|Offender||Bradley Michael Shackleton|
|Charge||Charge Number||Offence Date||Date Convicted||Regulation||Section||Penalty Provision||Penalty Imposed||Date Sentenced|
|1||PE31029/2021||Between 20 November 2018 and 21 November 2018||17th September 2021||19(1) 19A(2) 55(1) 55(1)(b)||3A(3)(a)(i)||$50,000.00||29th October 2021|
|Description of Breach(es)||
Being a Manager or purporting to act in the capacity as a Manager of PGQW Pty Ltd previously known as Boxline Industries Pty Ltd (a body corporate) when PGQW Pty Ltd previously known as Boxline Industries Pty Ltd was guilty of an offence under sections 19(1) and 19A(2) of the Occupational Safety and Health Act 1984 and that offence occurred with the consent of and/or was attributable to the neglect of the Accused.
PGQW Pty Ltd previously known as Boxline Industries Pty Ltd (Boxline) is a sheet metal fabrication business that manufactured electrical switchboards, battery boxes, sheet metal enclosures, cabinets and controller boxes.
At the time of the incident, Boxline operated a fabrication workshop in Welshpool, Perth (they have since moved their premises to Kewdale, Perth). The workplace is a 1000 square metre factory containing a powder coating area, welding bays and sheet metal machinery including guillotines and benders.
At the time of the incident, Boxline had one Director, a manager Bradley Shackleton, two supervisors and tradesmen’s and labourers.
The Director purchased an established sheet metal fabrication business and registered Boxline under his name on 6 September 2004. He has been the sole director and company secretary of Boxline since and is qualified at PHD level in electrical engineering.
Boxline’s manager, Bradley Shackleton was the workshop supervisor of the previous business who was hired by the Director in 2004 as the workshop manager for Boxline. Mr Shackleton was a qualified sheet metal tradesmen and was employed by Boxline via a subcontractor arrangement as per an agreement between the Director and Mr Shackleton at the commencement of his employment.
At the time of the incident, Boxline had twelve employees, including the victim.
The victim was a 21 year old welder/fabricator who completed a Certificate 2 and 3 in Engineering at TAFE. He commenced full time employment with Boxline at the end of July 2018, around 4 months prior to the incident. The victim was initially put on a three month probation period by Mr Shackleton in the anticipation that if he passed probation, he would be offered an apprenticeship with Boxline by January 2019.
Description of the work being carried out at the workplace
The fabrication of an electrical switchboard at Boxline required flat sheet metal (aluminium and stainless steel) to be punched and snipped, bent and welded into shape. The product is then either powder coated or orbital sanded for finish, depending on the customer’s needs. If the product was not painted, it would be orbital sanded. Boxline’s process at that time was to sand the sheet metal with a pneumatic orbital sander and kerosene to produce a non-reflective and corrosion resistant finish. The orbital sander is a hand held pneumatically driven device with a round disc that spins at speed. Sometimes the orbital sanding was done prior to the sheet metal being bent (flat sheet) because the sander cannot get into the bends of the metal.
The flat sheet metal was placed onto a bench, kerosene was squirted onto the flat sheet metal from an unlabelled plastic bottle with a straw like nozzle. The kerosene was applied liberally and coated onto the flat sheet metal with a rag to provide an even coverage of kerosene on the sheet metal.
The kerosene was stored in a drum in the compressor room which was located next to the powder coating area. To replenish the plastic bottle, the employees would decant the kerosene from the drum to fill the plastic bottle.
The sander was then used to buff the kerosene into the metal, pressing down on the metal with circular motions. The spinning motion of the orbital sander would cause the kerosene on the metal to flick onto the operators chest, legs and arms. One sheet can take about ten minutes to orbital sand. This process was done at least once a week.
Anyone in the workshop could perform orbital sanding, including welders such as the victim. There was no specifically designated areas to do this task. When a welder would orbital sand, they would ordinarily perform this task it in their welding bays.
If a welder has performed orbital sanding, they will bend the sheets into shape then weld the product. When it is busy, the welder may perform this process twice a day. Prior to welding, the sheet is wiped with a rag to remove excess kerosene because the kerosene will contaminate the weld.
As kerosene is a hazardous and flammable substance, when a heat source such as a welding is applied on kerosene, it can catch fire.
Rag fires were known to occur at Boxline. Kerosene soaked rags (from orbital sanding) would catch fire from welding sparks generated during welding. The rag fires would be controlled by placing a flat sheet of metal on top of the fire.
It was not uncommon for employees clothing to have burn holes from the welding sparks that ignited during welding.
Description of the accident
On 20 November 2018, the day before the incident, the victim had started the working day welding and finished this task just before 10am. The victim was instructed by Mr Shackleton to orbital sand with kerosene about 30 stainless steel sheeting which were two meters long by one meter wide. The victim had spent the day orbital sanding the flat sheets of metal with kerosene and had sanded about 20 sheets.
The kerosene the victim was applying onto the metal sheets had been decanted from the kerosene drum into an unlabelled plastic bottle. He was not aware or advised that kerosene was a hazardous substance and was a flammable product. The victim was not trained on how much kerosene to apply from the plastic bottle onto the metal sheets. The victim was not provided with or instructed to wear any personal protective equipment (PPE) such as an apron. There were insufficient aprons to use at Boxline and the use of aprons was not mandatory but was considered a recommendation.
The victim was not wearing any PPE such as an apron on top of his shirt. As such, the kerosene was being splashed onto his clothes when orbital sanding.
The following day, 21 November 2018 (day of incident), the victim arrived at the workplace wearing the same shirt from the day before and started his work day orbital sanding the remaining metal sheets with kerosene. The victim was not provided with or instructed to wear any PPE such as an apron.
An employee of Boxline, witnessed the victim putting too much kerosene on the metal sheets and warned him to which the victim replied “How much do I need to use? What do I need to do?” the employee replied “You just put a little bit on, sand it evenly then wipe with a rag”. The victim responded saying “No-one’s showed me how to do this”.
The victim completed the task of orbital sanding the metal sheets with kerosene before lunch and asked one of the supervisors what work to do next. The supervisor sent him to the other supervisor (second supervisor) as he didn’t have any work for him to do. The second supervisor told the victim to weld shipping container locking handles. He set up a welding bay for the victim and showed him how to do the first one. The second supervisor left the victim to his new task and returned to his own welding bay that was situated next to the victim.
To protect from welding burns, the victim put a long-sleeve shirt on top of his short sleeve shirt which had kerosene splashed onto it from his orbital sanding task. The victim was not provided with or instructed to wear PPE when orbital sanding with kerosene. The victim was not wearing an apron when he was orbital sanding prior to welding. The lack of an apron allowed kerosene droplets to splash onto his shirt.
When the victim was tasked to weld after orbital sanding with kerosene, he was not instructed to remove the shirt he was wearing which was had kerosene splashed onto it and he was not provided with clean PPE to perform the welding task.
The shipping container handles were left and right handed locking handles, they were steel tube 25mm in diameter with two sets of steel prongs to be welded. Each type had a jig to hold the parts to be welded and the work done at waist height. Once clamped into place the victim started with tack welds, this holds the parts together while welding.
At the time the victim was using a Mig welder. A Mig welder uses a roll of steel wire which is fed from a reel and down through a hand set and touches the piece of metal to be welded. It forms an electrical circuit and melts the wire forming a weld. Mig welding produces hot sparks that can be thrown from the weld of about one meter.
After the tack welds, the victim started welding and had completed an 80mm weld when he felt his shirt get hot. This was about ten seconds after he began welding. When the victim lifted his mask, he saw that his shirt was on fire. The second supervisor told the victim to drop and roll. As the victim tried to drop and roll, he tripped over a pallet and hit his head. The victim’s pants and shirt were on fire. When the victim tried to pull his shirt off, his shirt burnt his head. It took some time to locate the fire extinguisher which was later used to put out the flames. The victim was taken to the shower where they waited for an ambulance that arrived about fifteen minutes later.
As a result of the incident, the victim suffered 30% burn injuries to the following areas of his body:
a) Face, nose, right ear;
b) Both armpits, chest, upper limbs, right hand, stomach, torso; and
c) Both thighs.
The victim has had a total of 13 surgeries for his burns including skin grafting, laser therapy, scar releases, reconstructions and multiple laser treatments.
The victim has lifelong scarring and scar contractures affecting his face, neck, right hand and anterior trunk and flank – all of which have received reconstructive surgery and will require ongoing surgeries to improve his cosmesis and function.
The victim’s physical functioning as a result of the scarring will impact his ability to return to work as a fabricator/welder. Further, the incident and the subsequent visible scarring has impacted the victim psychologically.
The victim is currently still undergoing more surgeries for the injuries sustained.
Safety systems on and prior to incident
The use of kerosene
Boxline ought to have eliminated the use of a hazardous substance such as kerosene to orbital sand metal sheets. A water based compound (non-flammable) was already being used at Boxline at the time and prior to the incident to cool cut blades during cutting.
Other like companies at the time of the incident had eliminated the use of kerosene and were orbital sanding sheets dry or using a non-flammable product given the safety risk it poses being a flammable product.
Induction, training and supervision
Boxline had not established any of the following:
a) Systems to ensure that new employees were given adequate induction at the commencement of their employment;
b) Adequate information, instruction and training during their course of employment in relation to safe work practices including practice and procedures around the correct use of a hazardous substance such as kerosene, orbital sanding and welding;
c) Systems to ensure that new, inexperienced and young employees were adequately supervised and monitored during their course of employment including work involving orbital sanding with kerosene and welding after orbital sanding with kerosene; and
Safe systems of work for the correct application of a hazardous substance, kerosene on metal sheets when orbital sanding.
The victim was not provided with any induction, training or supervision during the course of his employment.
The victim was not adequately trained or supervised prior to being allocated the task of orbital sanding with kerosene.
The victim was not adequately trained or supervised when welding, including welding after orbital sanding with kerosene.
Protective Personal Equipment (PPE) - Aprons
There were a limited amount of aprons available in the workshop. These aprons were not stored in a specific area and could be difficult to find. Most employees did not wear an apron when orbital sanding with kerosene. The use of aprons when orbital sanding with kerosene was not enforced but left up to the personal preference of the employee.
Boxline had not provided employees with sufficient PPE such as aprons when orbital sanding with kerosene to reduce the kerosene being splashed on their clothing.
Boxline had not ensured that employees’ clothes were free from kerosene and did not provide them with clean PPE if they were welding after orbital sanding with kerosene.
Charge 4 Accused Shackleton - Section 55(1) of the Act
Mr Shackleton was the manager of Boxline. Mr Shackleton provided direction to Boxline employees and was the Workshop Manager who oversaw many of the practices of Boxline. Mr Shackleton was a qualified sheet metal tradesmen and was aware of the lack of induction, training and supervision provided by Boxline and many of these tasks were within his capacity as Workshop manager to implement.
Mr Shackleton consented to and or neglected to do any or all of the actions as outlined in the particulars to this charge which attributed to the hazard being employees orbital sanding with kerosene and then welding that resulted in the victim suffering serious harm.
Boxline Charges pursuant to the Occupational Safety and Health Regulations 1996 (the Regulations)
Charge 2- Regulation 5.13(1)(c) of the Regulations
Boxline failed to ensure that a Material Safety Data Sheets (MSDS) for kerosene was readily available to all employees who are or who might be exposed to the hazardous substance (kerosene).
A MSDS identifies flammable substances such as kerosene as a fire risk and identifies precautions that are required to be taken when these substances are combined with heat sources such as welding.
At the time of the incident and prior, Boxline used the Digger’s brand of Kerosene that came with a 7 page MSDS which provided the following relevant information:
Preventative: Keep away heat, sparks, open flames, hot surfaces and smoking
Response: If on the skin or hair, take off contaminated clothing and wash before reuse. Rinse skin with water and shower
At the time of the incident, Boxline had this Digger’s MSDS for kerosene which was located in a file cabinet in a supervisor’s office. The employees were unaware of the existence of the MSDS’s, they were not readily available to employees to access and no information from these MDSD’s was given to the employees.
Charge 3- Regulation 5.12(3) of the Regulations
At the time of the incident, Boxline stored kerosene in a drum in the compressor room which was located next to the powder coating area. To replenish the plastic bottle, the employees would decant the kerosene from the drum to fill the plastic bottle, similar to a Powerade/Gatorade bottle. This plastic bottle was then used when performing any task with kerosene.
The plastic bottle did not have any labelling, including it being a hazardous substance, the brand name, trade name and the risk and safety phrases that apply to kerosene.
Prior Improvement Notices
On 8 May 2013, Boxline was inspected by WorkSafe where Mr Shackleton was noted as the contact name for the business. Boxline was issued with 10 improvement notices. Boxline was issued with an improvement notice as outlined above under regulation 5.12(3) of the Regulations. On 21 July 2013, the Director signed the improvement notice confirming the direction had been completed and the notice had be complied with.
Further in May 2013, Boxline was also issued with an improvement notice for a breach under section 19(1) of the Act for insufficient safety induction for new and existing employees. Boxline were directed to provide a written record stating that an induction program for new or existing employees has been conducted and understood by each inductee. The induction could include, but is not limited to, hazard identification, hazard reporting, injury and accident reporting, evacuation procedure, use of fire extinguishers, first aid, hazardous substances, personal protective equipment and other matters to minimize the risk of injury or harm. On 21 July 2013, the Director signed the improvement notice confirming the direction had been completed and the notice had be complied with.
On 23 August 2013, WorkSafe again attended Boxline and four improvement notices were issued. During this inspection, it was identified that training in the use of plant equipment was inadequate. Further, there were MSDS available but no risk assessments or records of training for the use of hazardous substances. A hazardous substance handout (with templates and examples), examples of a hazardous substance register, risk assessments and records of training was provided to Mr Shackleton on behalf of Boxline.
On 8 October 2014, WorkSafe attended Boxline to inspect the health and safety concerns raised in 2013. During this attendance, Mr Shackleton was present. There were no improvement notices issued.
Relevant to Mr Shackleton’s charge, he was present and accompanied the Inspector during the above 2013 and 2014 attendances by WorkSafe and he received Improvement Notices and relevant literature on behalf of Boxline.
Improvement Notices subsequent to the Incident
As a result of the incident, WorkSafe attended Boxline on 7 January 2019 and issued 14 improvement notices for breaches under the Act and the Regulations, which included failing to conduct a risk assessment on hazardous manual tasks, lack of signage for the use of PPE, decanted and unlabelled bottles of hazardous substances and lack of welding screens in place to reduce the risk of injury to persons in the vicinity of welding. There was compliance of this improvement notice on 6 February 2019.
WorkSafe again attended Boxline again on 27 May 2019 and two improvement notices were issued which were received and signed by Mr Shackleton. One of the notices related to a breach against regulation 5.21(1) as it was identified that there was still no training provided to the employees for the use of hazardous substances used in the workplace. Boxline were directed to comply with the following by 24 June 2019:
a) Provide each person who is likely to be exposed to hazardous substances in the workplace information and training on but not limited to:
• The potential health risk and any toxic effects associated with the hazardous substance/s;
• The control measures used to minimise the risk to safety and health;
• The correct use of method used to minimise adverse effect of exposure to the hazardous substance; and
• The correct care and use of personal protective clothing and equipment.
Changes made post incident
On or about 20 June 2019, Boxline engaged an external safety advisor to improve its health and safety practices. Boxline subsequently established the following as a result of the incident:
Eliminating the use of the hazardous substance, Kerosene
Following the incident, the workplace ceased using kerosene for orbital sanding and removed the remaining kerosene from the workplace. The kerosene was replaced with Ecocool Durant cutting fluid. That product was already used at the workplace to cool metal when cutting.
All the employees were given a demonstration on how to orbital sand with the Ecocool Durant.
After the incident a documented Safe Work Procedure was established for the orbital sanding process. The correct method for this task was then demonstrated to the employees.
Aprons were individually supplied and made mandatory PPE when orbital sanding. Employees were provided welding jackets to be worn when welding.
Training and other measures
All employees were provided online hazardous substance training. A hazardous substance register (including Material Safety Data Sheets and risk assessments) was established. All employees were provided training for the hazardous substances used at the workplace.
A safety consultant was engaged to establish a system of safety management at Boxline.
Fire extinguishers were installed in the welding bays and employees were provided with fire extinguisher training.
The offender entered a guilty plea and was convicted on 17 September 2021. On 29 October 2021, Bradley Michael Shackleton was sentenced to a fine of $50,000 and costs awarded in the sum of $2682.50.
|Court||Magistrates Court of Western Australia - Perth|
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