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Prosecution Details

Defendant BGC (Australia) Pty Ltd (ACN 005 736 005)
Trading Name BGC Plasterboard
Section 19(1) 19A(2) 3A(3)(b)(i)
Offence Date 21 June 2010
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 failure caused serious harm to an employee, contrary to sections 19(1) and 19A(2) of the Occupational Safety and Health Act 1984

Background Details

Accused's operations

The Accused is a corporation that operates a number of businesses in Western Australia from individual locations and under individual business names.  One of those businesses is BGC Plasterboard, a manufacturer of plasterboard products. Since 2003, BGC Plasterboard has operated from a 56,000m2 site at 290 Bushmead Road, Hazelmere, including a 32,000m2 building housing its production, warehousing and dispatch facilities (Workplace).

The Accused employed approximately 110 employees at the Workplace, including employees in the following roles.

a)  General Labourer/Machine Operator

b)  Factory Hand

c)  Machine Operator

d)  Warehouse & Dispatch Supervisor

e)  Maintenance Manager

f)   Warehouse & Distribution Manager

g)  Factory Manager

h)  General Manager

Approximately a further 20 to 25 workers also worked for the Accused at the Workplace under labour hire arrangements.

The general labourer, factory hand and machine operator listed above reported to the warehouse and dispatch supervisor who reported to the warehouse and distribution manager who with the maintenance manager reported to the factory manager who reported to the general manager.

The automatic glut machine

One of the machines owned and operated by the Accused at the Workplace is an 'automatic glut machine'. This machine, when fully functioning, would automatically produce plasterboard gluts from sheets of plasterboard unsuitable for other plasterboard products.  These gluts are then used to create spaces between stacks of other plasterboard products for access by the tines of a forklift.

The automatic glut machine is constituted by a series of component machines: a vacuum loader (or 'vacuum lifter'), a perforator, a concertina press (or 'folder') and a palletiser (or 'stacker'), with conveyors in between.

The Accused had been operating the automatic glut machine at the Workplace since approximately early May 2010.

This complex of machines is housed within an external barrier fence.  The complex is operated using a control panel on the fence exterior. Once the automatic glut machine was fully commissioned it would not be necessary for the operator to enter the complex interior frequently and the automatic glut machine would shut down automatically if a complex gate was opened or if operator movement within the complex was detected.

The process by which gluts are produced using the automatic glut machine is as follows:

a)   A stack of approximately 10mm-thick 1200 x 1200mm plasterboard sheets (or 'blanks') is loaded into the glut blank infeed (or 'glut trolley') which is then retracted alongside the conveyor leading to the infeed of the perforator (the 'perforator feed conveyor')

b)  The vacuum loader picks up a plasterboard sheet and places it on the infeed conveyor of the perforator.  A sensor detects the sheet, upon which the perforator commences operation and the sheet is squared up.

c)   The plasterboard sheet then passes through the perforator. The perforator consists of two shafts approximately 150 mm apart. Cutting and perforating discs are arranged in pairs, one on each shaft, at intervals of approximately 100 mm along the shafts. These discs, each of a diameter approximately 150 mm, simultaneously cut and perforate the plasterboard.

d)  The plasterboard then travels along a conveyor to the folder, which folds the sheet along the cut and perforated lines into a glut. The glut travels along another conveyor and is grouped with other folded gluts.

e)  When enough gluts have been grouped to form a pallet layer, the gluts are lifted by the jaws of the stacker and placed on a pallet to be removed by a forklift.

The machine complex can be accessed in a number of ways. There are gates in the centre of the west (front) fence and in the southeast and southwest corners of the complex.  As at 21 June 2010, there were no permanent latches or bolts in use on the gates.  There were also no interlocking devices in use as at 21 June 2010 that would shut down the automatic glut machine if the gates were opened. The Accused had ordered such devices but, due to an administrative error by the supplier, they had not yet arrived. The Accused had interlocking devices on gates to machines in some other areas of the Workplace.

The complex can also be accessed via the gap between the glut trolley and the fence, when the trolley is ejected outside the enclosure.  The complex can also be accessed by stepping over the fencing to the stacking area on the west side of the complex, which is waist-high.  The complex can also be accessed via the gap between the fence and any stacked gluts in the stacking area on the east side of the complex.

There have been numerous signs on the fence exterior reading 'DANGER: ISOLATE BEFORE ENTRY'.

There were also emergency stop (e-stop) buttons located at various points around the exterior of the fence, and on the central control panel.  When pressed, these buttons would shut down (but not isolate) specific components of the automatic glut machine.

In order to isolate the Glut Machine in a manner that could be locked-out and tagged-out, it was necessary to switch it off at the orange electrical unit outside the complex and at the red air release button on the exterior of the fence near the electrical unit.

The perforator

The Accused had been operating the perforator at the Workplace since around the time work began there in 2003.  At first, the perforator had been used in conjunction with the perforator feed conveyor component of the automatic glut machine, rather than in a complex. Plasterboard sheets were fed into the blades manually along an infeed conveyor by one operator, and then collected from the outfeed and folded manually by other operators.

When purchased by the Accused, the perforator did not come with any written safe work procedures or instruction manuals.  There was no external fence around the machine at this time; it was open to access.

However, the perforator came with a yellow guard for the blades, which had been improved by the Accused. The guard sat over the blades.  This same guard was modified again for use on the perforator when it was incorporated into the automatic glut machine.

The Accused devised the automatic glut machine with a view to making the glut production process safer for operators, and to reduce the cost of the process.

The warehouse and distribution manager, who was responsible for identifying hazards and assessing risks involved in the automatic glut machine, had identified the perforator discs as a hazard capable of causing serious injury. However, the guarding was such that he did not believe that an operator could come within proximity of the perforator discs and he therefore concluded that the perforator was a hazard of very low risk.

Automatic glut machine operators

Due to his previous experience operating the perforator as a stand-alone machine, one of the machine operators was trained on the automatic glut machine by the maintenance manager and operated it for several weeks until approximately 14 June 2010.

A general labourer was directed to use the automatic glut machine by his supervisor, the warehouse and dispatch supervisor because this machine operator was on leave at the time.  The general labourer had been employed by the Accused since 2007. He had extensive experience using the perforator as a stand-alone machine, prior to its incorporation into the automatic glut machine.  He had first used the automatic glut machine on 14 June 2010, and had been working in the automatic glut machine area for a week as at 21 June 2010.

At the supervisor's direction, the maintenance manager showed the general labourer how to use the automatic glut machine on 14 June 2010. The central gate to the complex was left open while he showed him the machine in operation during this instruction session.

The maintenance manager's instruction included:

(a)     informing the general labourer that he would need to enter the complex frequently to deal with faults, including:

(i)   that the folder would often fail to properly flip the folded plasterboard to be conveyed to the stacker, which would then have to be done manually; and

(ii)  that the stacker jaws would sometimes get stuck when stacking the folded gluts; and

(b)    indicating that the entire system could be isolated by switching it off at the orange electrical unit outside the enclosure fence; and instructing the general labourer not to enter the enclosure without pressing the e-stop.

The maintenance manager's instruction on 14 June 2010 did not include:

(a)     informing the general labourer of the possibility that plasterboard sheets would get stuck in the perforator, or how to deal with this potential fault; or

(b)    specifically instructing the general labourer to lock-out/tag-out the isolation switch when isolating the machine at the at the orange electrical unit, as it was not anticipated that he would be performing any work that would require him to positively isolate the automatic glut machine.

The general labourer was aware of the rules regarding guards and positively isolating machinery (as set out in the Accused's induction handbook and the isolation procedures). He had been trained in those procedures, had acknowledged in writing that BGC would summarily dismiss individuals who disregarded the isolation/lockout procedures, and had had refresher training in the isolation procedures in June 2010.

After this instruction and observation the general labourer began using the automatic glut machine, with the maintenance manager attending the machine for up to 4 hours throughout the day to observe the machine in operation and to remedy faults.

It was usual for employees at the Workplace to sign off on competency checks when being trained in the use of new machines. However, on this occasion the general labourer was not required to do so. He was also not shown any documentation developed specifically for the entire automatic glut machine, as the Accused had not developed any such documentation. However, he had been trained and competency tested in the written procedure for the operation of the perforator as a stand-alone machine and, as stated above, had received refresher training in the Accused's isolation of energy procedure in June 2010.

The machine operator and the warehouse & dispatch supervisor also provided the general labourer with informal guidance as to the use of the machine, including as to isolation. 

On 21 June 2010, the general labourer commenced work at 5:30 a.m. His tasks for that day were to operate the automatic glut machine. His shift was to run until around 5 p.m.  Gluts were in high demand at the Workplace and were running low. The Accused had decided to run the automatic glut machine for two shifts daily as of 14 June 2010 (i.e., the general labourer's shift and the night shift), in order to meet demand. The general labourer was aware of this demand but was not directed to produce a particular number of gluts or to work at a particular pace.

The general labourer was aware of the demand for gluts within the business and, on 21 June 2010 he decided to work through lunch in order to produce more. He was not told to work through lunch.

During the morning, a belt came off the folder. The general labourer pressed the e-stop on the control panel, and then called the maintenance manager who manually fixed the folder belt and restarted the machine at the control panel.

On another occasion, the general labourer noticed that the belt had started to come off and so he pressed the e-stop on the control panel, pushed the belt back on, and restarted the machine at the control panel.

At least once during the day on 21 June 2010, the stacker jaws got stuck when stacking folded gluts. The general labourer again shut down the machine via the e-stop on the control panel and then reset the machine on the control panel to release the jaws. 

Around half a dozen times during that day plasterboards snapped and broke in the folder.  On each occasion, the general labourer again shut down the machine via the e-stop and then removed the broken boards before restarting the machine.

During the morning of 21 June 2010, the general labourer also experienced issues with the perforator because the vacuum lifter was not dropping the plasterboard sheets square on the perforator feed conveyor. Also, the vacuum lifter would sometimes pick up and deposit two sheets at once.  Consequently, some sheets were getting stuck in, or otherwise not passing through, the perforator. Each time this happened, he shut down the machine via the e-stop on the control panel and then removed the problem boards before restarting the machine.

The general labourer's injuries

On the afternoon of 21 June 2010, the general labourer had taken a chair inside the complex enclosure. He had been sitting on the chair for around an hour and a half, manually flipping over folded gluts that the folder had not automatically flipped.  Just before 2 p.m., he noticed that no more gluts were coming through and saw that, although the perforator was rotating and not jammed, two plasterboards were stationary on the perforator feed conveyor, one flush on top of the other, neither going into the perforator.

The yellow guard was not bolted to the perforator housing. Although the general labourer was aware from the Accused's induction handbook and isolation procedures that machine guarding was not to be removed, he had, on an earlier occasion, lifted the yellow guard in order to clear jammed sheets from the perforator rollers. The yellow guard was therefore sitting at an angle, not flush, creating a larger aperture from the infeed.

Without hitting the e-stop or otherwise stopping the machine, the general labourer rushed over to the perforator and reached across and around with his right arm to pick up the top board on the edge closest to the infeed.  When he did so, the lower board went into the perforator, knocking his right arm in the process and drawing it too into the perforator, through the gap in the guard. The perforator continued to rotate, drawing his arm further into the machine.

He shouted for help. A factory hand heard him, ran across and stopped the machine using the e-stop closest to him. After checking on him the factory hand called his supervisor, the warehouse and dispatch supervisor.

The supervisor isolated and locked out the machine at the orange electrical unit outside the fence behind the machine upon arriving at the scene of the incident.

Employees of the Accused lifted the yellow guard from the perforator. However, the employees gathered were unable to free the general labourer's arm.

Eventually paramedics arrived to treat the general labourer followed by an emergency crew. Around 40 minutes after he had first been caught in the automatic glut machine, the emergency crew was able to free him.

As a result of being drawn into the perforator, the general labourer suffered extensive injuries, including:

(a)     open radial and ulnar fractures;

(b)    brachial artery transection; and

(c)     multiple tendon and nerve injuries.

The general labourer was taken to Royal Perth Hospital and on the same day underwent multiple procedures on his injured right forearm, including:

(a)     external fixation of the ulna;

(b)    brachial artery revascularisation, via graft from the saphenous (leg) vein;

(c)     extensive tendon and nerve repair; and

(d)    the fitting of various pins in his fingers.

He remained in hospital for 11 days, during which time he underwent further tendon repair and received internal fixation (i.e., pins and plates) of his ulna and radius.

The general labourer was left with limited sensation in his right arm. He underwent physiotherapy every few days for approximately ten months.  In March 2011 he underwent a further operation to realign his forearm bones, stretch his tendons and remove scar tissue. He then underwent physiotherapy twice a week for approximately two months.

In around June 2011 the general labourer was to have a plate removed from his arm when he was diagnosed as having contracted a staphylococcal infection. As a result, for six weeks he had a PICC (peripherally inserted central catheter) line fitted that delivered 24-hour slow release antibiotics directly into his heart. This was replaced daily. He then commenced oral antibiotics and having blood tests weekly.

In October 2012 he received a bone graft in which bone from his hip was grafted into his arm to address an unhealed area.

After his accident, the general labourer was diagnosed as totally unfit for work until September 2010 after which he was variously diagnosed as either totally unfit for work, or fit for restricted duties only, until at least October 2012.

Control measures implemented

Engineering controls

The Accused had engaged a manufacturer of sensor-type safety systems, to assess the automatic glut machine on 18 May 2010. As a result, the Accused ordered the following safety components.

(a)     Dual-contact fail-to-safe interlock switches for the gates in the external barrier fence.  These switches function by cutting off power to the entire machine when a magnetic connection is broken by the opening of any of the gates.

(b)    Two scanners inside the central and south-eastern gates to the complex.  These scanners function by cutting off power to the entire machine when a person is detected within the fence, independently of whether the gates are open or closed.

(c)     Light curtains for the access points from the east and west stacking areas. These devices function by cutting off power to the entire machine when a fixed light beam is blocked by intrusion towards the complex interior.

These components did not begin to arrive at the Workplace until 22 June 2010. Some components arrived later, on various dates between 24 and 30 June 2010, due to administrative oversight by the supplier. They were installed in various locations.

The Accused also manufactured a new guard for the perforator discs that could be bolted to the perforator housing and which ensured that the aperture to the infeed and outfeed conveyors was only barely large enough to admit a single sheet of plasterboard.

The Accused further enclosed the glut trolley to prevent access to the complex through that area.  A gate was also installed across the west stacking area with an interlock switch that functions as described in above, unless the automatic glut process is at the point at which a completed pallet can be removed, in which case a light illuminates to indicate as such.  A keyed e-stop was installed beneath the central control panel.  This functioned such that once the key was removed the e-stop could not be reset (i.e., the machine would remain shut off).  Finally, the Accused installed a latch on the central gate.

After the general labourer's accident the automatic glut machine was taken out of operation until the above control measures were implemented.

The total cost of parts and labour to implement all of the above control measures was $46,545.09.

Administrative controls

As at 21 June 2010, the Accused had a written general isolation policy for machinery at the Workplace, produced by the factory manager. This policy was communicated to and available to workers at the Workplace. It included the following content.

(a)     General instructions as to isolation and lock-out/tag-out (LOTO) procedures, including explanation that e-stops and control switches are not positive isolators.

(b)    Specific instruction not to access plant or machinery behind safety fences without following isolation and LOTO procedures.

The injured general labourer had been trained in this policy in June 2007.

The Accused also had written isolation procedures, including LOTO procedures, for at least one specific machine at the Workplace (the pack saw). Employees using that machine were required to be trained in, and sign off on, those procedures. The general labourer had done so in December 2008.

The machine operator had asked the warehouse and distribution manager for a written isolation procedure for the automatic glut machine a few weeks before 21 June 2010. The warehouse and distribution manager advised him that one would be produced. The factory manager intended to write one (or to have one written) and have operators trained in accordance with it. However, this had not been done by 21 June 2010.

As at 21 June 2010 there were no written procedures specific to the automatic glut machine.  The written procedures with applicable rules were:

(a)     the induction handbook;

(b)    the isolation procedures; and

(c)     the procedure for making gluts.

Subsequent to 21 June 2010, the Accused developed a written, mandatory Work Instruction specific to the automatic glut machine, including the following content.

(a)     A prohibition on entering the enclosure unless the machine has been manually stopped using the control panel, and the e-stop pressed and locked in place by removing the key, and a corresponding warning not to rely on the gate interlocks to stop the machine.

(b)    A prohibition on entering past the folder outfeed or approaching the operating zone of any of the component machinery unless the entire machine has been isolated at the external electrical unit.

(c)     A prohibition on operating the machine without being trained in the procedures for isolating it at the external electrical unit (including LOTO and releasing the separate air isolation button), which are themselves detailed in the Work Instruction.

Subsequent to 21 June 2010, the Accused developed a written assessment to confirm operators' competency in this Work Instruction.

Publications

Prior to and as at 21 June 2010, WorkSafe had published numerous individual media releases and safety alerts in respect of machinery and equipment safety.  WorkSafe had also published a guide entitled Machinery and equipment safety - an introduction (1st ed.) (Guide).  The Commission for Occupational Safety and Health had published the Code of practice: Safeguarding of machinery and plant - 2009 (COP).

The Guide and the COP specifically refer to:

a)   mechanical hazards such as that posed by the perforator discs;

b)   permanently fixed and securely fitted guarding;

c)   interlocking of access points;

d)   presence-sensing systems such as light curtains and sensors;

e)   isolation and LOTO procedures; and

f)   the requirement for engineering controls to take preference to administrative controls where practicable.




Outcome Summary

The accused entered a guilty plea and was convicted on 4 November 2013.  The Magistrate fined the Accused $40,000.00 (after reduction for guilty plea and other mitigating factors).

Conviction Date 04 Nov 2013
Court Magistrates Court of Western Australia - Midland
Fine $40,000.00
Costs $1866.30
Charge Number MI1840/13