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Prosecution Details

Offender Visy Board Proprietary Limited (ACN 005 787 913)


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Charge Charge Number Offence Date Date Convicted Regulation Section Penalty Provision Penalty Imposed Date Sentenced
1 FR132/2023 7/01/2020 17th September 2023 3A(3)(b)(i) $275,000.00 7th November 2023
Description of Breach(es)

Being an employer, failed, so far as was practicable, to provide and maintain a working environment in which its employees were not exposed to hazards, and by that contravention caused serious harm to an employee

Background Details

Visy Board Pty Ltd (ACN 005 787 913) (Visy) operates a cardboard box factory at 49 Peel Road, O'Connor (the Workplace) where it produces cardboard packaging products, such as cartons, pizza boxes, removal boxes and shoe boxes. At the Workplace, Visy maintains and operates the Titan 1, which is a Rotary Die Cutter System. The Titan 1 is designed to process blank corrugated cardboard sheets to create printed, creased and cut sheets which are to be folded along the crease and cut lines to form a cardboard container, such as pizza boxes.

On the morning of 7 January 2020, the victim was making adjustments to the feed end of the Titan 1 while it was running when his left hand was pulled into the feed rolls, amputating two segments of his middle finger and the top segment of his ring finger.


The Titan 1 is comprised of several units. Cardboard sheets are placed on the feed table of the feed unit (often automatically via a conveyor belt known as the 'extendo'). Those sheets are pulled from the bottom of the stack by a vacuum onto a set of feed wheels and are advanced into the feed rolls. The feed rolls pull the sheet from beneath the stack and advance it into the pull rolls of the next unit, being the print unit. When a feed cycle begins, the feed wheels rotate as the feed plate drops allowing contact between the feed wheels and the cardboard, this allows the rotating feed wheels to drive the sheet of cardboard into the feed rolls. Once the feed rolls receive a cardboard sheet, the feed plate moves up to its home position and the feed wheels are below the surface of the feed plate. When the cardboard sheet clears the feed gates, the feed plate moves up, so the feed wheels are under the feed plate awaiting the next cycle. There are two feed gates at the feed end which ensure, when properly adjusted vertically, that only a single sheet of cardboard can be fed into the feed rolls.

Viewed from the operator's position, there is a control panel on the left-hand side of the feed unit with 12 buttons across 5 rows of 3 (three button positions were unused at the time). On the top row of buttons there were two buttons, a red machine stop or e-stop on the left and a green feed interrupt button on the right. The red machine stop button would stop the Titan 1. The green feed interrupt button did not stop the machine,

rather it stopped the feed cycle, meaning the plate stops cycling up and down, therefore stopping the cardboard from contacting the feed wheels and driving sheets into the feed roller. The button on the left-hand side immediately under the machine stop button turned the vacuum on and off. Ordinarily, three persons would be involved in manning the Titan 1: the operator; the feeder (or setter); and the stacker. The roles of each are set out in in the Standard Working Practice for the Titan 1 Machine (the SWP).

In practice, and largely consistent with the SWP, the operator would be responsible for the fine tuning of the Titan 1, such as the setting of belts, quality controls, the pressures and the inks. The feeder or setter would generally put the die on and set the feed so that the system can run. The stacker gets the dies, the stereos (printing plate) and sometimes they put the stereos on (or take them off) the machine and assist with ink change overs, but generally the stacker is there to stack the finished product and is not responsible for the performance of tasks on the feed unit.  The feeder or operator is responsible for starting up the Titan 1 and would be responsible for restarting the Titan 1 in the event of a jam. Similarly, it would generally be the role of the feeder or operator to clear a jam up on the Titan 1, with the stacker unlikely to have a significant role in this part of the operation. However, if appropriately trained, stackers are competent to assist with this task and, do participate from time to time, most often assisting the feeder or operator in the removal of the cardboard. The starting and restarting of the Titan 1 occurs via the control panel on the feed unit.

When the Titan 1 is producing 'pizza runs' the feeder will often work in the pizza wrap tunnel which is approximately 20 metres from the feed unit. As a result, the operator performs the dual roles of operator and feeder.


On the morning of the incident, the Titan 1 was crewed by three workers, the operator, the feeder and the victim (as the stacker). No other person was assigned to the Titan 1 that morning.

As the job being performed was a 'pizza job', the feeder was working at the pizza wrap tunnel and the feed unit, as required. This meant that the operator was, in effect, performing both the role of operator and feeder at the time of the incident. This was and remains a method of resourcing the task that has been approved by Visy.

When the Titan 1 was running a 'pizza job' it was not uncommon for jams to occur at the feed end of the machine. Prior to 8.30 am on the morning of 7 January 2020 there had been four jams of the feed unit (along with several other jams at the delivery end). Just after 8.30 am, there was a fifth jam of the feed unit. The operator raised the extendo conveyor belt out of the way and cleared the jam. The victim went over to assist the operator in checking the gap at the feed gate through the use of a blank card. The victim was standing on the side closest to the control panel (known as the Operator side) and the operator was standing on the other side of the feed end (known as the Drive side).

At the time, the machine was still running and had not been stopped by the operator or the victim as Visy's procedures required. The only steps that had been taken in relation to the running of the machine were that the vacuum on the feed table had been turned off, and the feed interrupt button had been pressed. The victim was aware that the machine was still running. After the operator had made adjustments at his end, the victim proceeded to adjust the feed gate on his side. He pushed the blank card under the feed gate which then

contacted the feed roll, pulling his hand into the machine. The operator then hit the 'machine stop button'. The machine came to a stop.


 In 2016, Visy also issued the O’Connor Hazard Induction Training across the site, which provided a basic introduction to the hazards in the Workplace. From May 2017, Visy had in place a SWP for the Titan 1, it replaced a previous version which had been in place since 2012. The SWP required that before any work could commence all persons involved in the operation of the Titan 1 must be site inducted, complete the site general hazard induction, be trained in the relevant SWP and complete the relevant competency tests.

Clause 9 of the SWP also set out the procedure for dealing with the clearances of jams. Importantly, clause 9.1 and 9.2 instructed as follows:

9.1 When clearing any blockages or jams always ensure the machine is completely stopped, lockout and tag out if required.

9.2 If clearing the jam from the feed end raise the prefeeder extendo up, ensuing the locking pins have engaged. Push in the machine stop button and once the machine has stopped then commence clearing the blockage.

The SWP also contains a section dealing with hazards associated with the prefeeder and feed sections of the Titan 1. The final hazard is:

The Feed hopper is designed to hold sheets of board and feed one sheet at a time into the machine. This process happens very quickly. If any adjustments or clearing of blockages need to occur in this vicinity the machine must be completely stopped. This area of the machine has a very hazardous infeed nip point that will cause significant damage to hands. Never attempt to clear blockages (jams) whilst machinery is running. (emphasis in original)

The relevant competency test for the Titan 1 requires practical assessments be undertaken at intervals during the month following training on the SWP and the progress recorded in the competency assessment form. The intervals occur immediately after the SWP training then at 1 week and 1 month after the SWP training. Until the 1 week assessment has been completed, an employee must be under the direct supervision of a competent person at all times whilst completing on the job training and mentoring.

The competency assessment also requires that the facilitator of the assessment observe the employee perform each of the tasks indicated and indicate whether the employee has met each criteria by placing a tick in the Yes or No boxes in the columns on the form.


The Hazard in this case was the nip, crush pinch and/or trap points on the feed unit of the Titan 1, including the nip, crush, pinch and/or trap points at the entry to the feed rolls from the feed table, and the feed rolls themselves. In June 2017, Visy issued its SWP which specifically warned about the Hazard and the severity of any potential injury if a person was exposed to the Hazard.

The Hazard was also identified in a Machine Guarding & Nip Point Audit that was completed across May to June 2019, in response to an Improvement Notice issued as a result of guarding concerns on other machinery.

Finally, Visy was generally aware of Hazards of this nature as three employees had suffered nip, crush or pinch injuries previously, albeit on different machines, in different circumstances, and over a period exceeding 10 years.


The operator had not been trained in the SWP or completed the relevant competency assessments, as required by the SWP.

The operator, the person primarily responsible for clearing jams on the feed end of the Titan 1 that morning, only saw the SWP after the incident and was not the subject of a relevant competency test.

The operator commenced employment with Visy in August 2019. On or about 12 August 2019 he completed the Hazard Induction Training. This training lasted over 30 minutes and involved the supervisor taking the operator through various machines in the Workplace, identifying various hazards and asking him to explain or demonstrate his understanding of the various hazards and issues identified in the document. Included in the Employee Training and Induction Form which evidences the Hazard Induction Training is a generic section for "Feed Units", which notes "Machine must be stopped before any jam-ups are cleared. Stopping the machine maybe achieved by pushing the normal machine stop." The generic nature of this mandate is because the manner in which 'stop' buttons function at the Workplace are not materially different across all the machines on site.

Sometime in late 2019, the operator commenced training to perform the role of operator on the Titan 1. He had not previously worked with such machines prior to his employment with Visy.

The training provided was on the job training, with the operator paired with an experienced operator of the Titan 1. The training involved the operator observing the experienced operator perform the role, asking questions and learning from what the experienced operator did. This occurred on an ad hoc basis for around 6 weeks. The experienced operator who trained the operator did not assess his competency to operate the Titan 1. No competency assessment was performed in relation to the operator prior to 7 January 2020. Nor was the operator ever asked to demonstrate the procedure for clearing a jam on the feed end of the Titan 1 to the floor supervisor (who was ordinarily responsible for doing the competency assessment) or the experienced operator who trained him on the Titan 1.

At the time of the incident, the operator was not under the direct supervision of a competent person as was required by the Competency Assessment and the SWP. In attempting to clear the jam and reset the feed gates with the machine operating, the operator and the victim acted in contravention of the SWP. Neither the operator or the victim turned off the Titan 1 to ensure that it was fully stopped before attempting to clear the jam. Both the victim and the operator had received the Hazard Induction Training and initialled the section that stated, for feed units such as the one on the Titan 1, that machines must be stopped before any jam-ups are cleared.

Following the incident, a competency assessment dated 10 February 2020 (with purported assessment dates on 9 January 2020, 23 January 2020 and 23 February 2020) was completed by the operator.  The competency assessment was performed on a single day (not in intervals as was ordinarily required) and was conducted in Visy's cafeteria, not on the actual machine as the assessment required.

Notwithstanding that the competency assessment was not performed in the manner the assessment required, the operator passed the assessment conducted in the cafeteria.

A subsequent audit of competency assessments after the incident identified that approximately 200 such assessments had either not been completed or there was no record of such assessments being completed. The victim was aware of the SWP and had his competency as a 'stacker' assessed.  However, that assessment focused on the functions he ordinarily performed as a stacker. Further, he had not been specifically trained on how to deal with jams on the feed end of the Titan 1 but had initialled that he had received the general instruction in the Hazard Induction Training to stop the machine when clearing a jam.

Physical modification to the Titan 1

At the time of the incident the opening to the feed rollers exceeded the recommended separation distances contained in Appendix 5 to the Commission for Occupational Safety and Health's Code of Practice Safe Guarding of Machinery and Plant 2009 by approximately 5 to 7 mm.

Following the incident, Visy installed an additional plastic strip to the infeed of the Titan 1 to reduce the opening to the feed rollers. The 3 mm pre-incident strip which was fitted to the machine was added to with a strip that tapered from 10 mm to 8 mm, reducing the opening to 6 mm.  As a result of the installation of the strip, the opening to the feed rollers is now consistent with the recommended separation distances, reducing the risk associated with the Hazard. The strip was installed on 10 February 2020, with the work required to install the strip (which was performed by a fitter employed by Visy) taking a couple of hours. The strip itself cost $143.00.

Engineering or Electrical Controls

Following the incident, Visy have installed three engineering or electrical controlsthat further reduce the risk associated with the Hazard.First, a "two hand feed system", which uses a presence sensing eye on the feed table) to monitor the level of cardboard in the feed unit. When the level ofcardboard on the feed table drops to a certain level, the machine automatically stopsfeeding sheets. If the level drops below the set point required for “two hand feeding”the machine automatically stops all together. When the level of cardboard on the feed table drops to the set point the feed end operator must press two buttons on the control panel (which are at such a distance that two hands are required), to run the remaining board out of the machine. If the operator removes one or both hands off the controls the machine will stop feeding sheets and the machine will also come to a complete stop as the level of cardboard is now too low to allow machine operation. This is a safety function to prevent a reoccurrence of this incident.

Using the "two hand feed system", the Titan 1 cannot operate where only a single piece of card is placed at the feed gate (unless an employee presses the two-buttons and manually overrides the automatic stop). The "two hand feed system" took the Workplace's in-house electrician about a month to design and implement, and cost approximately $1,200 to $1,300.

At the time of the incident, other machines in the Workplace had a "two hand feed system" in built as part of the machine’s design. A "two-hand feed system" had also been installed as an additional feature on a pallet sweeper at the Workplace prior to the incident.

Second, a jam detection system was fitted to the Titan 1, which automatically shuts the machine if a jam is detected at the feed end and any point within the machine. The system was developed and installed by Visy's in-house electrician. Once the system was developed by Visy's specialist national research and development engineering team, which took several months, the work to develop and install it took approximately three weeks and cost approximately $2,500, excluding man hours (which included installation as well as research and development time). Third, the controls of the Titan 1 were altered such that if the vacuum is turned off, (as was the case at the time of the incident), the machine is automatically stopped.


Visy failed to take reasonably practicable steps to ensure that its employees were not exposed to the Hazard by failing to:

a)         ensure that an engineering control being the manual override two-hand feed system was retrofitted to the Titan 1 that would have stopped, or prevented, the feed unit of the Titan operating when only a single piece of cardboard was placed on the feed table at the feed gates in the event the machine was not stopped as required to by the SWP to clear a jam;

b)        provide and maintain a system of work which:

i) required the competency of an employee operating the Titan 1, be assessed prior to operating the machine without direct supervision; and/or

ii)  ensured that persons working in the working environment were provided with such information, instruction, training and supervision as was necessary to enable them to perform their work in such a manner that they were not exposed to the Hazard or Hazards and ensured that those persons understood and complied with that information, instruction and training.

Serious Harm

As a result of being exposed to the Hazard, the victim suffered a partial amputation of the fingers of his left hand, being the amputation of two segments of his middle fingers and one segment of his ring finger but has regained hand function sufficient to enable him to return to his pre-injury duties.

Outcome Summary

The offender entered a guilty plea and was convicted on 17 October 2023. Sentencing occurred on 1 November 2023 with the Magistrate handing down decision on sentence on 7 November 2023. The Magistrate issued a fine of $275,000 and ordered costs of $8500.

Court Magistrates Court of Western Australia - Fremantle
Costs $8500.00

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