Prosecution Details

Being an employer failed, so far as was practicable, to ensure that the safety of a person, not being its employee, was not adversely affected wholly or in part as a result of work that had been or was being undertaken by its employee, and by that contravention caused serious harm to another person.

The Accused

The Pilbara Infrastructure Pty Ltd (TPI) is a wholly owned subsidiary of Fortescue Metals Group Ltd (ACN 002 594 872) (FMG). TPI operates an iron ore ship loading facility at Anderson Point Port Facility (Anderson Point), near Port Hedland.

Iron ore is transported from FMG mine sites to Anderson Point by rail. Once at Anderson Point the iron ore is unloaded, and then transported to ships by way of conveyor belts.

Anderson Point constitutes a mine for the purposes of the Mines Safety and Inspection Act 1994 (MSIA). TPI is the "principal employer" of the mine.

The MSIA relevantly defines the principal employer to be the person "who has overall control and supervision of the mine". TPI at all relevant times had overall control and supervision of Anderson Point.

Overview

This charge arises out of an incident that occurred at Anderson Point on 8 July 2011, in which there was an uncontrolled release of energy (incident). The release of energy manifested as the movement of a component of a machine known as a train unloader "indexer" (Indexer) while four men were working on and in the vicinity of that Indexer (engineering company work crew). The men had been assigned to work on the Indexer by an engineering company who are specialists in industrial gearboxes and precision maintenance and fitting services. None of the men were employed by TPI.

One of the men working on the Indexer, the injured worker was caught between the moving component, which was known as an "arm", and pinch points on the Indexer. The injured worker’s left leg was immediately amputated below the knee. His right leg was crushed between the moving arm and fixed steelwork. The injured worker was later transferred to Royal Perth Hospital where his right leg was deemed unsalvageable and amputated below the knee.

The charge which has been brought against TPI does not allege that the injuries suffered by the injured worker were caused by TPI's contravention of s 21(2)(a)(i). However the parties agree that the injured worker’s injuries are relevant in that they demonstrate the hazard posed by the uncontrolled movement of the Indexer arm.

Notwithstanding that Anderson Point is a mine for the purposes of the MSIA, the parties agree, and jointly submit, that the Indexer is subject to the operation of the Occupational Safety and Health Act 1984 ("OSH Act"), as the result of a declaration made under s 4(3) OSH Act by the Minister for Resources and the Minister for Employment Protection. The declaration was served on TPI on 20 August 2008 and published in the Government Gazette on 26 August 2008.

The Train Unloader

The incident occurred during the course of a three day maintenance shutdown at Anderson Point (July Shutdown).

TPI had scheduled work on numerous pieces of plant over the course of the July Shutdown, and had contracted with numerous companies to carry out maintenance at Anderson Point during that time.

One of the pieces of plant that was scheduled to receive maintenance was a custom built piece of plant known as a "train unloader". TPI is the owner of the train unloader.

The train unloader was designed, manufactured, supplied and installed, by the original equipment manufacturer. The equipment manufacturer began operation on 15 April 2008 and is, and was, part of an international business, supplying mining-related equipment and services around the world.

The purpose of the train unloader is to automatically unload iron ore from ore cars, and transfer it on to conveyor belts. The train unloader consists of two parts, being the tippler and the Indexer.

The Tippler

The tippler is essentially a large tube that ore cars move through, two at a time. Once the ore cars are inside the tippler their wheels are locked into place, and they are then rotated until they are inverted, so that the iron ore falls from the ore cars and then drops down to conveyor belts.

The tippler is installed inside a large hangar, and each end of the tippler is connected to permanent railway tracks.

The safe operation of the tippler requires that the two iron ore cars that are to be tipped are precisely aligned, so that their wheels can be effectively gripped.

It is not practical for the precise alignment of the iron ore cars to be achieved by the train driver. Instead, this is achieved by the Indexer.

The Indexer

The Indexer is an electrically powered machine which resembles a train engine. It runs on a short set of tracks that are parallel to the railway line which brings iron ore carrying trains into Anderson Point.

A locomotive first positions a train of iron ore laden ore cars in front of the Indexer. The Indexer then shunts the ore cars along the railway line via use of its "arm" (Indexer arm). The Indexer arm is a large rectangular block of steel which can be extended from, and retracted back into, the Indexer. This is the part of the Indexer which trapped and injured a worker.

The Indexer arm is mounted on rollers, allowing it to slide in and out of the Indexer. A dedicated electric motor drives the mechanism which extends and retracts the Indexer arm (drive assembly).

The torque from the electric motor acts upon the Indexer arm via a series of connected parts which together make up the drive assembly. The components of the drive assembly are (in the order in which each component connects to the next): motor → gearbox → crankshaft → crank arm → link arm → Indexer arm.

The Indexer arm, link arm, crank arm and crankshaft are all moving parts of the Indexer arm system during the operation of the Indexer.

The rollers on which the Indexer arm rests are at different heights, with the result that the Indexer arm is installed at a downward incline of approximately 5 degrees from the horizontal. The Indexer arm weighs approximately 14 tonnes. The design of the Indexer means that if the Indexer arm was in the retracted position, and not being restrained by some form of brake, it would immediately start to slide down the rollers, and accelerate as it did so.

The brake associated with the Indexer arm gearbox (Gearbox) is a disc and calliper mechanical brake, and it is located on the high speed (input or motor side) of the Gearbox (Brake).

The Brake is, and was, a common unit used extensively throughout the Pilbara and the iron ore industry and the mining industry with respect to application as a holding brake.

The Brake is guarded by a metal guard system that is solid over most but not all of the circumference of the guard. Whilst that guard is in place it is possible to identify part of the Brake through the meshed section of the metal guard system.

When the Indexer arm is retracted, and the Indexer is not operational, the restraining effect of the Brake operates on the Indexer arm via the drive assembly. That is, the effect of the Brake operates through the crankshaft (which is inserted into the Gearbox via a splined socket) and then via the crank arm → link arm → Indexer arm.

The result of this design means that if any of the links between the various components of the drive assembly were broken, then the restraining effect of the Brake would no longer act upon the Indexer arm. That would occur if, for example, the link arm was separated from the Indexer arm, or the Gearbox was separated from the crankshaft. If the Indexer arm was in the retracted position when this occurred (and if it had not been restrained by some other means), it would immediately slide down the rollers and extend from the Indexer.

As is discussed in further detail below, the maintenance work being done on the Indexer on 8 July 2011 was the replacement of the Gearbox. This work necessitated a break in one of the links between the various components of the drive assembly, namely, a break in the link between the Gearbox and the crankshaft.

Prior maintenance work on the Indexer arm drive assembly

Components of the Indexer arm drive assembly have failed, and been replaced by TPI, prior to the incident on 8 July 2011.

In particular, the link arm failed, and was replaced, in January 2010.

In January 2010 when the link arm was replaced, links in the drive assembly were necessarily broken. Once links in the drive assembly were broken, the restraining effect of the Brake would no longer act on the Indexer arm, as explained above.

In order to prevent the uncontrolled movement of the Indexer arm when the link arm was replaced, TPI, prior to the replacement of the link arm, restrained the Indexer arm with chain slings and cum-a-longs.

In addition to the January 2010 link arm replacement, and prior to the incident, TPI also carried out other maintenance work on the drive assembly that resulted in links in the drive assembly being broken. This maintenance work included changing of the "bushes" in the link arm (bushes are mechanical fixings between two moving parts). On each occasion that such maintenance work was undertaken, TPI would restrain the Indexer arm with chain slings and cum-a-longs.

As a result of the information it had acquired through the replacement of the link arm, and the other maintenance work that it had carried out which involved breaking links in the drive assembly, TPI should have known, and TPI's maintenance personnel actually knew or should have known, prior to the incident, that:

1. the support rollers on which the Indexer arm rested were configured such that the Indexer arm was installed at an angle;
2. that the breaking of any link in the drive assembly would result in the restraining effect of the Brake ceasing to act on the Indexer arm (and that if the Indexer arm was retracted when this occurred and was not otherwise secured, it would immediately begin to extend); and
3. work which would result in the breaking of a link in the drive assembly should only be carried out once the Indexer arm had been extended and held up by something that would bear its weight, or otherwise secured.

In order to allow for the Indexer arm to be extended without positioning ore cars in front of the Indexer, TPI arranged for an "Indexer Arm Trestle Support" ((Trestle) also known as a "dummy drawbar") to be designed and built in or about April 2010.

The Trestle was available for use on the day of the incident. Camera footage from a CCTV system operated by TPI shows that the Trestle was situated approximately 20m away from the Indexer at the time of the incident.

Additionally, following the link arm failure in January 2010, TPI developed a Standard Work Instruction (SWI) so as to document the step by step process that should be taken in order to safely replace the link arm.

Clause 2.01 of the SWI relevantly provided as follows:

Obtain Authority to Work Permit, Hot Work Permit and isolate as per FMG procedure. Ensure indexer arm is fully extended and is supported either by Ore Car or Specified trestle on rail. Indexer arm must be extended to allow for pivot pin removal. Care must be taken to ensure arm is fully supported over rail, and may need to be restrained from further extension when link arm is removed, by the way of chain slings and cum-a-longs.

The instructions set out in cl 2.01 of the SWI were suitable for (although not prepared for) any work on the Indexer that would result in a break in the drive assembly. Had those instructions been followed by TPI or the the engineering company work crew working on the Indexer on 8 July 2011, then the Indexer arm would not have moved once the Gearbox was disengaged from the crankshaft.

TPI engages the equipment manufacturer and the engineering company to carry out work in the shutdown

On 9 May 2011 shutdown planner, Worker 1, a contractor acting as agent for, and on behalf of, TPI, raised an internal company work order 100035693 to arrange for the equipment manufacturer to inspect the tippler and to "oversee the work being conducted in the July shutdown".

On 30 May 2011 the equipment manufacturer provided TPI with a quote in respect of the "Train Unloader maintenance shutdown in July". The quote was to "provide technical assistance during the shutdown". There was no discussion that the equipment manufacturer assists the engineering company with work at site.

On 4 June 2011 Worker 2, a mechanical maintainer employed by TPI, raised work order 100040081 to arrange for the equipment manufacturer and the engineering company to "[c]heck the alignment of the Indexer arm support rollers".

On 15 June 2011, Worker 1 raised internal work order 100041436 to arrange for the changeout of the Gearbox during the July Shutdown. The work order provides that "We will utilise the engineering company to perform the work under the equipment manufacturer’s guidance".

The engineering company’s business specialises in providing maintenance services in the area of gearbox repairs, installations, pump overhauls, machining, shut down work, and work shop work. The engineering company had previously changed out the "long travel gearboxes" on the Indexer (being gearboxes that controlled the side to side movement of the Indexer, as opposed to the movement of the Indexer arm when extending and retracting). The engineering company had also carried out an indexer arm gearbox changeout on a train unloader approximately 2 years before the incident, at a BHP site at Nelson Point (near Port Hedland). However the arm of that indexer was installed horizontally, and not at an incline as is the case with the TPI indexer.

The engineering company was known by TPI personnel, including Worker 1 and Worker 3 (TPI mechanical supervisor) to have experience and expertise in general gearbox changeout work.

On or before 15 June 2011, the engineering company was engaged to changeout the Gearbox during the July shutdown.

Despite the reference to the equipment manufacturer in work order 100041436, the equipment manufacturer was not engaged to supervise the engineering company in respect of the gearbox changeout. None of the purchase orders TPI provided to the equipment manufacturer indicated that it was to supervise the Gearbox changeout. TPI did not inform the equipment manufacturer that its employees were to supervise the the engineering company’s employees, nor did it inform the engineering company that its employees were to be supervised by the equipment manufacturer’s employees. At all material times, the engineering company understood that the equipment manufacturer had no supervisory role in respect of the Gearbox changeout job. The engineering company did not request TPI to engage the equipment manufacturer or any other expert to supervise or assist it, or to provide expert advice to it, in respect of the job.

On 29 June 2011, in response to the request from Worker 4 for drawings of the Indexer, Worker 1 emailed Worker 4 a single drawing which did not show that the Indexer arm was installed on an incline. The email relevantly read "attached is all I could find", even though TPI possessed a full suite of technical drawings and an OEM manual for the Indexer.

Both the technical drawings and the OEM manual to which Worker 1 had access showed that the Indexer arm was installed at an angle.

On 7 July 2011 Worker 4 and Worker 5, an employee of the engineering company who was to supervise the Gearbox changeout the following day, went to site for the purpose of inspecting the Indexer. They had an inspection. The machine was in operation and as a result they did not have physical access to it. There is no evidence that they made any request of TPI to have physical access. Worker 4 later told the investigatory officers that, during the inspection, Worker 5 told him that the job was “no problem” that his team would be able to “handle it” and it was a “relatively straightforward job”.

TPI isolates the Indexer

TPI's system of isolations

At all relevant times TPI operated a system whereby it would "isolate" plant and equipment (Equipment) at Anderson Point prior to allowing work on that Equipment to take place.

The word "isolation" was defined in a published policy to which TPI's employees were subject at all relevant times. The policy was entitled: Procedure for Isolation and Tagging (Isolation Procedure). It was intended to prevent the hazardous release of energy whilst personnel were performing work on Equipment.

The Isolation Procedure defined isolation as being: "a means of preventing the transmission build-up or unintentional release of pressure/energy/power by whatever means necessary to ensure that the plant or equipment is safe to work on". It identified various types of energy including: "Mechanical [e.g. kinetic or potential]" and "Gravitational".

The Isolation Procedure prohibited people who were not qualified as isolation officers by TPI from carrying out any isolations.

The Isolation Procedure did not prohibit contractors from identifying the isolations that had been undertaken or physically checking them, and requiring client confirmation that the isolation was effective. The engineering company’s senior personnel understood that the engineering company always had this option when working at sites. Clause 4.4.7 of the Permit Procedure (referred to further below) provided that the Permit Holder or any Permit User may conduct a physical inspection of any isolation that had been established.

The Isolation Procedure recognised (at cl 11) that qualified isolation officers could be authorised as being mechanical, electrical or radiation isolation officers. At the time of the incident only a single person had completed the mechanical isolation officer assessment. While that person was then authorised to act as a mechanical isolation officer, they were not actually appointed as a mechanical isolation officer until December 2011. Accordingly, at the time of the incident there were no appointed mechanical isolation officers at Anderson Point.

The Isolation Procedure specified that where scheduled work would require more than a single isolation point, or where the work group exceeded six people, then a "group isolation" was required and an "isolation plan" had to be developed. The term “Isolation Plan” is defined in the Isolation Procedure as a “detailed plan of the isolation points needed to effectively de-energise or make a piece of plant safe”.

The Isolation Procedure document references numerous “Associated Documents” but the isolation plan template is not one of them. However, the isolation plan template is listed as an "Associated Document" in the Permit Procedure (referred to further below).

TPI recognised the work involved in the Gearbox changeout required a "group isolation", and that an isolation plan was required.

The Isolation Procedure further specified that Isolation Designers (being the persons who were able to design isolation plans) and Isolation Design Checkers were required to be:

"A subject area expert familiar with the equipment, layout and isolation points associated with the plant and necessary requirements involved in the isolation."

The isolation for the Indexer is designed and implemented

On 12 June 2011 Worker 6, an employee of TPI, prepared the isolation design for the train unloader in respect of the July Shutdown.

Worker 6 was an electrician, and a qualified electrical isolation officer. However was not a qualified mechanical isolation officer.  Worker 6 had no mechanical qualifications and was not a subject area expert familiar with the Indexer and, in particular, was not aware of its potential gravitational energy.

Worker 6’s isolation design was set out in a document titled "ISOLATION LIST Train Unloader" and sub-titled "Electrical Isolation for Train Unloader" (Isolation List). The Isolation List did not purport to be a list with respect to the isolation of the Indexer alone.

Worker 6 did not make use of the isolation plan template when designing an isolation plan.

Worker 6 designed and signed the Isolation List in the capacity of "Isolation Designer" even though Worker 6 was not a subject area expert familiar with the Indexer and its isolation. Worker 6’s Isolation List did not provide for the mechanical isolation of the Indexer arm.

When Worker 6 designed the Isolation List for the Indexer on 12 June 2011, Worker 6 was not (and could not have been) aware of the Gearbox changeout work.

Worker 6’s usual practice was to regularly check for new maintenance jobs as they were added to the TPI system. As a result would have seen that work order 100041436 had been added to the system at some time after Worker 6 had designed the isolation for the Indexer. However Worker 6 did not amend the existing isolation in light of work order 100041436, or design a new isolation for the Indexer. As indicated, Worker 6 was not aware of its potential gravitational energy.

In relation to the work scheduled on the Indexer support rollers of which Worker 6 was aware as at 12 June 2011, Worker 6 did not liaise with any representative of the equipment manufacturer as to whether the Isolation List was adequate with respect to that work.

On 7 July 2011 Worker 7, an electrical supervisor and qualified electrical isolation officer, checked the Isolation List in the capacity of "Design Checker". Worker 7 did not identify the need for the mechanical isolation of the Indexer arm or for any other form of mechanical isolation in respect of the train unloader.

Also on 7 July 2011 Worker 8, an electrician and authorised electrical isolation officer employed by TPI, performed the electrical isolation of the Indexer in accordance with Worker 6’s Isolation List.

Later that day Worker 9, another electrician and authorised electrical isolation officer employed by TPI, verified that the isolation had been performed in accordance with the Isolation List.

Neither Worker 8 nor Worker 9 identified the need for the mechanical isolation of the Indexer arm or for any other form of mechanical isolation in respect of the train unloader. The Isolation Procedure did not require either person, acting in the capacity, in which they did, to identify necessary isolations.

TPI permits work to take place on the Indexer

TPI's system of work permits

At all relevant times TPI operated a system under which a permit to work was required before any work (other than minor work such as visual inspections) could be undertaken on Equipment.

The system was set out in a published policy to which TPI's employees were subject at all relevant times. The policy was entitled: Procedure for Permits to Work (Permit Procedure).

The Permit Procedure specified that "for any work activity requiring a permit to work there shall be a clearly defined scope of work" [emphasis added]. The word "shall" was defined in cl 5.1 of the Permit Procedure as follows: "Indicates the requirement is mandatory". Confirmation of the scope of works was the second step in the "Work Permit Process Flow Chart" set out in Appendix 1 to the Permit Procedure.

One of the roles provided for by the Permit Procedure was that of Permit Coordinator. The Permit Coordinator was responsible for, amongst other things, ensuring that "the nature, scope and objectives of the work are clearly understood and stipulated on the permit".

Clause 4.4.1 of the Permit Procedure provided that, once a comprehensive scope of works was available, the Permit Holder (as the person with overall responsibility for the work being conducted under the permit) could consult with the Permit Coordinator to prepare the relevant documentation.

The Permit Procedure stipulated that the responsibilities of the Permit Holder include ensuring that: the Permit Holder has knowledge and experience to fully appreciate the potential hazards which might be present in a task; that all hazards associated with the job are identified and controlled; that the Permit Holder shall explain the hazards, controls and requirements of the permit to the Permit Coordinator; and ensure that permit users conduct a risk assessment prior to commencing any task. The required competencies for the Permit Holder included knowledge and experience in the work being conducted.

The Permit Procedure also stipulated that the Isolation Officer would conduct isolations in accordance with the Isolation Procedure and advise the Permit Coordinator that the plant has been isolated and submit the isolation plan, associated paperwork and lock boxes to the Permit Coordinator.

Another of the roles of the Permit Coordinator was to ensure that, prior to the issue of a work permit, evidence was present indicating that all necessary precautions and controls had been identified. One of the controls specifically mentioned by the policy was a "JHA", being a job hazard analysis. The Permit Procedure provides that a JHA shall be developed by the Permit Holder, in consultation with the Permit Users, to identify hazards associated with conducting the work and determine necessary controls.

On 22 June 2011 work permit 8819 (the work permit) was prepared by Worker 10, an employee of TPI. Worker 10 was not the Permit Coordinator for the July Shutdown, but was carrying out preliminary work in preparation for that shutdown. Worker 10 wrote on the work permit, alongside the field "Description of work to be completed" the words "Replace indexer arm gearbox".

When Worker 10 prepared the work permit, he was not in possession of a clearly defined scope of works. The engineering company did not provide a scope of works for the Gearbox changeout after one was requested by Worker 1 and no further steps were taken by TPI to obtain a scope of works from the engineering company.

Worker 5, one of the engineering company’s work crew members on 8 July 2011, in the capacity of Permit Holder, signed a Permit Holder Declaration acknowledging that he would be responsible for ensuring that he had the knowledge and experience to fully appreciate the potential hazards which might be present in a task.

Worker 5 was a mechanical fitter. He had previously worked on a train unloader at a BHP site but not on a job involving the indexer arm; he had worked on the wheels of the indexer which allow for its side to side movement.

TPI accepts the engineering company’s work crew's JHA

On 8 July 2011, early in the morning, Worker 4 of the engineering company met the engineering company work crew at site. He explained to them a number of jobs that the engineering company had to perform, and he went to the Indexer to show and discuss with Worker 5 and the injured worker the task which had to be performed with respect to the Indexer arm.

The injured worker was an automotive mechanic. He had experience in shut down work on mines. He had worked in the tippler portion of train unloaders before, but had never worked on an indexer before.

The work crew consisted of an additional apprentice fitter (Worker 13) and a fitter and turner (Worker 14).

On 8 July 2011 the engineering company’s work crew, prior to commencing work to replace the Gearbox, completed a JHA for that task. They completed the JHA after first visually inspecting the Indexer. The Indexer arm was in the retracted position when the engineering company’s work crew inspected it. The members of the engineering company work crew were consulted by the engineering company’s crew supervisor, and made contributions to the preparation of the JHA.

The first job step of the JHA was listed as "Isolate". The engineering company’s work crew specified as the control measure for that step "lock on as per isolation list".

A document listing what particulars things were isolated was located near the lock box 14. The engineering company’s work crew supervisor, Worker 5 was aware that the list existed.

The JHA completed by the engineering company work crew did not identify as an existing or potential hazard that the Indexer arm might move once the Gearbox was disconnected (in the event that it was otherwise unrestrained).

Once the engineering company’s work crew had completed their JHA they presented it to Worker 3 for approval in his capacity as supervisor for the shutdown.

The Job Description on the JHA was "Gearbox changeout". As already noted, the control measure specified by the engineering company’s work crew for the isolation of the Indexer did not require that the Indexer arm be extended.

As a result of the link arm failure in January 2010, TPI and Worker 3 were aware, or ought to have been aware of the matters referred to earlier.

Moreover, Worker 3 was mechanically competent. He was a Fitter Machinist, and Engineering Tradesperson Mechanical, and had held those qualifications for a decade prior to the incident. He was the Mechanical Supervisor for TPI. Had Worker 3 turned his mind to the fact that the engineering company’s work crew intended to replace the Gearbox while the arm was not extended or otherwise secured, he should have realised that they would thereby break a link in the drive assembly, and the Indexer arm would thereby extend having regard to the slope of the Indexer arm.

Notwithstanding that the JHA did not recognise the hazard posed by the uncontrolled movement of the Indexer arm, Worker 3 approved the JHA as Supervisor.

TPI allows the engineering company’s work crew to sign on to the work permit

Once Worker 3 had approved the JHA the engineering company’s work crew went to the "permit hut" to be signed on to the work permit.

The Permit Coordinator for the July Shutdown was Worker 11 an employee of TPI. On the morning of 8 July 2011 Worker 11 attached to the work permit the Isolation List that had been designed by Worker 6 (and then checked by Worker 7, implemented by Worker 8, and verified by Worker 9). He then signed his name alongside a box with the words: "Attached isolation plan correct and verified by"

Worker 11 did not know whether the Isolation List was correct; he was merely checking to see whether it had been signed off. Worker 11 did not identify that the work specified on the work permit (being the replacement of the Gearbox) was not the same as that specified on the Isolation List (being only the generic "July Shutdown").

The engineering company’s work crew provided their completed JHA to Worker 11. At this point Worker 11 was in possession of the work permit, the Isolation List, and the JHA. However he was still not in possession of a clearly defined scope of works. Notwithstanding that cl 4.4.1 of the Permit Procedure stipulated that it was mandatory for a scope of works to be available to the Permit Coordinator before a work permit was issued, Worker 11 allowed the engineering company’s work crew to sign on to the work permit.

Worker 11 then presented the engineering company’s work crew with a lock box and allowed the four men comprising the engineering company’s work crew to attach their personal locks to the lock box. Lock boxes provide a means by which individuals carrying out work on isolated Equipment are able to ensure that the Equipment is not de-isolated while they are working on it.

The presentation of a lock box is an indication to those persons about to commence work on Equipment that it has been properly isolated.

The incident

The members of the engineering company’s work crew signed on to the work permit.

They worked steadily on the Indexer throughout the morning, and then took a break for lunch.

At one point, the supervisor of the engineering company’s work crew, Worker 5, together with Worker 14 approached the equipment manufacturer’s employee, Worker 12 to ask for information as to how far into the Gearbox the splined crankshaft extended. In doing so, Worker 5 was asking for information as to how far the Gearbox would have to be moved before it would disengage from the crankshaft.

Worker 12 provided Worker 5 with some technical documents and drawings of the Indexer which showed that the crankshaft extended approximately 150mm into the Gearbox, and that approximately 200mm clearance would be required to remove the Gearbox. One of the drawings provided to Worker 5 indicated that the Indexer arm was installed at an incline.

During the course of the work Worker 4 attended on two occasions at the Indexer to check how the engineering company’s work crew were going with the job and had discussions with the crew.

Prior to the incident, the injured worker and Worker 5 had removed the electric motor from the top of the Gearbox arrangement, and preparations were made in readiness for the Gearbox to be lifted off by crane.

Shortly after work had resumed after lunch, the engineering company’s work crew was in a position to disengage the Gearbox from the crankshaft. They knew that the Gearbox was connected to the crankshaft by a spline. The injured worker while standing on top of the Indexer arm, used a long piece of timber to apply leverage to dislodge the Gearbox from the end of the crankshaft, thereby disconnecting the components. The injured worker was experiencing considerable resistance and tension in trying to remove the Gearbox from the crankshaft. All four men comprising the engineering company’s work crew were standing in the immediate vicinity of the Indexer arm when the Gearbox was disengaged from the crankshaft.

The 14 tonne Indexer arm immediately began to extend, sliding down the rollers and accelerating as it did so. At the same time as the Indexer arm was extending the link arm moved forward, and the crank arm moved upwards. All of the engineering company’s work crew were in the immediate vicinity of the moving components of the drive assembly. Worker 5 was standing in front of the link arm. He had to jump over the crankshaft to avoid being struck by the link arm when it rose up as the Indexer arm extended. Worker 13 was standing immediately adjacent to the injured worker when he was struck by the moving Indexer arm.

The parties are agreed that the uncontrolled movement of the Indexer arm is a significant hazard, and that being struck by the arm, or caught between the arm and pinch points on the Indexer, could result in death or serious injury.

The safety of members of the engineering company’s work crew was seriously jeopardised by the sudden and uncontrolled movement of the Indexer arm after the Gearbox was disengaged from the crankshaft.

As previously noted, the injured worker suffered serious injuries after he was caught by the moving Indexer arm and ultimately lost both legs. The prosecution again stresses that, while these injuries are a relevant circumstance, in that they illustrate the potential consequences of the breach of s 21(2)(a) OSH Act, it is not alleged that TPI's breach was the legal cause of the injured worker's injuries. TPI is not culpable for causing those injuries.

The risk caused by the location of the Indexer arm on an angle was not written into the operations and maintenance manual. The equipment manufacturer-supplied manuals for TPI’s Indexer contained no procedure for a gearbox changeout. The manual gave no warning or instruction to secure the Indexer arm before disconnecting the Brake. Nothing in the manual indicated that it was a high risk job; a red danger sign appears in several places for less dangerous tasks.

There were no warning signs upon the Indexer to alert persons that there was potential energy or that the Indexer arm could move unexpectedly.

There was no designed mechanism, as part of the Indexer, to hold the Indexer arm in place when the Brake was disengaged, or any hook point or lug to use to hold the Indexer in a retracted position.

The charge and the particulars do not preclude TPI from contending that engineering company and/or the equipment manufacturer were partly responsible for the Hazard.

Note: this is not the complete agreed facts but a summary only.

The accused entered a plea of guilty and was convicted on 27 April 2016.   On 9 June 2016 the Magistrate fined the Accused an initial fine of $60,000 and then final fine of $50,000 after mitigating factors. Costs of $145,000 ordered on the 9 September 2016.