighting, worn out and improperly laid-out wiring); and
-- Inadequate levels of workplace and electrical safety regulation.
At the same time, by turbo-boosting the installation of insulation, the Australian government hightened the likelihood of these risks leading to problems. In that respect they must shoulder a share of the responsibility.