Prosecution Details

Being an employer, failed, to so far as was practicable, ensure that the safety or health of a person, not being its employee, was not adversely affected wholly or in parts as a result of work that was being undertaken by the Accused, and by the contravention caused the death of person; contrary to sections 21(2) and 21A(2) of the Occupational Safety and Health Act 1984.

The Accused is a State Government Department which became the Department of Justice on 1 July 2017.  It is responsible for Hakea Prison (Hakea), a maximum security remand facility that receives adult male prisoners entering the prison system.

At the time of the incident the Department of Justice was known as the Department of Corrective Services.

The victim was a remand prisoner at Hakea.  He worked in the maintenance workshop. The maintenance workshop is one of a number of workshops. Together with the kitchen the workshops are collectively known as “industries” (Industries).  The Industries are grouped around a rectangular yard known as the industries or services yard (Yard).

The Yard has one vehicular access point known as a “sally port” (Sally Port).

The Yard has multiple potential pedestrian access points.  Each of the workshops backs on to the Yard and has roller doors.  The Yard also has gates which the Accused’s staff can use to access a short cut through the prison.

Vehicles access the Yard multiple times a week to make deliveries to the Yard e.g. to the kitchen; and to collect rubbish.

The Yard is a physically tight space for bigger vehicles.  There is not enough room for a big vehicle to turn without reversing.  Vehicles typically choose to exit the Yard by reversing into the kitchen loading dock (Kitchen Dock) or other workshops.

The incident

On 19 August 2015, Facilities and Industry Manager, organised a work party to clean out residential units 11 and 12 (Units 11 & 12) prior to a redevelopment.  Units 11 & 12 were not part of and did not abut the Yard.

The work party comprised a number of prisoners from different workshops (including the victim) and supervising vocational support officers (VSOs).  Steele GROCOTT, who was one of the VSOs, was to drive the kitchen truck.

The day before, it had been decided that Steele GROCOTT, a gardens VSO, was told he would drive the kitchen truck.

The kitchen truck was a large truck so it could not turn in the tight space of the yard. It had to be reversed before being driven forward.

Before driving the truck Mr GROCOTT was briefly familiarised with the truck.  The tail lift and gear shift were pointed out but no handover was given on operating the truck.

The work party were not briefed on how to safely work around the truck when it was operating and there were not any procedures, training, supervision or enforcement of measures to safely move around when vehicles were in the yard.

Once Units 11 & 12 had been cleared, the contents were loaded onto the truck. The prisoners returned to the Yard for lunch.  Mr GROCOTT drove the Truck back to the Yard.  He parked it outside the cleaning party workshop and it was unloaded.

When Mr GROCOTT drove the truck into the yard the prisoners were directed to move bins out of the way of the truck whilst it was moving forward to park. Pedestrians were also in the yard as Mr GROCOTT drove the truck up to the cleaning workshop. 

After lunch the victim, two fellow prisoners and their supervising VSO (Group) walked across the Yard to check the pigeon holes in the administration area.

At around the same time, Facilities and Industry Manager instructed Mr GROCOTT to drive the Truck back to Units 11 & 12 to collect a second load. Another VSO was instructed to and did walk ahead of the Truck to the Sally Port to radio for the door to be opened.

Mr GROCOTT reversed the Truck through the Yard and backed into the Kitchen Dock in order to turn it around to exit the Yard through the Sally Port.

As he was doing so, the Group returned to the Yard to walk back to the maintenance workshop next to the Sally Port.  The victim offered assistance to reverse into the Kitchen Dock.

The victim walked down the side of the Truck into the Kitchen Dock where he gave directions to Mr GROCOTT.

After reversing into the kitchen dock, the truck then drove forward and turned left towards the Sally Port.  At this moment, the victim moved forward in an attempt to leave the Kitchen Dock, again down the side of the Truck.  As the Truck drove forward and turned, its right rear swung out to the right, pinning the victim between the Truck and the side wall of the Kitchen Dock.

The victim suffered fatal injuries and was pronounced dead shortly after arriving at Fiona Stanley Hospital.   

Systems Prior to the Incident 

Prior to the incident a risk assessment was not carried out to identify the risks created by the task. The briefing to the work party on the day of the incident did not include vehicle movements.

Sometimes pedestrians were in the yard while trucks were moving.

An industries risk register was in place but while it identified pedestrians and vehicle interaction as a hazard, no steps were taken as a result. In addition, many staff were unaware of the existence of the Register.

Between 1 January 2010 and 18 August 2015, two hundred and twenty two improvement notices were issued by WorkSafe Inspectors to the Department of Corrective Services.  Sixty seven of these Improvement notices were issued for Hakea Prison. Improvement Notices identify a breach of the Occupational Safety and Health Act 1984 and specify a date for compliance. A breach of the requirement is an offence. 

Two of the improvement notices issued concerned warning signage in relation to movement of operating plant, namely forklifts. 

During the same period, six prohibition notices were issued by WorkSafe Inspectors to the Department of Corrective Services. Prohibition Notices immediately stop work on the basis that an activity at the workplace involves or will involve a risk of imminent and serious harm. It is an offence to restart the work without the agreement of an inspector.

In March 2013, the WorkSafe Commissioner personally wrote to the Accused’s Commissioner to arrange a meeting to discuss the Accused’s inadequate safety management system. After the meeting the WorkSafe Commissioner sent a further letter. It confirmed the matters discussed at the meeting including the need for the Accused to review its resourcing of a safety management system.

On 30 May 2013, a load of steel struck a VSO who was in the yard. The steel fell from a forklift. After the incident the Accused carried out some risk assessments and job safety analysis. Documents concerned safe movement of traffic. However, by the date of this fatality the documents were still in draft form.

Systems After the Incident

Between 19 August 2015 and 4 August 2017, seventeen improvement notices were issued to the Accused.  

After the incident the Accused implemented a range of procedures –

• The yard is cleared before a vehicle enters the yard;
• A VSO wearing a high visibility vest controls traffic movement in the yard;
• Hakea staff notice 26/2015 was implemented and published;
• Safety bollards were put into place in front of the cool room and inside the kitchen loading dock;
• Keep clear signs were painted in the yard;
• A vehicle and mobile plant check list, which required facilities develop a traffic management plan, was developed;
• Warning signs were placed on pedestrian access gates;
• DANGER LOOK OUT FOR TRUCKS
• NO ENTRY AUTHORISED PERSONNEL ONLY
• A traffic management plan was developed;
• Prisoner training included vehicle and pedestrian access; and
• The Hazard Inspection Checklist was updated to include vehicles and mobile plant.

The cost of the system implemented after the offence was minimal.

The Magistrate fined the Accused $100,000 and ordered costs of $4189.50