Prosecution Details

Being an employer, failed, so far as was practicable, to provide and maintain a working environment in which its employees were not exposed to hazards, and by that failure caused serious harm to an employee, contrary to sections 19(1) and 19A(2) of the Occupational Safety and Health Act 1984 (Act).

The Accused is a corporation that, trading at all material times as Roofmart WA, manufactures steel building products, including door frames, rainwater goods and roller doors.

The Accused operates from offices and factories at 5 and 10 Chilver Street in Kewdale.

As at 3 February 2010, the Accused employed approximately 174 employees.

The fly wheel press

The Accused operates a number of machines at 5 Chilver Street (Workplace), one of which is a John Heine fly wheel press (Press).

The Press involves a rotating fly wheel that stores rotational energy when powered. The power itself comes from a fixed electricity source. The fly wheel in turn drives a ram (or ‘slide') which descends when the pedal is depressed by the operator.

The process for which the Press is used is determined by the tools that are attached to it, and which come together when the ram is brought down. The first tool is the top part, which is attached to the ram, and is sometimes known simply as ‘the tool' or a ‘punch'. The bottom part is fixed in place below the ram and is known as the ‘die'. These tools are manually changed and adjusted by the operator to suit the particular task.

One process for which the Press is used is the manufacture of downpipe clips (the small metal fittings that hold in place a downpipe running from a gutter).

This process involves the operator feeding thin strips of metal into the opening between the top and bottom parts of the tool. The operator then depresses the pedal, which brings down the ram and the punch and stamps and cuts off the downpipe clip, which is ejected from the Press via a chute at the back of the machine, into a receptacle for collection.

As at 3 February 2010, the Press was also fitted with a front guard (also variously known as a ‘gate guard' or ‘cage guard'), a large latticed panel across the front and sides of the Press. The default position for the front guard was down, which prevented physical access to the guarded parts of the Press.

The front guard was also engineered to perform an interlocking function. If lifted, it would prevent the ram from descending even if the pedal was depressed. In this way, the front guard could be manually lifted with pneumatic assistance if safe access to the moving parts of the Press was required, such as to adjust the tools.

However, it was also necessary for there to be an aperture in the front guard through which material was fed into the moving parts. The size of this aperture could be adjusted using the finger guards (or ‘grille guards') attached to the front guard. These finger guards had no interlocking function; they were purely physical guards.

As at 3 February 2010, the finger guards could be adjusted using a regular Allen key, which was available to employees at the Workplace.

As at 3 February 2010, there was a sign on the front of the Press setting out instructions for use. Those instructions included:

1.  Always use safety gloves.

4. ... Make sure all safety guards are in place or if removed for any reason are fixed on again.

6. Position your job correctly on the marks and ensure to keep your hands away from working tools.

3 February 2010

On the morning of 3 February 2010, the supervisor in the meter box section of the Workplace was showing a process worker how to use the Press to manufacture downpipe clips. It was the process worker's first day at the Workplace.

The supervisor had almost 20 years' experience working for the Accused. He was an Occupational Health and Safety Representative (OHSR), had attended manual handling safety and OHSR courses and was regularly tasked with training new employees.

The supervisor was feeding through a strip of metal when it became wedged in the die. It was not uncommon for this to happen. Usual company procedure in this situation was for the material to be dislodged using another strip of metal or a screwdriver. In this case, however, the supervisor reached into the machine with his bare, ungloved hand to dislodge it manually.

The supervisor did not raise the interlocking front guard; nor did he switch off power to the machine using the switch on the side of the machine, or lock out the switch so it could not be switched back on.

The supervisor was able to reach into the machine because he had raised the central finger guards to the maximum possible height. The finger guards should have been set to the minimum practicable aperture for the task, which in this case would have been slightly higher than the point where the two parts of the tool came together inside the Press.

The supervisor had raised the finger guards for convenience. Raising the finger guards also made it easier for him to see where the metal strip should go.

The process worker was standing behind the supervisor. Before reaching into the Press, the supervisor told the process worker several times not to step on the pedal.

As a result of a misunderstanding between the two, the process worker stepped on the pedal while the supervisor's hand was in the Press. The ram consequently came down, trapping the supervisor's right hand and ultimately severing his index and middle fingers.

Prior incidents

In the two-and-a-half years preceding the supervisor's injuries, two previous amputation injuries had been sustained by the Accused's employees using fly wheel presses at the Workplace.

In August 2007, an employee reached into a press to attempt to dislodge jammed material, through an excessively large aperture in the front guard. He inadvertently stepped on the pedal and had the tip of his right thumb amputated

In November 2008, the Accused carried out a workplace inspection that identified that its machine guarding worked, but could be bypassed. The risk attendant upon this was identified as major, being of ‘moderate' likelihood and ‘high' consequence.

In November 2009, another employee had his hand inside a press when he inadvertently stepped on the pedal, severing the tips of his middle and ring fingers. The employee was able to access the moving parts of the press because the guarding of the press had been intentionally bypassed and/or incorrectly adjusted. It was not unusual for operators in that area to bypass the guarding.

The Accused's production manager, who was also effectively responsible for occupational health and safety, subsequently circulated a report bringing the 2009 incident to the attention of all employees. That report concluded that the guarding on the press was not being adjusted to suit each operation. The report also set out the details of the injury that the employee had sustained as a result of not adjusting the guarding correctly, explained that the safety guards on the machines were there to ensure the safety of the operators and "for no reason should they ever be taken off or tampered with unless the machine is tagged and locked out" and that "this is a very serious matter and any practice such as this will result in instant dismissal."  The report also displayed a picture of the Press showing how the guarding should be set up.

Subsequent changes

As at 3 February 2010, the Accused had formalised its procedures on how to operate the Press safely by introducing a ‘Safe Operating Procedure' for the Press, provided signage on the Press setting out the Safe Operating Procedure and provided training information to its supervisors to pass on to workers under their supervision on when and how to lock out, isolate and tag out machines (that is, how to disable machines so they are unable to operate by mistake). However, the Accused had not ensured that its employees had been sufficiently trained in how to appropriately adjust the finger guards, or when to isolate or lock out machinery.

The Accused has now, at a total cost of approximately $500, fitted the finger guards of the various fly wheel presses at the Workplace with ‘tamper-proof' screws, such that the finger guards cannot be adjusted without the use of a special tool or ‘key'. These keys are available only to senior employees that have been formally trained in, and demonstrated competence in, how to appropriately adjust the finger guards to create the minimum practicable aperture for their particular task.

The Accused has now also fitted the Press with an adjustable lower front guard below the finger guards. Like the finger guards, this guard can be adjusted to ensure the minimum practicable aperture for any particular task. This, along with other improvements to guarding throughout the Workplace, cost no more than a few thousand dollars.

The Accused has also now hired a full-time occupational health and safety officer to allow the production manager to concentrate on his main role.

Prior to and as at 3 February 2010, it was reasonably practicable for the Accused to have:

1. ensured that adequate training and enforcement systems were in place to ensure its employees followed isolation and/or lock-out/tag-out procedures when requiring access to the moving parts of the Press; and/or
2. ensured, through training and/or supervision, that pre-start checks were undertaken to ensure the guarding on the Press was adjusted to provide the minimum practicable aperture for the particular task prior to energising the Press; and/or
3. ensured that tamper-proof screws were used on the finger guards, with keys only available to senior employees that had been formally trained in, and demonstrated competence in, how to appropriately adjust the finger guards to create the minimum practicable aperture for any particular task, in order to prevent the finger guards from subsequently being adjusted to provide an aperture larger than that minimum practicable aperture; and/or
4. installed an adjustable lower front grille below the finger guards to help prevent contact with the moving parts while in operation.

Taking any or all of these measures would have reduced the risk of the supervisor's hand being caught in the Press, and consequently the risk of his injuries, on 3 February 2010.

Convicted on plea of guilty.