Vic: Complacency was systematic at CSIRO lab: coroner

AAP General News (Australia)
04-23-2007
Vic: Complacency was systematic at CSIRO lab: coroner

By Mariza O'Keefe

MELBOURNE, April 23 AAP - Complacency had become systematic at a Victorian CSIRO laboratory
where a technician died when one of its chambers filled with leaking nitrogen, a coroner
has found.

Scientist Set Van Nguyen, 44, had worked at the CSIRO's Australian Animal Health Laboratories
(AAHL), in Geelong, for 13 years before his tragic death in 2001.

The father of two was found dead in the laboratory early on December 11 after his wife
arrived and told a staff member he had not come home the night before.

Mr Nguyen died from lack of oxygen as he tried to enter an oxygen depleted area of
the AAHL about 4pm the day before, Coroner Audrey Jamieson found.

Her finding follows the inquest held into his death in June last year.

Mr Nguyen died in an air-lock chamber which led into a liquid nitrogen room, which
was not safe to enter as it was filled with nitrogen gas and significantly oxygen depleted,
the coroner found.

The inquest heard an air handling problem had been detected a few days before Mr Nguyen's
death and a post-it note and two other signs were placed on doors leading into the liquid
nitrogen room warning of the danger.

Ms Jamieson said the death of Mr Nguyen - who had a reputation as a conscientious,
diligent and careful worker - was preventable and it was evident complacency had become
systematic at his workplace.

"Sat Van Nguyen's behaviour on that day can only be attributed to a level of complacency,"

she said.

"It is otherwise inexplicable.

"But Set Van Nguyen does not stand alone, there is evidence that complacency had become
systematic in this workplace."

Victorian Workcover Authority inspector, James Chasser, told the inquest several factors
contributed to Mr Nguyen's death, including human error and equipment failure.

He said staff should have been prevented from entering the liquid nitrogen room once
a low oxygen alarm had been activated.

The inquest also heard no one knew that Mr Nguyen was still in the building until they
were alerted the next day by his wife.

In a statement, CSIRO chief executive Dr Geoff Garrett said the organisation deeply
regretted Mr Nguyen's death and expressed its condolences to his family.

He said it would be examining the coroner's findings in detail and it had already implemented
several recommendations about the operations at AAHL.

"We have learnt several important lessons from this tragedy so that a similar event
shouldn't ever happen again," he said.

In her finding, Ms Jamieson said CSIRO conducted its own investigation and "expeditiously"

initiated a number of safety improvements.

She also recommended the introduction of additional closed circuit television monitoring
and distress buttons within airlock and liquid nitrogen rooms.

AAP mok/ks/sp

KEYWORD: NGUYEN

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