An inquest into the death of Crossrail worker René Tkacik has found that “unclear” processes and an “unclear” definition of the exclusion zone he was in when he died contributed to his death.
Following a six-day hearing at St Pancras Coroners Court, a jury delivered a narrative verdict, saying the death was “accidental”.
It added that the experienced Slovakian concrete sprayer had “most likely entered the exclusion zone to trim wet concrete by hand”.
Mr Tkacik was crushed to death by a falling section of wet concrete in the Fisher Street tunnel, near Holborn, while working for the Bam Ferrovial Kier joint venture on 7 March 2014.
In delivering a narrative verdict today (3 March) the jury found it was “not established if at the time of his death he was aware of the wet concrete above him, but if he was it was out of character”.
The nine-member jury found there were three elements that made a “significant and necessary contribution to René entering the area”, including a lack of clarity about the exclusion zone and unclear working guidelines, known as “the method statement”.
The jury found that Mr Tkacik’s “state of mind” was one of those factors contributing to his death.
According to the determination the 44-year-old felt isolated as a result of his rudimentary English and tired because of cramped living conditions.
Mr Tkacik’s widow, Renata Tkacikova, had told the court that he had felt discriminated against because he did not understand English.
“If he saw people stand up and go somewhere, he would just stand up and follow them,” she said.
“He had difficulty understanding even very basic things.”
She also told the court how he had been sharing a room with three other men up until a week before his death, and that their different shift patterns meant they frequently disturbed each other.
The jury also said that processes and procedures contributed to Mr Tkacik’s death, as “unclear” guidelines resulted in different practices being used for trimming concrete.
Its determination found that “the method statement was not clear, leading to alternative methods of trimming by different people at different times”.
Bam Nuttall health and safety director Philip Cullen had earlier told the court the method statement was produced by the BFK joint venture and approved by Crossrail.
The jury found that the daily briefing given to workers “did not mitigate this confusion” and that translations of the briefing for Mr Tkacik “occurred on an ad hoc basis”.
In addition, the jury found that an “unclear” definition of the exclusion zone, the area under freshly sprayed concrete which workers were not allowed to enter, contributed to Mr Tkacik’s death.
In its determination, the jury said: “The definition and supervision of the exclusion zone was unclear and changed from time to time. The lack of physical demarcation did not mitigate the confusion.”
In her summing up, coroner Mary Hassell said: “The number one rule is you do not work underneath wet shotcrete until the engineer has tested it. The reason for that is that wet shotcrete falls.”
Mr Tkacik’s mother, Marta Tkacikova, had earlier told the court that her son had been told to work directly underneath wet shotcrete.
She said: “He had to go forward with the shovel when it was wet, because after the concrete had hardened it would not be possible to do it.
“He was frightened to say ‘I will not go’ because he did not want to lose his job.”
The coroner did not issue a prevention of future death report.
She concluded she was satisfied that matters identified during the inquest had been or were in the process of being dealt with.
A spokesperson for Crossrail said: “Everyone who works on Crossrail continues to be affected by this terrible incident. Our thoughts and sympathies are with Rene Tkacik’s family, friends and colleagues.
“Safety has always been, and continues to be, the number one value for Crossrail and is critical to the delivery of the project.
“Crossrail has a good safety record and sets the most stringent contractor safety requirements in the industry. There is nothing so important on Crossrail that it cannot be done safely.”