Prosecution Details

Being an employer, contravened section 19(1) of the Occupational Safety and Health Act 1984, and by that contravention caused serious harm to its employee.

SUMMARY OF THE INCIDENT

On 13 May 2019, a young worker was seriously injured at a warehouse in Kewdale when a stack he was working in front of, comprised of twelve bundles of steel beams, collapsed upon, and partially amputated, his right leg. The steel beams in question are properly called lintels and were 12 metres long. Each bundle weighed approximately 1.952 metric tonnes. Approximately 5 or 6 bundles fell on the victim’s right leg. The Incident would have been fatal had the victim not promptly received medical attention.

THE ACCUSED

The offender (Lisson) had at all relevant times direct control of a business, known as 'BGC Builders Supplies', via its office as trustee for the PBS Unit Trust. From 2015, to 2020 when operations ceased, Lisson controlled the workplace, being a warehouse at which it conducted a business.  This involved storing, distributing and performing limited manufacturing tasks upon certain building supplies and materials, including lintels. The workplace was fitted with three 10-tonne overhead gantry cranes. 

RELEVANT WORK PERFORMED BY THE ACCUSED AT THE WORKPALCE

Lintels were stored and distributed at the Workplace. In many cases they were also cropped (that is, cut to a desired size) at the Workplace. A lintel is a beam or horizontal structural element that spans the top of openings such as doors, windows and fireplaces. It can be a decorative and/or a structural item. Lintels can sometimes be seen at the top of a doorway or window. In this case, the lintels were two-plane right-angled structural steel beams of various lengths, sizes and thicknesses (size meaning the width of the planes; thickness meaning the thickness of the planes).

Workers interviewed by WorkSafe inspectors estimated that the Workplace might have dealt with 10 to 11 different sizes of lintels (e.g. 30 x 30 mm, 100 x 150 mm). Importantly, some lintels had planes of equal width (e.g., 30 mm x 30 mm) and others unequal (relevantly, 90mm x 150mm). An unequal lintel is most stable when placed flat on its widest plane as this provides the largest base and the widest plane has more material and so is heavier. If such a lintel is placed with its peak pointing up, it will lean to the plane of lesser width as it is shorter than the other plane.

The relevant work performed at the workplace with respect to lintels is as follows. Lintels were ordered to the Workplace, according to business need, from the head offices of Lisson in Canning Vale. Lintels arrived at the workplace in stacked bundles, tied or belted together with plastic or steel. The vast majority of bundles were manufactured in China. These arrived in shipping containers delivered to the outside yard of the warehouse. There also was the odd delivery by truck of locally manufactured bundles. Individual lintels in bundles could be, approximately, 0.9 metres to 12 metres long and various lengths in between. A shipping container when delivered might contain 25-50 bundles of lintels.

There was a roughly 2 tonne limit on the weight of each lintel bundle. That weight limit and other factors including how many lintels had been ordered by the workplace, and size limits as to what can be tied, determined the number of lintels in a bundle.

A worker could find out how much each lintel bundle weighed by looking at a label affixed to the bundle. The overwhelming majority of bundles arrived stacked in a 'stacked offset' or an 'interlocked' fashion where two lintels are placed with their peak facing up and a single lintel is placed in the middle with its peak facing down. This pattern is repeated continuously until there are sufficient lintels in the bundle. The resulting 'M' shape bundle is wrapped or tied.

Relevantly to the Incident, the workplace would rarely, but more frequently before the incident, receive bundles from Chinese manufacturers in 'single file' stacking, where each lintel was stacked on top of the other single-file with its peak facing up.

Lintel bundles were always safer to handle when they were stacked in a stacked offset, because the wider base and the lower height of the bundle increased stability and ease of handling. Single-file stacked bundles were known to topple over and/or collapse the glutting on which they were stored, when being delivered to the workplace in a shipping container and/or when being removed from a shipping container and/or when otherwise being handled or moved.

Shipping containers when received would often be packed in 2-3 rows of lintels with each row separated by a "glut". A glut is a bar placed beneath or around an object to create separation between the object and something else. In the Workplace, the gluts were made of either hardwood, generally Jarrah, or softwood such as pine. A worker would put a glut on the ground at an appropriate distance from the open door, drive a forklift with a chain-lift attachment to the door, secure using their hands the chain-lift under and around the end of a bundle closest to the door, lift that end of the bundle using the forklift and then drive the forklift back to drag the bundle out of the container and onto the glut. The bundle on top of the glut would then be lifted up by a combi-lift (a multi-directional forklift which at the workplace had its lifting apparatus on its side) and then driven up to 30 metres inside the warehouse.

Critically to the incident in this matter, in which a stack of lintel bundles requiring cropping collapsed on a worker during the stacking exercise, once lintels requiring cropping were removed from a shipping container lintel they were:

• first, moved up to 30 metres inside the workplace, using the combi-lift for this purpose; and
• secondly, one of the three overhead gantry cranes would be used to stack the bundle on a stack of lintels of the same size, closer to the benches for the cropper machines.

When building this stack of lintels, prior to the incident, generally a jarrah glut would be used to support the first row of the stack and pine gluts would be used to support subsequent rows.

Lastly, for lintels requiring cropping, one of the overhead cranes was used to move a bundle of lintels to a roughly 12 metre long cropping bench. The bundle was cut open and a sorting apparatus and/or magnets were used to separate lintels. At the cropper machine, the operator would pick up a single lintel and cut it to the desired length and a packer would pack the cropped lintel for delivery.

THE INCIDENT

At all relevant times the victim was engaged by Lisson as an operator.

On or by Monday 13 May 2019 the workplace had received a shipping container with 150mm x 90mm, 12 metre long unequal width lintels. Seventeen of the bundles in the container were stacked single-file.

These lintels, due to their 12 metre length, required cropping. The victim and other workers commenced removing the lintel bundles from the shipping container and stacking them inside the warehouse for cropping.

On or by Monday 13 May 2019, the victim had constructed inside the warehouse a stack of twelve single file 150 x 90mm x 12 metre lintel bundles. The first row of gluts, placed on the ground, comprised four Jarrah gluts, evenly spaced. The succeeding rows comprised four pine gluts evenly spaced and lined up with each other. At 1:42pm on 13 May 2019, having placed the twelfth bundle on the stack and having just removed the overhead crane chain from it, the stack collapsed towards the victim whilst he was facing its longest length. The collapse took about two seconds. The victim managed to move most of his body out of the way, however his right leg was crushed.

AFTERMATH

Following the incident, the victim was brought to the Royal Perth Hospital Emergency Department at 2:46pm on 13 May 2019. Approximately half a litre of blood loss was observed on the ground at the workplace. At 4:30pm doctors decided that the victim’s right leg could not be saved and would have to be amputated at the mid-thigh. The amputation was performed that day and on 16 May 2019 further debridement (cleaning of wounds) was performed under general anaesthetic.

Ultimately the victim was admitted to RPH for 19 days and transferred to Fiona Stanley Hospital for ongoing rehabilitation. The intervention of medical treatment by staff at Royal Perth Hospital prevented the victim suffering catastrophic blood loss, shock and, ultimately, death. The victim suffered depression and adjustment disorder as a result of the amputation.

HAZARD

The Hazard was possible crushing by lintels. With one exception, workers were exposed to that Hazard when undertaking all of the work processes and tasks.  The exception is the prosecution does not contend that workers were exposed to the hazard when cutting open a bundle of lintels on a cropping bench and using a sorting apparatus and/or magnets to separate lintels and when packing cropped lintels for delivery.

PRACTICABLE MEASURES TO AVOID THE HAZARD THAT LISSON FAILED TO UNDERTAKE

Practicable Measure One: Risk assessment

Despite being well aware of the Hazard, Lisson failed to carry out a formal risk assessment in relation to the handling of lintel bundles that adequately identified the Hazard and means to control the Hazard. Workers were given few instructions in relation to the handling and stacking of lintels other than to employ common sense and operate in a manner that seemed safe.

Further, a Lisson Job Safety Analysis for 'Unloading Containers' dated 6 July 2015 listed 'crush' as a risk for the task of 'Pull Load from Containers', but merely proposed 'stand clear of container' as a measure.

Practicable Measure Two: Racking or load containment

The second practicable measure Lisson failed to undertake was to have installed racking or some other load containment, and instructed workers to use it, as to ensure that an effective physical control was used for the storage of bundles. Within the industry racking and load containment is best practice and relatively easy to install. With proper engineering and analysis racking can be installed and fabricated onsite from off-cuts of steel, or alternatively procured from a third party. In fact, prior to 2015 Lisson had conducted its business at a different premises in Canning Vale that employed racks for stacking 150 x 90mm and 150 x 100mm lintel bundles.

Practicable Measures Three to Five: Safe Stacking Procedure

The third to fifth measures Lisson failed to undertake were to:

a. have had in place a formalised safe stacking procedure;

b. adequately instruct and train its workers in the procedure; and

c. enforce the procedure through adequate supervision.

Prior to the incident, there was no formal safe stacking procedure at the Workplace and workers were in essence required to employ common sense and build a stack that looked safe. Many of the workers had received their informal instruction in stacking from the victim. Providing a formal safe stacking procedure to employees was a simple and straightforward measure. In particular, in order to minimise their employees' exposure to the Hazard, Lisson could have instructed workers, in circumstances where load containment is not available, that lintel bundles are:

a. not to be stacked from the ground any higher than in rows of 2;

b. in any event, are not to be stacked higher than 500mm;

c. the first row of the bundles is be spread out wider than the second so that the second was supported by a wider base in a ‘pyramid fashion';

d. if stability cannot be achieved by stacking the lintel bundles in rows of 2 in a pyramid fashion, then the lintel bundles must not be stacked at all.

The adoption of just one of the measures would have materially reduced the Hazard. Following the incident, Lisson adopted a safe stacking procedure by instructing workers that lintel bundles were not to be stacked from the ground any higher than in rows of two. A majority of the workers interviewed by WorkSafe inspectors stated that the adoption of this incident did not materially affect business operations and no witness suggested that this measure was unworkable.

Practicable Measure Six: 'Line of fire' analysis and adjustment

The sixth measure Lisson failed to undertake was to conduct line of fire analysis and physically adjust the Workplace and/or instruct workers as was necessary following that analysis. The line of fire is an area in which the collapse or fall of an object will likely occur. Line of fire analysis aims to ensure that workers work outside the line of fire. The victim was inside the line of fire when the Incident occurred being the two longest sides of the stack as these are the areas to which a 12-metre-long stack of thin beams will most likely collapse towards. The Incident occurred when the victim had just placed the last bundle on the stack and, facing the long sides of the stack, was removing the chains from under that bundle.

While a line of fire instruction is generally not necessary where steel lengths are adequately racked, it may remain desirable when placing or removing lengths from a rack, and may remain desirable in the event the rack fails. The single hoist crane used at the Workplace encouraged exposure by workers to the line of fire. A dual loop or chain was attached to a single hoist. A worker could place a loop at one end of a bundle facing a short end of the bundle, outside of the line of fire. However, once that loop was secure, the worker had to manually move the other loop to the other end of the bundle and place the loop there. Walking alongside the line of fire is the speediest way to get to the other end and do this. In order to minimise exposure to the Hazard from being in the line of fire, similar workplaces have installed dual hoist cranes on the gantry rail. A dual hoist crane with a single loop on each hoist allows a worker to use crane controls to independently secure each loop to each end of a bundle. Accordingly, the worker does need to enter the line of fire to ensure that the chains are secured at either end of the bundle. Similarly, the worker can remove both chains from the bundle using only the crane controls. Such a set-up also allows workers to be instructed at the longest sides of stacks are exclusion zones which workers are to avoid.

Practicable Measure seven: procure and require the use of adequately rated gluts

The seventh measure Lisson failed to undertake was to procure and instruct workers and any relevant manufacturing or distributing entity to use metal or hardwood gluts, including in the Workplace and in shipping containers. This measure is consistent with industry practice. In the workplace, before the Incident, generally jarrah gluts were used for the first row of a pile and then pine gluts for subsequent rows.

Several workers interviewed by WorkSafe inspectors stated that pine gluts were prone to breaking, particularly in shipping containers. This was particularly so where single-stacked bundles of unequal lintels were placed upon them. Where pine gluts broke, the stack of lintel bundles could collapse and become unstable. There was no evidence or indication that Lisson ascertained whether the gluts it used were adequately rated for their required weight. After the Incident, Lisson required the use of hardwood gluts at all times.

Practicable Measure eight: refuse delivery of single-file stacked bundles of lintels

The eighth measure Lisson failed to undertake was to have not accepted delivery of single-file stacked bundles of lintels to the Workplace and to have instructed the relevant manufacturing or distributing entity not to provide them. Prior to the Incident, Lisson undertook little if any engagement with manufacturers/distributors to prevent the delivery of single-file stacked lintel bundles to the Workplace. Other workplaces in the same industry had experienced little difficulty in instructing manufacturers and distributors, including China-based manufacturers and distributors, not to provide single-file stacked bundles.

Practicable Measure nine: instruct workers to not handle or move single-file stacked lintel bundles and request that they be returned to the supplier The ninth measure Lisson failed to undertake was, if practicable measure eight was not followed and single-file stacked bundles of lintels were received at the Workplace, to have returned those bundles to the supplier and to have instructed workers not to deal with those bundles.

The offended entered a guilty plea and was convicted on 9 March 2023. On 27 July 2023 the Magistrate sentenced the offender with a fine of $400,000 and ordered costs of $6000.00