Prosecution Details

Being an employer, failed, so far as practicable, to provide and maintain a working environment in which employees of the employer 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.

Background

A large construction company was the principal contractor in relation to a construction project to construct the New Perth Museum at 5 (Lot 510) Francis St, Perth (New Perth Museum).  The design and construction of the New Perth Museum was a large and complex project involving the integration of heritage listed buildings and a new building.  The Offender was awarded a subcontract to install the roofing package for the New Perth Museum.

Risk assessment

Prior to the commencement of the roofing works, the construction company and the Offender participated in a Construction Risk Assessment Workshop (CRAW) and a CRAW worksheet was completed.

In relation to the task of ‘Installation of penetrations and manholes’ the CRAW worksheet identified various hazards, including the following:

• a.             ‘working adjacent to open penetrations (>200mm x 200mm)’; and
• b.             ‘Working/falls from heights’.

Relevant controls agreed to be implemented in relation to the above hazards were:

• a.             ‘Use fall prevention equipment when working with / creating penetrations’;
• b.             ‘Penetration / manhole to be marked’; and
• c.             ‘Prior to each break penetrations to be covered’.

The person responsible for implementing these controls was the Offender.

Work being undertaken on the day of the incident

On 17 April 2019 the New Perth Museum was a construction site and roof plumbing works were being undertaken on a roof described as the ‘Wrap Roof’ (Wrap Roof).

There were a number of roof plumbers working at different locations on the Wrap Roof, including four of the Offender’s employees (the Roof Plumbers).

The work assigned to the Roof Plumbers on the day of the incident included the installation of box gutters on the Wrap Roof.

In order to install a box gutter, it is necessary first to remove the compressed fibre cement (CFC) sheeting that covers the roof gutter penetration in order to lay a waterproof material, called sarking, down. The sarking is taped down and stops moisture from entering the building. Then a pre-fabricated box gutter is installed in the penetration to collect water.

The installation of the roof coverage and gutters for the New Perth Museum was particularly complex as there were many layers which meant the normal work sequence and process could not be used. The box gutters for the New Perth Museum were installed after some of the roof layers were installed and before the roof was sheeted. Ordinarily, box gutters are put in before the roof is sheeted, via an elevating work platform, so workers do not need to be on the roof when box gutters are installed.

Safe Work Method Statement

On 11 April 2019 a Safe Work Method Statement (the SWMS) was signed onto by the Roof Plumbers and approved by a supervisor employed by the Offender.

The SWMS identified hazards associated with the task of installing box gutters and the control measures listed relevantly include that:

• a.             a static line is to be installed by a competent employee using an elevating work platform;
• b.             exclusion zones are to be set up;
• c.             Roof access permits should be used; and
• d.             Appropriate PPE (personal protective equipment) should be worn.

The SWMS identified falls from heights as a hazard associated with penetrations.  The relevant control identified was ‘use fall injury prevention or restraint system if mesh has been cut on existing roof’. There was no mesh under the roof gutter penetrations at the time of the incident.

The SWMS also provided that the personal protective equipment to be utilised included fall arrest equipment.

A further control under the heading ‘general planning’ relevantly provides:

• a.             ‘make sure the employees are instructed in the correct use of: Personal Protective Equipment (PPE);
• b.             Have as a minimum HRWL, Crane, EWP, forklift & working at heights training;
• c.             Conduct daily prestarts and toolbox meetings;
• d.             Attend site induction; and
• e.             Conduct SWMS’;

The Roof Plumbers were not instructed to use a fall injury prevention system prior to undertaking work on the day of the incident.

The Incident

On 17 April 2019, the Roof Plumbers were working on the Wrap Roof. In the north western section of the Wrap Roof, one of the Roof Plumbers (not the victim) removed the CFC that was laying over the penetration in the gutter (the Cover), thereby creating / revealing an open penetration measuring approximately 600mm x 600mm. Removing the Cover was a necessary work step activity involved in the task of installing the box gutters as it allowed the sarking to be installed.

One of the roof plumbers (the victim) had been working on the south-west side of the Wrap Roof laying sarking and was not aware that a cover had been taken off a penetration in the north-west corner.

Another Roof Plumber (Roof Plumber 3) moved sarking over the open penetration and taped the sarking down. As a result, the open penetration underneath the sarking was not visible. The Cover was not immediately replaced over the roof penetration and Roof Plumber 3 began talking to his supervisor.

The victim then approached the north-west corner of the Wrap Roof.  The victim, roof plumber 2 and roof plumber 3 had a discussion about another work task. Roof plumber’s 3 and 4 walked away to attend to the other work task. Then the victim stepped on to the sarking covering the penetration which tore and he fell approximately 6.83 metres onto the concrete floor below.  

The victim suffered a fracture dislocation of the left shoulder and fractured left leg as a result of the fall from height.

Aftermath

An ambulance was called and the victim was taken to Royal Perth Hospital. The victim underwent two internal fixation surgeries during which nails and screws were inserted into his left shoulder and leg. The victim spent 3 weeks in hospital and has since received extensive occupational therapy, physical therapy and medical treatment.

In around February 2020 the victim was referred to a specialist orthopaedic surgeon as he was experiencing pain on the inner side of his left distal thigh with a grinding sensation on knee bend, which was compromising his ability to mobilise and walk. On 12 March 2020 the victim had further surgery to remove the locking bolts in his left leg to reduce the pain from the irritation of the screws which were protruding into his soft tissue. The victim was certified as unfit to return to work for 13 months after the incident. On 11 May 2020 the victim was certified as being able to return to light duties only.

System of work in place at the time of the incident

On the day of the incident, no fall injury prevention system was in use by any of the Roof Plumbers.

Given that the sump penetrations in the gutter exceeded 200mm x 200mm in area, a fall injury prevention system was required to be used by the Roof Plumbers for the duration that they were uncovered. Once the Cover was replaced, no fall injury prevention system was required, because the roof was flat, and the perimeter barricaded.

The Offender had all the necessary equipment on site to create a suitable fall injury prevention system at the New Perth Museum. All of the Roof Plumbers had safety harnesses available on site which could be attached to an anchor, static line or similar to create a fall injury prevention system.

The Offender also had an employee available who was a licenced rigger with specific expertise and ability to install a fall injury prevention system (such as a static line that the Roof Plumbers could attach to).

This employee of the Offender, qualified to install a fall injury prevention system, had not been instructed to install a fall injury prevention system.

A temporary anchor point was approximately five metres away from the open penetration which the victim fell through, but the temporary anchor point was not secured or otherwise fixed into position and was not in use by the Roof Plumbers.

The Roof Plumbers had been using a fall injury prevention system when initially carrying out works to construct the Wrap Roof.

Practicable measures

Prior to, and as at 17 April 2019, it was practicable for the Offender to have:

a.             ensured that the Roof Plumbers used an adequate fall injury prevention system (such as safety harnesses attached to a static line, anchor or similar) while undertaking any work on the roof at the workplace involving the removal of a cover of a roof penetration or while undertaking any work on the roof while roof penetration covers were not fixed in place over the roof penetrations; and/or

b.             ensured that a safe work procedure was in place and followed by the Roof Plumbers, which identified:

i.              the need to use a fall injury prevention system while undertaking any work involving the removal of a cover of a roof penetration or while undertaking any work on the roof at the workplace while the roof penetration covers were not fixed in place over the roof penetrations; and/or

ii.             a requirement that a cover of a roof penetration is only removed for the purposes of a necessary work task in circumstances where the removal takes place immediately before the necessary work task is performed and the cover is immediately replaced after any necessary work task is complete; and/or

c.             ensured that adequate physical barriers, warning signs or other visual indicators were placed around any open penetration on the roof to mitigate or eliminate the potential for a person to suffer injury or death as a result of being exposed to the hazard.

Taking any or all of these measures would have reduced the risk of the hazard, posed by the uncovered penetration, eventuating and consequently the risk of an injury being caused to any person on 17 April 2019.

If the Roof Plumbers had been using a fall injury prevention system it would not then have been necessary to install any physical barriers, warning signs or other visual indicators.

Subsequent changes

After the incident, orange flagging was installed around the open penetration (that the victim had fallen through) to alert others to the hazard.

The Offender plead guilty on 23 July 2021 and was sentenced on 12 August 2021.  The Magistrate fined the Offender $450,000 after a 25% reduction for a guilty plea and further reductions for other mitigating factors.  Costs of $3,056 were ordered.