Prosecution Details

Being an employer did not as far as is practicable provide and maintain a working environment in which the employees of the employer are not exposed to hazards.

Background

Unique Metal Works Pty Ltd (ACN: 150 525 876) (“Unique Metals”) is a sheet metal manufacturing business in Wangara with various types of equipment in its workshop. Unique Metals specialises in the fabrication of stainless steel, aluminium and general sheet-metal products and laser cutting.

Machines in the factory include but is not limited to benders (press brakes), welders, punches, saws and guillotines, and lasers. It had two guillotines in its workshop which are used to cut sheet metal with one of these being a 4m LVD guillotine (“4m Guillotine”).

Unique Metals employees includes a Managing Director, a Production Manager and a Foreman. The production manager was responsible for the daily running of the factory and the foreman was responsible for assessing job cards, allocating work and supervising workers. They also employed approximately 2-3 apprentices every year, including the 17 year old victim. New employees, including apprentices, usually start work in the press brake and guillotining sections.

The victim started an apprenticeship at Unique Metals on 31 January 2019 as a sheet-metal worker. During the 5 months he worked at Unique Metals he did general cleaning and worked in the press brakes and guillotining section and regularly used the 4m Guillotine.

The records show that the victim had worked for at least 130 hours on the guillotine at Unique Metals. He was due to start his TAFE modules in the second half of 2019.

The 4m Guillotine

The 4m Guillotine is located in the middle of the factory in the press brakes and guillotine section. The 4m Guillotine is approximately 4m wide and 2m high. It can cut sheet metal that is 4m wide and approximately 6mm thick.

The 4m Guillotine was purchased in 2006 and was approximately 13 years old at the time of the incident. The 4m Guillotine is operated by entering information into the electronic control panel. Information may include a number of parameters such as the thickness of the sheet-metal and the width of a cut. The width of the cut may be determined by the distance the backstop is set from the blade.

A piece of sheet-metal is manually slid onto the bed of the guillotine, under the fixed metal guard and firmly to the backstop. A guide on the side of the bed is also used to ensure the sheet-metal is square to the cutting blade.

The guillotine operator then depresses the foot pedal which is covered by a pedal box cover. Depressing the foot pedal is the only way to initiate a cutting cycle for the guillotine.

The 4m Guillotine had a fixed metal guard fitted to the front of the machine, which had protection indents within the guard that allow a worker to push a narrow strip of sheet metal further into the guillotine.

The fixed metal guard was approximately 150mm wide and made up of two pieces of metal that was approximately 1.6mm thick, each two meters long. There were 8 protection indents evenly spaced along the length of the fixed metal guard. The protection indents were part of the fixed metal guard.

In normal operation the fixed metal guard and the protection indents sat between the worker and the blade. The fixed metal guard prevented a worker from being exposed to the operating zone of the blade. The protection indents in the guard created an additional few millimetres of space into which workers could reach their fingers, thereby allowing them additional access to the metal that was being cut by the 4m Guillotine.   However, there was no requirement for workers to put their fingers into these protection indents although some employees did so whilst working on the Guillotine. Some employees used other materials (such as spare pieces of sheet metal) rather than using their own fingers to move the sheet metal which was being cut.

The LVD Operators Manual states that “not only the blades can give serious mutilations but also the plate holders can cause injuries”.   The MVS-TS Guillotine Shears Pamphlet states that is has “assured protection of hands by fixed guarding of blades and hold downs”.

The Code of Practice on Safeguarding Machinery and Plant 2009 (“Code of Practice”) provides general guidance and notes that the work practices included may not represent the only acceptable means of achieving the standard to which the Code of Practice refers.

One of the qualified mechanics is the Storeman and dispatcher and undertakes Plant Maintenance for Unique Metals. The Storeman carried out basic maintenance work on various machines at Unique Metals which included the 4m Guillotine. Each month he would check each piece of equipment on the Preventative Maintenance Schedule however he was not instructed to check or inspect the protection indents in the fixed metal guard.

On 20 June 2019 the Storeman conducted a visual preventative monthly maintenance inspection of the 4m Guillotine.

Worksafe attended and conducted inspections at Unique Metals. Those inspections had included an inspection of the 4m Guillotine. WorkSafe never raised any formal or informal concern about the fixed metal guard on the 4m Guillotine. No improvement or prohibition notices regarding the appropriateness and safety of the fixed metal guard had ever been issued by WorkSafe.

July 2019

On 1 July 2019, the victim was operating the 4m Guillotine at the workplace to cut galvanised sheet metal.  There was no documented or recorded pre-start check of the 4m Guillotine prior to the victim using the machine. There were no issues identified with the guard and no issues reported on the day that the victim was injured.  There was also no documented operating procedure in place to ensure a pre-start was carried out before use.

At an unknown time prior to the incident involving the victim using the 4m Guillotine on 1 July 2019, something occurred in relation to the fixed guard in place on the 4m Guillotine which allowed the victim to inadvertently push his hands past the fixed metal guard and reach forward into the blade operating area.  The guard was damaged in such a way as to allow the victim’s hands to access the blade operating area.

In order for the victim’s hands to have been exposed to the blade they must have breached the fixed metal guard. It is not clear how the guard had been damaged such as to allow the victim’s hands to fit past the guard and into the blade operating area. It is established that at the same time the victim stretched his hands 50 millimetres past the end of the indented part of the fixed guard, he simultaneously, also inadvertently, pushed the foot pedal which was housed in a separate pedal cover box at the front of the 4m Guillotine. This activated the cutting cycle of the blade.

The victim suffered amputation of seven fingers (all but the tip of one was able to be re-attached). There were no direct witnesses or CCTV of the incident.

It is not alleged that Unique Metals contravention of the Occupational Safety and Health Act 1984 (WA) caused the injuries to the victim.

Changes following July 2019

After 1 July 2019, a risk assessment was completed and documented for the 4m Guillotine.  Unique Metals made a decision to fit a fixed metal guard without protection indents.  Unique Metal did not take this step based on WorkSafe’s input.   Since July 2019, documented weekly/daily maintenance checks were put in place which included checking the guard of the 4m Guillotine.

The offender entered a guilty plea on 4 November 2022 and was convicted. On 20 February 2023 the Magistrates issued a fine of $300,000 and ordered costs of $6436.30