$400k fine for fatal crane incident

Australian rental company Clark Cranes has been fined $400,000 following a tragic incident in September 2018, in which a fully loaded 1.5 cubic metre concrete bucket fell from one of its tower cranes on the site in the Box Hill suburb of Melbourne, Victoria, killing a man and leaving another, 28, with life changing paralysis.
The crane shortly after the incident occurred

The failure was caused by a missing split pin that normally retains a castellated nut on the end of the shaft/pin on the hoist cable termination fitting. Without a split pin the critical nut was able to gradually loosen and - one assumes - drop off, which in turn enabled the shaft /bolt to work it's way out of the clevis in the hoist rope termination assembly, allowing the load to freefall onto those working below.
How the nut should have been installed

Clark Cranes was found guilty of breaching one critically important occupational health and safety law in a jury trial, which found the company guilty of ‘failing to ensure equipment was safe and without risk’. Clark had imported, commissioned and installed the new Raimondi crane on the multi-storey apartment block development almost three months earlier.
Sadly one of these was missing

The judge noted the company was not charged with the death of Shaun Burns or injuries to his colleague. He also said: “Measures were available to Clark Cranes to address the risk, including examining the bolt at the time the crane was received, or installed at the work site, and inserting a new pin if one was missing or replacing it if the pin was faulty. But there was evidence that such an inspection was not industry practice, and it would be reasonable for Clarke Cranes to expect quality assurance practices had been adhered to by the manufacturer, Raimondi Cranes.”

“While the likelihood of an incident occurring because of a missing or improperly fitted split pin was low, the risk of death or serious injury arising from a failure of the rope hoist termination assembly was high. Such a failure was likely to occur when the crane was in operation, at a time when the site was occupied. As the incident of September 6th demonstrates, the likely outcome would be catastrophic. I am satisfied the company knew, or should have reasonably known, that the bolt was critical to the safe operation of the crane and that it would have been obvious to a competent person that the split pin was an essential safeguard.”

However, he also pointed out Clark's professionalism and good safety record, describing the company as a good corporate citizen that had taken substantial steps since the incident to ensure a similar tragedy did not occur. The maximum fine for the offence was $1.42 million.

WorkSafe said that its investigators had found that it was reasonably practical for Clark Cranes to have ensured the split pin's presence by completing a thorough inspection, adding: "This tragedy should never have occurred, and WorkSafe will continue to prosecute employers who fail in their duty to provide safe equipment."
For more information see:
Fatal Crane incident in Melbourne
Worksafe statement on fatal crane incident
Update on the Box Hill incident


FAO Michael Clark esq
Chief Executive Officer.
Clark Tower Cranes
2 - 4 Cameron Parade,
Victoria, Australia 3658.

Good Morning Mr Clark,

Thank you for your phone call last Friday Morning confirming
Receipt of the ’Safety Checklist’ book that I posted to you.

As your Colleagues in the UK Construction Plant Association (CPA)
will confirm, I personally have researched and corroborated
1311 Crane and Lifting Incidents worldwide since 7 May 2007.
All of which has led to 735 Fatalities involving 302 Tower Cranes.

These figures are Inclusive of but are not limited to ….

45 x Wind Turbine Lifting Disasters.
553 x Mobile Crane Incidents.
689 x Examples of Poor Outrigger Set-up or No Mats or both.

As if all that was not bad enough on Wed 10 May 2023 the Jib
of a Luffing Tower Crane in Taiwan became disconnected
from its Pendant Ropes and Boom Foot-Pins to drop the entire
Lattice Structure from a height of 31 x Floors or approx 95
metres (or 311ft) onto a Commuter Train in the Station
below with an Innocent Female Passenger killed by this
negligent act.

Thus confirming once again that Safety is Important very
Important and much too Important to leave it to chance.

I trust you and your colleagues in Australia would agree ?

Yours Sincerely
Mike Ponsonby

May 21, 2023

FAO Michael Clark esq
Chief Executive Officer.
Clark Tower Cranes
2 - 4 Cameron Parade,
Victoria, Australia 3658.

Good Morning Mr Clark,

Thank you for publishing this Fatal Incident on Thursday 6th Sept 2018.

As yours was Tower Crane Incident number 293 in my 16yrs of research
into 1284 Incidents, with 725 Fatalities. It follows that someone should
speak up for Shaun Burns (d) so I will.

1. This Split Pin for your Crane cost me 20 pence on 4 March 2023.

2. This Missing Hookblock Split Pin cost Shaun Burns (d) his Life.

3. This Missing Split Pin then cost you $400,000 Australian dollars.

Therefore this entirely foreseeable and avoidable fatal incident then
Prompts the following searching and necessary questions

4. Was this Hookblock Castleated Nut Inspected before First Use
in Line with legislative obligations in The Work HSW Act 2011.

5. Was this Castleated Nut Inspected again before Daily Use
in line with Work-Safe Code of Practice published in Dec 2015.

6. Why was this Missing Split Pin not Inserted by the Tower Crane
Erection Team OR the Crane Inspectors OR the Crane Operator ?

Please dont declare this Missing Split Pin to be yet another ‘Freak Accident’
or some other Un-acceptable reason. But instead please adopt a Systematic
Approach to Safety by following the Mfrs checklist or better still read
‘Checklist Manifesto’ (to get things done right first time every time)
By Dr Atul Gawande which is ISBN number 9780312430009.

Should you wish to avoid any further damage to your companies excellent
repute, then I will post you my copy of this excellent book for you to apply
In your great company. Please then train all Operators in how to Inspect
Crane Safety and Mechanical functions as these are Fundamentally
important for Tower Crane Safety.

Yours Sincerely

Mike Ponsonby

Mar 9, 2023