THE DUBLIN city coroner has said that the recommendations of the jury after an inquest into the workplace death of a young man in a new job would be formally communicated to the Health and Safety Authority (HSA) and the employers body Ibec.
The jury returned a verdict of death by misadventure at the inquest into the death of the electrician, who suffered head injuries when a boiler exploded at a Dublin sweet factory.
Stephen O’Brien (24), Rathmullen Road, Drogheda, Co Louth, died at the Mater hospital on October 5th, 2007, after an explosion at the Haribo Dunhill factory in Finglas the previous day. It was his second week working at the factory.
An inquest heard that there had been a problem with a steam boiler, which was vital to production at the factory, for about a week before the explosion and that it stopped working on the morning of the explosion.
CCTV shows Mr O’Brien, accompanied by Roderick O’Rourke, who was injured in the incident, entering the boiler room with tools in his hands about 15 minutes before the “violent explosion” occurred.
An investigation by the HSA concluded that the source of the explosion was a “bunching” of wires in the burner control panel and that the bunching was carried out by Mr O’Brien.
Electrician Henrick Banaszewski, who was sick on the morning of the explosion, told the inquest he would not have let Mr O’Brien touch the panel on the boiler if he was with him.
Dublin City Coroner’s Court heard that the day before the incident, a faulty part was identified as the source of the problem.
Arrangements were made for a new part to be couriered over the following morning.
In the meantime, the faulty contact, which was found to be working, was refitted.
Engineer with the maintenance company Ken Birney showed the factory head of engineering Les Keating how to operate a “short- cut” to get the boiler working in the event that it failed to operate.
Mr Keating, giving evidence on an earlier date, said he did not make any arrangements to have the auxiliary contact bypassed by Mr O’Brien or by anybody else.
Coroner Dr Brian Farrell said there were a number of risk factors, including the communication between the employees.
“Stephen may have felt he had sufficient information to proceed to the boiler room that morning . . . it seems he felt he had sufficient knowledge and was entitled to go to the boiler room,” said Dr Farrell.
The deviation from the normal work practice by the electricians the previous evening was also a risk factor, he said. Mr Banaszewski had agreed to fit the new auxiliary contactor despite the fact that electricians never touched the boiler apart from pressing a restart button.
A jury of three men and three women returned the verdict under the direction of the coroner. It recommended that all new employees should be supervised and/or work-accompanied by an experienced member of staff until an adequate induction period had elapsed.
It also recommended that rules in relation to restricted access areas should be rigidly enforced by all organisations and that handover procedures and written detailed logs should be maintained by manufacturing companies.
A file was sent to the DPP but no prosecutions were directed.
Mr O’Brien’s parents, Seán and Annmarie, were in court with their two other children, John and Louise, and other family members.