Melbourne Box Hill building

Executive Summary

The purpose of this case study report is to explore and examine the Melbourne Box Hill building tragedy of 2018 that lead to the death of one site worker and two others injured on the building site. The report also illustrates the importance of health and safety at the workplace. Due to various unsafe working conditions, the incident was able to pass. Through extensive investigation of the incident, the main cause of the crane calamity was as a result of a missing lock nut split pin on the cable fitting, which led to the loosening of the critical nut. The critical nut eventually fell off releasing the hoist rope which resulted in the drop of the concrete into the construction site. The report includes a literature review that illustrates some of the issues that lead to the Melbourne Box Hill crane accident. Since the root cause of the incident showed a lack of oversight, some recommendations are made including, regular assessments of the workplace to ensure a secure working atmosphere. The report also provides safety procedures that can be followed to avoid such accidents from reoccurring


            In this report, the examination of health and safety in the workstation will be undertaken regarding the death of one site worker and the injuries of the other two personnel after a concrete tub fell from a crane at a worksite in Melbourne Box Hill. Paramedics at the site stated that two workers were submerged and trapped by wet cement (ABC News 2018,). The report examines this tragedy with respect to the health and safety of workers on construction sites around Australia. By advocating for safe working conditions, most fatalities that occur in the construction industry can be avoided. According to Mock et al. (2018), a significant amount of injuries in the construction industry has been reduced due to the development of work security. Melbourne Box Hill crane accident will be examined in-depth to uncover what risky practices can be identified in a construction site. More importantly, those practices will be identified in the case of the Melbourne Box Hill crane accident. The report will also provide recommendations on how to create a safe work environment for workers on construction sites.

Case Description

            On September 6, 2018, a construction site crane in the Melbourne Box Hill area experienced a technical problem. As a result, the crane dropped a tub of concrete on three workers. The wet concrete trapped two employees after the tub fell on them. Paramedics at the site said that one of the trapped workers died but they managed to rescue the other from wet cement (ABC News 2018). The individual trapped by the wet cement suffered extensive body injuries including, bone breakages and internal bleeding.

The main cause of the incident was believed to be a mechanic failure related to a missing component on the crane’s hoist cable fitting. The missing lock nut allowed the critical nut holding the hoist rope to loosen, releasing the drop hook.  Once the drop hook was dropped, the concrete also dropped and fell to the workers at the construction site. Mr. Setka, the Victorian secretary of the construction union CFMEU stated that a hook from one of the hammerhead cranes came off with the kibble still attached to it (ABC News 2018). The kibble is the part attached to the crane that holds concrete. Even if the root cause of the problem was a mechanical one, no one had a clear idea of what caused the issue. Operators did not even know if the split pin was inserted in the first place. However, a witness stated that he heard a noise before the incident and stated that he realized the crane was out of place. According to a witness, the incident was followed by a familiar sound and added that the crane rope was hanging freely in the air.

Before the crane was commenced to work on the construction site, it had been approved by relevant authorities and was confirmed to be working perfectly. Despite these approvals, the crane led to the tragic incident that claimed the life of one person and totally changed the lives of others. These three workers were not the only causalities of the accident since many more people were subjected to serious suffering. All because of one of the smallest elements but vital element of a crane. Witnesses around the construction site said that after the incident many workers left the site in tears. Some of these workers preferred leaving the site and meet with counselors. It was traumatizing what happened at the construction site. It is not something an individual ever wants to see in their lifetime (Smith 2018).

The incident was not only traumatizing but also costly to the city of Melbourne. According to (Smith 2018), urban search experts, rescue teams, and 40 firefighters were required to remove the deceased worker’s body from the site to recover it. Brendan Angwin, assistant chief fire officer, offered his opinion on the whole process to retrieve and rescue the workers and stated that it was an extremely tragic occurrence (ABC News 2018). The reason being that a lot of work was involved in retrieving the workers from the construction site.

The crane that caused the accident was owned by Clark Cranes, the same company that owned a crane that collapsed on another construction site in Richmond (Smith 2018). An alert was issued for all cranes owned by the company and the company was to stop their usage until they have been re-inspected to ensure they met set standards. Businesses affected by the incident considered taking legal action against Clark cranes. The Melbourne Box Hill crane accident is an indication of how ignorant most companies are towards health and safety in the workplace.

Literature Review

Root Causes of Accidents

Human error

            Most accidents in the workplace are a result of the tendency of persons to make mistakes under different conditions. Human error is defined as an act that has negative consequences and affects the overall intended outcome (Kanki 2018). For instance, when changing lanes while driving without signaling may be against the law but can only be deemed as human error after an accident and the error is taken as part of the accident. Also going to work thinking that an accident may never happen is human error. As a result, an individual may tend to sidestep some of the safety precautions that have been put in place or take shortcuts. All these actions can increase the chances of accidents in a workplace. However, all incidents in the workplace should not be blamed on human unsafe characteristics alone since some workplace designs and tasks may not consider human limitations (Abdelhamid & Everett 2000).

Unsafe work conditions

According to Abdelhamid and Everett (2000), an unsafe condition is a state in which the physical workplace setting or the site whereabouts, equipment, and tools’ status do not adhere to the set safety standards. Examples of unsafe work conditions include defective cranes, protruding steel plates, nails, rods, and defective equipment among others. Unsafe work situations also play a big part in causing accidents. Ignorance of safety practices can lead to unsafe work situations resulting in an accident. To improve work safety all involved must be willing to work together to create a safe environment. More importantly, new workers must undergo proper training on how to promote workplace safety. Inexperienced or new workers on a site may act unsafely creating an unsafe working situation for other workers (Abdelhamid & Everett 2000).

Work patterns

            Hours spent in the workplace can influence how people act at work. The human body works differently and maybe vulnerable at certain times depending on work time (Hywel 2018). Extended work time may likely result in fatigue which can lead to an accident. When assessing risk an individual’s work patterns need to be considered since they may contribute to the likelihood of errors at the work. Work patterns can have ab indirect contribution to workplace incidents in addition to direct health risks.

Strategies for Accident Prevention

Safety campaigns

            Safety campaigns are critical to make workers safety conscious and provide them with the opportunity to learn the importance of safety. These safety campaigns are essential in the construction industry in which the probability of accident hazards is very high. Through these programs, workers can be actively engaged and work towards achieving specific objectives such as work safety. Employee engagement is an essential element to promote the effective implementation of safety procedures and programs (Buniya et al. 2021). In the case of Melbourne, safety campaigns can increase employee involvement and in turn, create a work environment that supports safety. Ajayeoba et al. (2019), state that the sharing of safety information can lead to a positive impact on safety work, encouraging safety outcomes.

Safety training

Safety training primarily constitutes teaching workers safety methods of work. It also focuses on understanding any hazards that may be involved. (Buniya et al. 2021) outlines out that training is vital for any safety program since it allows workers to understand specific hazards and risks involved at their place of work. Also, training helps employees to acknowledge various safety procedures and policies at the workplace. When working with machines such as cranes, safety and health training is necessary and can help avoid tragic incidents. In addition, safety training can increase worker awareness of the best workplace practices on safety.

 Worksite analysis

On most construction sites, equipment accidents are common and their maintenance can minimize the risk of accidents. Supervisors and other involved leaders must conduct worksite inspections regularly to maintain equipment and identify any potential hazards Worksite analysis can help in the identification of actual and potential dangers that undermine worker’s safety (Buniya et al. 2021). Moreover, workplace analysis enables involved parties to implement risk management protocols to mitigate safety hazards. These protocols can include regular safety meetings to review set safety measures.

Case Analysis

In the case of the Melbourne Box Hill crane accident, it is clear that lack of oversight and planning contributed to the accident. The crane used in the construction site were left unmonitored over the week. It is an indication that the crane involved in the accident was not regularly checked and maintained. Regular maintenance of building machines is vital and this fact was neglected in the case of the Melbourne Box Hill crane accident. The incident could possibly have been stopped if the project supervisors constantly monitored the crane. The issue of the missing lock nut split pin could have been solved by replacing the component. It was important to monitor the crane since it was new and on its first job. The lack of regular safety sessions played a big part in the tragic incident. In the future, cases of crane accidents can be avoided by implementing safety protocols that promote workplace security.

The work done by the rescue team, firefighters, and specialist urban search was impressive. The reason is that they managed to save two men even if one of the workers did not survive the incident. It was a race against time and they managed to save the two workers trapped under wet concrete. Wet concrete sets as time passes, which means the paramedics had to capitalize on time when they got to the construction site (ABC News 2018). Also, workers traumatized by the event were offered counseling services which was a big step in helping them recover. In addition, the company that owned the crane that caused the accident took responsibility and halted its services until all the machines were re-inspected. It is an indication that the company compiled with the CFMEU request which is exemplary.

The Melbourne Box Hill crane incident of 2018 shows how dangerous the construction industry is; hence, it is important for those working in the industry to observe safety protocols and procedures to save lives.  The crane accident is a reminder to manufacturers and other people of how important it is to check every machine component regardless of its size. Project supervisors need to conduct regular safety and health sessions to avoid any potential hazards. These sessions will not only create a safe working environment but might save a life in the process.


            In my opinion, I believe the Melbourne Box Hill Crane tragedy could have been stopped. As a result, I would begin by recommending companies institute safety measures with regard to their equipment. Before these companies can sell their machines, they should constantly check them to ensure they are up to date set standards. As seen from the case analysis, risk management can play a big part in accident prevention. Therefore, I would also recommend manufacturers implement risk management strategies and identify potential risks and mitigate them. Moreover, these companies can start safety training programs to enable people using their equipment to understand any safety issues.

Additionally, I would recommend project managers to implement a worksite analysis plan. The plan will allow them to conduct regular maintenance and in turn, prevent any actual or potential dangers. The plan will also keep workers updated on their operations and they will know when heavy machinery is being used. In that case, they can avoid surrounding areas near the machines. I would suggest additional oversight near heavy machinery to minimize human error.

All machines used in construction sites must be approved by the relevant authorities. Any machines that are not certified or approved must be prohibited from use. Given the rate at which these accidents occur in Australia, certified inspectors must be deployed to inspect all construction sites. Any construction sites with unapproved machines should be closed and project managers should be taken to court for endangering human lives.   

            Lastly, I would recommend construction sites to implement control measures. Due to the variety of activities taking place in a construction site, workers are at risk of multiple hazards. Thus, hazard prevention and control measures can play a big role in minimizing those risks. The prevention and control system can be designed to match the activities of the construction site. For instance, site supervisors can ensure cranes lift loads that match their specified capacity to prevent them from tipping off. In doing so, not only will safety performance improve but workers will easily adapt to potential changes involving worksite situations.


            The Melbourne Box Hill crane incident was a result of a missing component that was supposed to be attached to the crane’s cable fitting which led to the loosening of the critical nut. The critical nut eventually fell off releasing the hoist rope. As a result, the concrete load dropped in the worksite killing one worker while injuring two more. The incident could have been avoided worksite safety rules and measures were not overlooked. It was the responsibility of Clark Cranes company to regularly monitor and inspect their equipment to ensure the safety of workers at the site. However, the company’s lack of oversight, lack of planning, and inefficiency lead to the mechanical failure of the crane. The company was at fault for not conducting safety and health sessions.

With that said, it is clear that safety performance is a major issue in the construction industry. However, safety performance in this industry can be improved through safety training, worksite analysis, and implementing risk management strategies. It is also important for companies to introduce safety programs. These programs are paramount since they involve workers, making them accountable for safety. Further on, safety training improves workers’ knowledge on safety allowing them to take part in improving work security in the workplace. For the future, I would recommend safety measures are implemented on the construction site. New and experienced workers must undergo safety and health training to minimize workplace hazards. Life is precious and no family should bear the burden of burying their loved ones or paying large hospital bills because an individual or organization ignored safety protocols. People need to adhere to simple safety guidelines to save lives.


ABC News, 2018, Box Hill crane accident: Melbourne worker killed, two men injured on construction site. [online] <>.

Abdelhamid, T.S. and Everett, J.G., 2000. Identifying root causes of construction accidents. Journal of construction engineering and management126(1), pp.52-60.

Ajayeoba, A.O., Raheem, W.A., Adebiyi, K.A. and OO, O., 2019. Modeling Safety beyond Accident Prevention in Construction Industry. Adeleke University Journal of Engineering and Technology2(1), pp.36-47.

Buniya, M.K., Othman, I., Durdyev, S., Sunindijo, R.Y., Ismail, S., and Kineber, A.F., 2021. Safety Program Elements in the Construction Industry: The Case of Iraq. International journal of environmental research and public health18(2), p.411.

Hywel, T., 2018. Accident and incident root cause analysis. pp.1-30.

Kanki, B.G., 2018, Cognitive functions and human error. In Space Safety and Human Performance (pp. 17-52). Butterworth-Heinemann.

Mock, C.N., Smith, K.R., Kobusingye, O., Nugent, R., Abdalla, S., Ahuja, R.B., et al. 2018, Injury prevention and environmental health: key messages from disease control priorities. Washington.

Smith, R., 2018, Crane company tight lipped after concrete dropped into pit of workers. [online] news. <>.

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