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Details of successful prosecution against E243081

Incident description

The defendant company held duties under s.19(1) of the Work Health and Safety Act 2011. It operated a factory manufacturing building materials, including fibrous board sheeting.

On 27 May 2017 an experienced plant operator was found deceased, crushed in a raised scissor hoist being part of a large piece of plant known as an Interleaver Phaser Machine or “IPM”. The IPM processed and configured fibre cement building products. It comprised various components including hoists, loaders, a guillotine, a gluing machine and scrap bins. It was largely automated requiring one operator.

Although multiple barriers, including mesh, light curtains and interlocked gates ere to prevent human access to the IPM, there were points where workers could enter components without having isolated them. It was not established how the worker accessed the hoist, but it was possible he climbed through a gap in a handrail, bypassing mechanisms which would lock-out/isolate the hoist. Circumstances suggested he did this to access to a limit switch which would sometimes fail when large boards were fed into the IPM. The defendant was apparently unaware of these limit switch adjustments because they had not been reported or recorded.

Although the defendant took significant steps in guarding the IPM, incorporating safety features and disciplining workers should they fail to observe lock-out procedures, it did not turn its mind to possible points workers could access the machine, accidentally or deliberately. This is a requirement of section 208 of the Work health and Safety Regulation 2011.

Court result

On 26 July 2019 the defendant pleaded guilty in the Ipswich Magistrates Court to breaching s.32 of the Work Health and Safety Act 2011, having failed to meet its work health and safety duties and was sentenced.

Magistrate Fowler fined it $215,000 and ordered professional and court costs totalling $1,596.15. The court ordered that no conviction be recorded.

In reaching a decision, the Magistrate noted that while the exact circumstances were not known, access to the hoist was achieved when it should not have been possible. The court viewed the matter as somewhat unique in that the defendant had taken considerable steps safeguarding the IPM, and while it could have provided more specific training to workers, no one should have had opportunity to enter the machine absent full isolation.

In essence, the defendant did not have adequate training, instruction and supervision of IPM operators in order that they were able to identify existing hazards and adequately assess consequential risk. Even understanding the deceased may have made an error of judgment, the defendant could have:

  • prevented operators accessing the hoist through use of permanently affixed guarding or fencing, making bypassing the IPM's safety features, whether deliberately or accidentally, as difficult as reasonably practicable;
  • developed and implemented an adequate procedure when the IPM processed larger fibre boards;
  • provided a hoist with a limit switch which worked consistently, eliminating the need for operators to use a board underneath pallets or adjustments which affected the operation of the limit switch and required an operator to enter the area of the hoist;
  • monitoring the operation of the IPM and supervising operators to prohibit foreseeable misuse.

Since the incident, the defendant implemented additional safety controls, including:

  • the limit switch was modified and now activates consistently;
  • grid mesh was installed preventing unauthorised access;
  • adjustments were made to light curtains to accommodate the extra width of the mesh which also de-energise the IPM's components;
  • an additional electrically interlocked gate precludes human interaction except when the isolation procedure is engaged.

Although a worker died, the Court did not view the offence as of high objective seriousness because the defendant did take steps to safeguard workers and was unaware the deceased had bypassed safety features to adjust the limit switch.

Magistrate Fowler also noted that post incident the defendant showed real remorse including assisting and supporting the deceased's family, accepted its responsibility through its early plea and had rectified issues without delay.

The court was aware of three previous offences committed by the defendant; however, all were under repealed legislation, were more than ten years old, factually had no bearing on or similarity with that before the court and could not be regarded as relevant to assessment of sentence in this instance.


Date of offence:
Ipswich Magistrates Court
Kurt Fowler
Section 32, duty 19(1) Work Health and Safety Act 2011
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