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Prosecution Details

Defendant A. Richards Pty Ltd (A.C.N. 008 734 852)
Trading Name Richgro Garden Products
Section 19(1), 19A(2) & 3A(3)(b)(i)
Offence Date 18 August 2012
Description of Breach(es)

Where under a labour hire arrangement work was carried out for remuneration by a worker for the accused who was a client of a labour hire agent, in the course of the Accused's trade or business, in relation to matters over which the accused had the capacity to control, the accused failed to, so far as was practicable, to provide and maintain a working environment in which a person was not exposed to hazards and by that contravention caused the death of that person contrary to section 19(1), 19A(2) and 23F of the Occupational Safety and Health Act 1984.

Background Details

The Accused, trading under the name Richgro Garden Products, manufactures garden fertiliser and has a business premises located at 203 Acourt Road, Jandakot in the State of Western Australia.

As at 18 August 2012, the Accused employed approximately 40 people including the following:

  • (a) Managing Director;
  • (b) Operations Manager;
  • (c) Maintenance Manager;
  • (d) Production Manager;
  • (e) Machine Operator 1;
  • (f) Machine Operator 2; and
  • (g) Machine Operator 3.

In addition to those employees, the Accused had entered into a labour hire arrangement with a labour hire company whereby that company supplied a worker who was a machine operator to the Accused.

The Premises

The business premises of the Accused contains an office, a number of sheds, an outside storage area for blending soils, a trade centre, maintenance and storage sheds and several manufacturing sheds.

Towards the rear of the premises there is a fertiliser shed where fertilisers are produced and packaged.

The fertiliser shed consists of three areas separated by metal walls. These are the bulk shed, the B & C shed and the small pack shed.

The Robot

The B & C shed contains a B & C Bagging and Robot Palletiser System which is comprised of a number of different machines that work together to bag fertiliser, seal the bags and stack them on a pallet ready to be collected by forklift. That process is fully automated.

One of those machines is the Okura Articulated Robot Palletizer (Robot). The Robot is a robotic arm with a hand on the end which collects bagged fertiliser from a loading station conveyor and stacks them on a pallet ready for collection by forklift.

When a bag of fertiliser reaches the loading station it is detected by a photo electric sensor which sends a beam across the loading station on to a reflector. When no bag is present the beam is reflected back to the sensor. When a bag is present the beam is broken and that is the signal for the Robot to collect the bag of fertiliser from the loading station.

The Robot is powered by a combination of electrics and compressed air.

Although the Robot is fully automated, it requires an operator to turn it on and off, and perform other tasks required for the maintenance and set-up of the Robot.

The Fence Surrounding the Robot

The Robot is surrounded by a fence that is made out of steel mesh panels and steel posts. The fence is approximately 6 foot high.

There are four points in the fence that allow an operator to access the Robot.

There is an operator access gate in the fence located next to and on the right hand side of the control panel for the Robot. The operator access gate is interlocked so that if the gate is open the Robot will not operate, or if the gate is opened during operation the Robot will immediately stop.

There is also a large opening in the fence where the pallet conveyor exits the fence. That conveyor is used to remove pallets loaded with bags of fertiliser from the area. The opening is covered by a light curtain. The light curtain is a safety device that operates so that if the light curtain is broken by, for example, a person trying to enter the area, the Robot will immediately stop.

As at 18 August 2012 there were two other areas in the fencing, other than the operator access gate or the opening for the pallet conveyor, by which a person could get through the fence to the Robot area. Neither of those areas was protected by safety devices.

The first was an area between the bag flattener and the fence on the left hand side of the operator's control (Bag Flattener Gap).  A person was able to fit through the Bag Flattener Gap, but it generally required the person to turn side on twice to do so.

The second area was a gate installed adjacent to where the pallet was loaded by the Robot (Pallet Access Gate).  The Pallet Access Gate had a latch on it so that it could be opened or shut whilst the Robot was in operation.

The Pallet Access Gate was from time to time fixed in the open position by wiring the Pallet Access Gate to a panel of fencing. On 18 August 2012 the Pallet Access Gate was in the wired open position.

The creation of the Bag Flattener Gap and the Pallet Access Gate

In or around December 2007 a bulk systems company was engaged by the Accused to design, supply, install and commission the entire B & C Bagging and Robot Palletiser System which included the Robot and surrounding fence.

Shortly thereafter the Accused decided it would use its own workers to install the perimeter fence which had been supplied by the bulk systems company. This company had supplied the Accused with a diagram to allow the Accused to do this.

Between January 2008 and June 2008 the Accused required a new bag turner and a replacement bag flattener to be installed which would be located just before the conveyor leading to the loading station. The bulk systems company supplied the Accused with a new bag turner, a replacement bag flattener, replacement fencing panels and a revised drawing.

The bulk systems company and the Accused agreed the bulk systems company would commission the B & C Bagging and Robot Palletiser System, as per the initial arrangement, but that the perimeter fencing would be installed by the Accused, as per the previous variation to that arrangement.

In or around June 2008, the bulk systems commissioned the B & C Bagging and Robot Palletiser System. The bulk systems prepared a commissioning report for the Accused in which it was noted that the perimeter fencing wasn't yet installed. This was noted as an action for the Accused.

The Accused did not install the fence panel between the bag flattener and the operator control panel and the Bag Flattener Gap was created.

At the time of the initial installation of the Robot, the Pallet Access Gate was a fixed panel of fencing.

Approximately one year after installation of the Robot, the Accused removed that fixed panel of fencing and installed the Pallet Access Gate.

The Pallet Access Gate was installed because it allowed easy access to remove pallets that were not fully loaded or had problems, such as broken bags. The Pallet Access Gate also allowed for easy access to the pallets with a forklift.

Accessing the Robot

A worker, usually the operator, will need to access the Robot in order to fix problems.

There are several problems which can be attended to that do not require the Robot to be completely shut down, but do require the Robot to be de-energised. These include:

  • (h) cleaning dirty sensors;
  • (i) re-aligning sensors;
  • (j) removing broken bags of fertiliser; and
  • (k) retrieving fallen or misaligned bags of fertiliser.

The Hazard created by the Robot

The risk of suffering an injury or harm to health as a result of being struck by the Robot or trapped by the Robot is a hazard (Hazard).

A person who is exposed to the Hazard may suffer a serious injury or a fatal injury.

As a result of the Bag Flattener Gap and the Pallet Access Gate, persons could access the Robot where they are exposed to the Hazard.

The incident on 18 August 2012

At 6:00am on 18 August 2012, the labour hire machine operator commenced work in the fertiliser shed using the Robot.  He worked alone, but there were other workers at the Accused's premises.

His job for the shift was to bag 5 kilogram bags of super and sulphate of ammonia using the Robot and was scheduled to finish his shift at 4:00pm.

At 3:42pm another machine operator (machine operator 1) clocked on for his shift. He was to take over from the labour hire machine operator in the fertiliser shed operating the Robot.

Shortly after clocking on, machine operator 1 walked in to the fertiliser shed. The first thing he saw was a lot of papers on the ground which he thought was unusual.

He then saw that the operator's access gate was open.

As he approached the Robot, machine operator 1 saw the labour hire machine operator in a kneeling position on the ground next to the loading station with his head face down on the loading station conveyors and the hand of the Robot pressed against the back of his head and neck. The hand had trapped him against the conveyors of the loading station and he was not moving.

An ambulance was called. The ambulance crew pronounced the labour hire machine operator as dead at the scene.

A post mortem found that the labour hire machine operator had died of airway obstruction / mechanical asphyxia.  As he was working alone, the exact circumstances of his death are unknown.

Eliminating or Mitigating Exposure to the Hazard

The Users Maintenance Manual for the Robot provided:

  • (l) At Section 1.4.2 During Automatic Operation, paragraph 1 - Absolutely never go inside the perimeter guard during automatic palletizing operations of the robot. Personnel must not be within the robot's operating envelope during normal product conveyance.
  • (m) At Section 1.4.2 During Automatic Operation, paragraph 2 - During normal operation, authorised personnel will sometimes enter the perimeter guard to fill pallets, place sheets, and to remove dropped or damaged product. To do so safely, stop the robot by pushing the stop push-button. When the robot arm has stopped at a suitable position, set the key switch to off position, remove the key, and put it in your pocket before entering the perimeter guard.

The Code of Practice for Safeguarding Machinery and Plant 2009 contains a section dealing with robots. At section 5.8, various hazards, including impact from the robot and trapping points are identified. The Code suggests various ways of dealing with these hazards, including the use of guards and interlocks.

The Guidance Note - Isolation of Plant 2010 provides guidance on isolation procedures for working with plant.

It was practicable for the Accused to have eliminated or mitigated the Hazard by doing the following:

  • (n) Guarding the Bag Flattener Gap; and
  • (o) Installing an interlocked safety device on the Pallet Access Gate.

The Accused failed to take those practicable measures.

Within a few days of the incident on 18 August 2012:

  • (p) the Accused had guarded the Bag Flattener Gap with a fence that it located at its premises;
  • (q) engaged a contractor to install an interlock on the Pallet Access Gate.

The cost to the Accused of installing the guard over the Bag Flattener Gap was estimated at $800.

The cost to the Accused to engage the contractor to install an interlock on the Pallet Access Gate was $2,780. That cost also included some additional work of adding further safety features to the Robot including a key lock on the start button of the Robot.




Outcome Summary

The Accused entered a guilty plea and was convicted on 15 October 2014.  on 24 November 2014 the Magistrate fined the Accused an intial fine of $150,000 whioh was reduced for early plea and other mitigating factors to $100,000.

Conviction Date 15 Oct 2014
Court Magistrates Court of Western Australia - Fremantle
Fine $100,000.00
Costs $3366.00
Charge Number FR2843/14