The Evidence
General
29It was generally acknowledged by the witnesses that BlueScope took its responsibilities as to safety seriously, as did the AWU; both BlueScope and individual employees had obligations in relation to the OH&S Act; and that BlueScope had been prosecuted in the past for safety breaches (although Mr Ciarelli said he was not aware of such prosecutions).
Events of 19 November 2010
30Mr Ciarelli maintained that on 19 November, after he had been advised by Mr Munkman about the isolation to be lifted, he then contacted the Shift Electrician Mr Tagliatietra by phone, who said that he had no knowledge of the work to be carried out and asked the whereabouts of the isolation procedure. Mr Ciarelli told him that the day shift Electrician should have left details of the job, and if he could not locate it that he should contact the Shift Leader. Mr Tagliapietra rang him about 10 to 15 minutes later saying that he had the procedure which had been located at the WBF2 Isolation Board and he would meet him there.
31Mr Spicer refuted this suggestion of "confusion" as to where the isolation procedure would be located, indicating that the isolation regulations stated that the procedure will be kept at the isolation board during the duration of an isolation and that both men should have known that.
32Mr Ciarelli said that when he arrived at the WBF2 Isolation Board (accompanied by Mr Sharrock), Mr Tagliapietra handed him the isolation procedure, (which was rolled up because it came out of a cylinder), with the equipment lock key. Mr Tagliatietra did not look at the procedure. Mr Ciarelli looked at the cover page of the procedure and then turned the page where he thought the page dealt with the isolation of the COG Bleeders. When he turned the page he was looking at the page where the names and signatures of the Isolating Person, Isolation Checker, and Isolation Coordinator were located. He then turned to Mr. Sharrock and stated "only two locks".
33Mr Ciarelli then proceeded to lift the isolation on the COG Bleeders and returned to the isolation board with the procedure and the 2 locks which he gave Mr Tagliapietra who placed the locks in the bag, stored it away and discarded the procedure in the bin. Mr Ciarelli then returned to the WBFRM pulpit and resumed his position at the control desk which had been covered by another Operator, Mr Ngo.
Events of 22-25 November 2010
34Mr Ciarelli said that when he was subsequently approached by Mr Spicer on Wednesday 24 November he was told by him that an isolation procedure had not been lifted correctly and asked what had occurred. Mr Spicer also told him that he was under instruction from Mr Willetts to find out what had occurred.
35Mr Ciarelli said that his initial response was one of surprise and he told Mr Spicer that he thought it was only two locks and proceeded to explain the course of events concerning the procedure, including that Mr Tagliapietra "threw it in the bin as it was no longer required."
36Mr Spicer's account of this first meeting, (having been asked to speak to Mr Ciarelli by Mr Willets) was that when he told Mr Ciarelli that the nitrogen was left isolated he replied - "no that was not on the procedure that I was given". Mr Spicer then printed out a copy of the procedure from the printer at the back of the pulpit and showed it to Mr Ciarelli and asked him if that was the procedure used, he looked and said it was, but that it had extra pages and showed Mr Spicer by pointing and saying words to the effect of - "this one, this one and this one", pointing to pages 3, 6 and 8 and said that they were not on the procedure he had used and that the one he had only had two locks on it. Mr Spicer showed him the front page where the number of locks required was five and Mr Ciarelli responded "the procedure I had only had two locks on it and that was what I took off."
37Mr Spicer said that Mr Ciarelli also asked Mr Sharrock to look at the procedure and confirm whether it was the one used, which he did.
38Mr Ciarelli made no mention in his written evidence of being shown a copy of the procedure as printed out by Mr Spicer or of indicating to him the actual pages that were missing. He maintained that this occurred during his second interview with Mr Spicer.
39It was Mr Munkman's evidence that early that morning he was on his way to talk to Mr Ciarelli about the issue of the Nitrogen Key being left isolated when he met Mr Spicer who told him that he had spoken to "Joe" and he had explained that he had missed removing three of the locks because he only had two of the pages of the isolation procedure. Mr Munkman acknowledged that he never subsequently spoke to Mr Ciarelli and relied on what Mr Spicer told him about what Mr Ciarelli said in the conversations.
40Whilst Mr Munkman responded that this probably explained it, shortly after this he decided to review the procedure on the lockout database and when he reviewed the procedure he realised that Mr Ciarelli's explanation did not account for the three locks being left on the Nitrogen Key. He maintained that he phoned Mr Willetts with this information who in turn asked him to print off a copy of the procedure and give it to Mr Spicer. This he did and then met Mr Spicer at the WBF/RM Pulpit where they had a conversation about Mr Ciarelli's explanation and checked that against the procedure. Finding that it didn't make sense he asked Mr Spicer to talk to Mr Ciarelli again.
41Mr Spicer maintained in his evidence that after the first meeting he phoned Mr Willets and relayed his conversation with Mr Ciarelli. Mr Willets asked him to come to the Scope room to discuss the matter further. When he arrived there a meeting took place with Mr Willets and Mr Munkman to discuss the incident. Mr Spicer still had his copy of the procedure which he had printed out and shown to Mr Ciarelli. They then tried a 'substitution test' using the information supplied by Mr Ciarelli to see if the pages that he had claimed were missing, were in fact missing, and whether the state of the equipment on WBF2 after he had finished de-isolating would correspond with the page he claimed to have followed.
42Mr Spicer said that in doing so it was readily apparent that Mr Ciarelli could not have followed the procedure. This was because page 2 dealt with the nitrogen block valve and the nitrogen system was still isolated on Monday 22 November 2010. They also determined that if it was assumed that Mr Ciarelli had only a copy of page 3, and page 2 was missing, the equipment de-isolated still did not match up, as this page involved three locks. One lock was for the nitrogen vent valve, and two for the COG bleeders. The state in which Mr Munkman found the equipment on WBF2 on 22 November 2010 was that the two COG bleeders were de-isolated but the nitrogen vent valve was still isolated.
43Both Mr Willets and Mr Munkman pointed out that on the first page of the isolation procedure, in the bottom right hand corner, it clearly stated that 5 locks were required. Page 2 only two had isolators on it, and both were for the Nitrogen Key, which were not de-isolated, and not the Coke Ovens Gas Bleeders. Mr Ciarelli had de-isolated the Coke Ovens Gas Bleeders which were on page 3, along with one isolator for the Nitrogen Key (which had not been de-isolated).
44Mr Spicer said that it was concluded that the de-isolation performed by Mr Ciarelli did not match with any of the pages in the procedure. Mr Willets asked if they still had the original procedure and Mr Munkman advised not to his knowledge.
45Mr Willets' recollection of this meeting was that it was Mr Munkman who "confirmed' that Mr Ciarelli claimed that pages 3, 5, 6 and 7 were missing from the procedure. Mr Willets also said that it was in the afternoon that Mr Munkman contacted him and told him that he had found the original procedure. Mr Willets then saw Mr Spicer a short time later and told him to speak to Mr Ciarelli to let him know about this latest development and speak to him again about his story. Mr Spicer reported back to him at the end of his shift and said he had given the information and he was sticking to his story.
46Mr Willets acknowledged that he was not aware that Mr Munkman had not spoken directly to Mr Ciarelli and had relied on Mr Spicer's account of his conversations with Mr Ciarelli.
47Mr Spicer also said that at the end of this meeting Mr Willets told him to inform Mr Ciarelli that until the matter was investigated further he was not to be used in an isolating role unless authorised by Mr Willets. He passed that information on to Mr Ciarelli.
48In contrast to this evidence, Mr Ciarelli maintained that this information was one of the outcomes of the subsequent meeting he had with Mr Willets and Mr Spicer (25 November), where he was informed that he was not to perform any isolation tasks until further notice.
49Mr Ciarelli went on to say that on that same day (25 November) a furnace trip occurred on WBF1 which required that a Gas Safety Level 2 (GSL2) person supervise other furnace accredited Operators in the operation of a Standard Operating Procedure (concerning Lightup of entire furnace when >800 degrees). Given the mitigating circumstances of the situation, he acted as the GSL2 and assisted a fellow Furnace Operator (Mr Campbell) return the furnace to its normal operation and a safe state. Mr Sharrock and Mr Spicer (as team leader) were also present and Mr Spicer did not object, or stop him from performing this role.
50Mr Munkman made no mention of meeting with Mr Spicer and Mr Willets and said that later that morning when he was in the Furnace Auto Equipment Room he inadvertently discovered a copy of an Isolation Procedure that had been used earlier in the week and that made him consider the possibility that he could find a copy of the original procedure that had been used on 19 November. He then went to the rubbish bin at the Furnace Group Isolation Board and found the original isolation procedure, which was still intact, with 7 of the 8 pages of the procedure stapled together. He said that the last page ( page 8), the 'List of Isolated Equipment' is removed from the procedure when the Group Isolation Board is activated. He then phoned Mr Willetts to let him know what he had found and was told to give it to Mr Spicer, which he did, but could not remember whereabouts this occurred. Mr Munkman had no further involvement in the investigation.
51Mr Spicer maintained that whilst he was walking with Mr Willets he received a phone Mr Munkman who told him he had found the original procedure in the bin. Mr Munkman was at the WBF lock out board. As Mr Spicer and Mr Willets were very close to that area he told Mr Munkman to wait and they would meet him there. They then looked at the procedure which was missing page 8 (which Mr Spicer said would be usual). In the light of this new information Mr Willetts told Mr Spicer to go and talk to Mr Ciarelli and let him know that they had found the procedure and see if he still claimed pages were missing.
52Mr Spicer said that within about half an hour he had another meeting with Mr Ciarelli, showed him the original procedure and asked him if it was the procedure he used on the Friday. Mr Ciarelli said that he 'guessed' that it was and that the names matched up. Mr Spicer pointed out that all the pages were attached but Mr Ciarelli replied that the one he had followed had pages missing. Mr Spicer then told Mr Ciarelli that it had been found in the bin at the lockout board by Mr Monkman and did he still think pages were missing. Mr Ciarelli replied that there must have been, as the one he had didn't have all those pages. Mr Spicer asked him what pages he did follow and Mr Ciarelli pointed at page 2 and told him 'that one' and that was why he removed two locks. Mr Spicer then told him that that page wasn't for the COG Bleeders, it was for the Nitrogen, and that he had taken the locks off the COG Bleeders, and that was on the next page.
53Mr Spicer maintained that he then went on to say to Mr Ciarelli words to the effect of:
"I am not saying that this is what happened but let's say if a person performing the de isolation had done so without referring to the procedure or for whatever reason had missed a step they would be better off admitting to that rather than trying to cover it up because management would take an even more dimmer view about it."
54He then asked Mr Ciarelli whether maybe he had just missed a page and he replied that he could have missed one perhaps, but he went on to say that pages were missing or they gave him the wrong procedure and that he was not even used to using these procedures. He said that they normally used gas isolation procedures and they were a lot easier to follow. Fitters and Electricians used these procedures, not Operators.
55Mr Ciarelli also told him that he wasn't supposed to lift the isolation on that night, another WBF operator on A Crew (Mr Ngo) was going to do it, but he offered to do it instead as a favour.
56Mr Spicer also asked Mr Sharrock if he could confirm whether the original procedure found in the bin was the one followed on the night and he told him that he thought it was, but hadn't looked at it very carefully as it was Mr Ciarelli who had the procedure.
57Mr Spicer said that he told Mr Ciarelli that the two locks he removed did not match up with the procedure but he maintained he had done nothing wrong and continued to maintain that the procedure he followed only had two locks and that pages must have been missing.
58Mr Spicer then relayed what he had been told by Mr Ciarelli to Mr Willets.
59It was Mr Ciarelli's evidence that about an hour after Mr Spicer first spoke to him he returned and told him that the original isolation procedure had been retrieved from the bin. Mr Spicer showed him this original procedure and asked him to confirm whether this was the one he had used on the night and he confirmed that it was from the names listed on the last page. Mr Spicer then told him that he had in fact missed a page on the procedure. Mr Ciarelli said his response to that was that in the process of turning the pages he must have turned 2 pages at once. He maintained that he admitted to Mr Spicer that he had made a mistake.
60Mr Ciarelli did not agree with Mr Spicer's recollection of what was said and maintained, in his reply statement, that it was at this time that he stated to Mr Spicer that - "perhaps because I was wearing the Kevlar gloves, I might have missed a page" (Exhibit 4).
61However Mr Ciarelli in his initial statement (Exhibit 3) made no mention of saying this to Mr Spicer and raised it in the context of the 25 November meeting with Mr Willets as follows:
........At that meeting, I reiterated what I had stated the day before to Mr. Spicer. In hindsight, I understand that my actions that night were both an unintentional lapse in concentration and a mistake. I can only think that I was wearing Kevlar gloves at the time as I'm required to do so under BlueScope policy, I have accidently (sic) turned two pages and have failed to pick up all of the isolation points.
62In cross examination Mr Ciarelli agreed that his attention to detail was quite good and that when he followed procedures he checked line by line that was required of him as an operator, if it was a gas procedure he would have followed all the steps. This (the incident) happened because he wasn't familiar with the lockout procedure. However he agreed he had followed procedures step by step and that was what he had done in the course of his employment and that as a proficient level 16 Operator he followed those procedures correctly.
63Mr Ciarelli indicated that if he was asked to perform a task that he didn't know how to appropriate steps to take was what they called "escalation". So he would escalate it to his Team Leader and if he couldn't find him he'd escalate it to the appropriate technical engineer involved in that section. If it would have been the furnace that would've been Mr Munkman. He did not escalate the matter that night because he did not think he had made a mistake. He thought he completed the procedure.
64When asked whether if he didn't know what he was required to do it he was required to "take two" he responded, ....."That's why you have an isolation coordinator. He's supposed to be checking on how many locks you return". He went on to say that was why he felt the isolation coordinator (Mr Tagliapietra) should have been under scrutiny. He could have checked his mistake and they wouldn't be here in the first place. He would have picked up that in five locks he only returned two. That's what happened in the past and they say you've got three locks missing and that was like a safeguard. He did not agree that it was not the responsibility of the isolation coordinator to check on every operator's de-isolation.
65He went on to say that at the time of the incident he "really believed" he only had two locks to take off. When it was pointed out to him at the second interview with Mr Spicer he agreed that he made a mistake and he also told that to Mr Willets.
66Whilst Mr Ciarelli initially maintained that it would have been page 5 that was put up on the Isolator Board he accepted that it was in fact page 8 that had been put there and agreed that once completed that page would also be thrown away just like the rest of the pages. He said he wasn't very aware of that as he did not do these sort of things very often and actually asked Mr Tagliapietra what to do with it and he threw it in the bin.
67Mr Ciarelli acknowledged that he had acted as a Gas Safety Level 2 person but was not isolating as part of that role, the supervisor was the isolating person.
68The difference between completing a procedure when he thought he was trained in it versus completing the procedure when he didn't believe he was trained in it he responded:
I say that the culture in the mill is sometimes you do the job, you don't - you always follow the safety standards of the mill, but you try to do the job as much as you can and then if you get to a standstill, in the case of case of a gas procedure, you must call a Level 3 - gas Level 3, but from a lockout procedure, especially when you think you didn't do anything wrong, because that's a sticky issue with this one. I thought that I completed the procedure to standard.
69He went on to say that he had never been shown where the isolators were, while he knew where they were he had never been shown how to do it. He had isolated the nitrogen key in regards to other isolations but this was the first time he had ever come up with this sort of isolation.
70He acknowledged that he did not really have any concern before attempting the task, did not have any concern about undertaking the task without training and on the night did not express any concern to Mr Munkman when he spoke to him on the phone about the fact that he had never done it before and he didn't know how to do it.
71Mr Ciarelli also said that his initial reaction was that he must not have had all the pages on the night but agreed that when he was able to think about it and was shown the document he realised that when he moved the pages he must have moved more than one page at a time. He had made a full disclosure of this. He was never told that a substitution test had been performed by Mr willets and Mr Spicer and that did not help resolve his confusion, it was being shown the actual document that he accepted that there were no pages missing.
72Mr Ciarelli agreed that a complex isolation was one that required three locks but said he only knew that because of the retraining he had received in February this year as part of his retraining after the incident. He wasn't very familiar with such procedures in November last year, Operators had a low exposure to gas procedures.
73Mr Ciarelli was taken in some detail to the original procedure used on the night. He agreed that the front page was a summary of the work to be done, that you read the safety requirements set out before you start the job and that there was a reference to 5 multi-locks and padlocks required and that dealing in with that page it would be easy to tell there were five locks behind it. He agreed to this last proposition on the basis of.... " yes, but that's if you're familiar with it", but then agreed that it was "simple" to read the front page.
74He agreed that he did not read it carefully, he only read part of it, the front page. He did not recall if he read the safety comments or the equivalent positioning section. He read some of it but couldn't remember what he read and what he didn't read. he knew he read about the gas bleeders valves.
75He also agreed that in the bottom right-hand corner there was a reference to 'multi-locks required 5, padlocks required 5' and that told the person reading the documents that there were five locks involved in the procedure but said that you had to look for it, if you were very proficient with this document.
76When asked to accept that a person not proficient with this document had been able to identify it and that on the front page of the document it was very clear that five locks were involved with this procedure he responded as follows:
I say that's what was visible, yes, it's visible and the isolation coordinator should have double checked it as well.
77He said he was not trying to pass the blame he was trying to say that the blame had only passed on to him. Other people were involved in this and there were no consequences for them, only himself. The Company had decided to make him the 'fall guy'.
78Mr Ciarelli also believed that the Company thought, and went down the path, that what he did was deliberate whereas he said it was a genuine mistake.
79He went on to agree that it didn't matter whether or not he moved one or two pages with his Kevlar gloves, it was still apparent from the front page of the document that he was required to get five locks, and that on this occasion he did not maintain attention to detail. He said it was a mistake, a lapse which he admitted to.
80Mr Ciarelli also maintained that he raised the issue of the wearing of the Kevlar gloves with both Mr Spicer (second interview) and Mr Willets.
81Mr Ciarelli was also taken at length and in some detail to the substitution test referred to in Mr Spicer's witness statement and to which Mr Ciarelli had not responded in his reply statement (paragraphs 27, 28 and 29) and taken through the pages in the procedure in response to his explanation of what he had done on the basis essentially that what he had done did not correspond to the pages in the procedure. He agreed that he did not read page 3 at all as he did not see it. He ultimately agreed that "by chance", he removed those locks using "intuition or your experience at the steelworks".
82In oral evidence Mr Munkman was also taken in some detail to the procedure and provided further extensive explanation to confirm the substitution test undertaken and why that could not have matched up with the pages that Mr Ciarelli maintained he did have and had followed.
83He also indicated in response to questions about Mr Ciarelli's explanation of how he had carried out the isolation (looking at Step 1 and making an assumption about 2 locks to be taken off), that Step 1 was a set up step for then carrying out the actual procedure and that if he had read Step 1 then he would hope that through his training and understanding of the furnace that he would then lift the isolation on the Bleeders as well as the Nitrogen Key.
84Mr Willets also provided further explanation in oral evidence about the substitution test and Mr Ciarelli's explanation of only reading Step 1 and making an assumption about two locks to be lifted. He discounted this as Step 1 went on to specify the Nitrogen Key and also the references to 5 multi locks of the procedure.
85Mr Munkman also maintained, in relation to Mr Ciarelli's claim of lack of specific training, that as an accredited Gas Level 2, although that accreditation was not specific about putting locks on and taking locks off, it is used in a gas isolation which is Gas Safety level 2 and his expectation was that Mr Ciarelli would understand and know how to use locks and how to use isolation procedures. He also agreed the one obvious step of an isolation procedure was that you read the procedure, that was the case for both gas procedures as well as isolation procedures. He further confirmed that if Mr Ciarelli believed he either could not perform the isolation or was not qualified to perform the isolation then the Company's expectation was that he would not carry it out and would stop and inform his supervisor.
86Mr Munkman also explained the procedure he followed if he was asked to de-isolate something similar, that being that he would take the procedure and then on each isolator label he would generally put a cross when he de-isolated that particular isolator. He indicated that the difference between gas isolations with their system of boxes to be initialled on both isolation and de-isolation as compared to isolation procedures, was that they had just evolved that way, it was tied up in the difference between the Company's Isolation Regulations and the Gas Regulations. He agreed that it had been raised on occasion within their department as to the utility of having such boxes in an isolation procedure but he did not think that was necessary. He considered the crossing out or the putting of some mark that you had removed the isolator seemed to have worked so far and that most people usually put a mark. His mark happened to be a 'cross' but other people just put a line through, it was very common. Once you had finished lifting the isolation the one thing he did do was to count the number of locks and see if it matched the number that was used in the procedure.
87Mr Munkman also explained that an Isolation Checker was not meant to assist or attend the de-isolation process because the process of carrying out right an isolation was more important than the process of lifting an isolation. In the de-isolation it was really taking the lock off, turning the valve on, nothing more complicated than that.
88Mr Munkman also indicated that the only role for Mr Tagliapietra as the Isolation Coordinator was to deactivate the Group Isolation Board, give the key for the equipment locks and the procedure to Mr Ciarelli so the isolation could then be lifted that was all he was required to do. When the bag came back either he or Mr Ciarelli could put the equipment away, and the locks away when they were finished.
89Mr Willets also confirmed that Mr Tagliapietra did not have a role under the Isolation Regulations that he fulfilled the role he had which was to "deactivate the board, line 6, activate and deactivate the group isolations. He has deactivated the Board, handed the procedure and the key over".
90He acknowledged that Mr Tabliapietra should have "technically" signed the procedure when he took over from Mr Relf, he had not done that step and had more or less done the step on behalf of Mr Relf who was at that stage still signed on as the Isolation Coordinator. He was unaware of how well the handover was between Mr Relf and Mr Tagliapietra. There was no requirement for Mr Tagliapietra to sign off when the locks were handed back to him.
91In cross examination Mr Munkman indicated that he could not recall whether he advised the day shift Plant Supervisor that the work was likely to carry over into the night shift. He acknowledged that there was a handover process between Isolation Coordinator (Mr Relf on day shift to Mr Tagliatpietra on night shift) he was not sure whether there was also an obligation for the Plant supervisor to be informed when an isolation had to be lifted.
92He also acknowledged that as one of the follow up actions resulting from the incident he had been advised that in relation to any tasks he assigned to WFB Operators he also had to inform their Shift Supervisor.
93Mr Munkman also acknowledged that during the 60 hours over the weekend (with the plant continuously operating) the locks not lifted had not been picked up during any scheduled routine shift inspection which would also take in both furnaces and take about 1 hours to complete. To check the particular area that had been isolated would have taken about 2 minutes. He did go back and check to see who had missed it but had not followed it up with those persons.
94Mr Munkman also indicated that isolations would take place routinely every week with the majority taking place in the Strip Mill on the second week as they stopped for maintenance every two weeks, with, he estimated, about 500 isolations per year being undertaken.
95Mr Willets also confirmed that isolations took place frequently and a particular isolation could sometimes last some days and essentially indicated that just because there was a yellow lock on an item of plant would not necessarily alert anyone that an isolation should have been lifted and that had not happened. He acknowledged that the matter had not been followed up with those shifts and acknowledged that should have happened.
96In cross examination Mr Munkman was also taken in some detail to the Isolation Regulations (Exhibit 11) and the Gas Regulations (Exhibit 12) and a specific gas SOP (Exhibit 10), he confirmed the steps that had to be followed in gas isolations, and that operators were familiar with the types of procedures in Exhibit 10 which involved both an isolation and de-isolation in a combined procedure, and that Mr Ciarelli, as far as he knew always followed these steps in a combined procedure.
97He did not agree that the isolation procedure used by Mr Ciarelli on 19 November should have had a gas procedure attached to it but agreed there was a link. What he did say was as follows:
A: There's definitely a link and I have discussed this issue with some more senior gas supervisors than me. It's a little grey, a little borderline, but essentially the isolation that we do - the isolations that you refer to, the one that Joe was involved in and the one for the harbour master, don't actually involve any purging or end point testing, fairly simple. So hence we made a decision that they didn't require a gas procedure.
98There was also extensive cross examination of Mr Munkman in relation to various other HARMinIE Reports and also the SOP (Exhibit 14) for the steps to restart Furnace 2 after a furnace trip. He acknowledged that it generally took an operator about 5 minutes at most to recover from such a trip. However he was not prepared to accept that in Mr Ciarelli's incident the furnace would not have purged and that the Operator would have had an alarm saying that the nitrogen hasn't purged saying that he wasn't sure about that because they had never tested that scenario. He then went on and postulated hypothetically what might happen and thought that it might take a couple of hours. He also pointed out that they had not tested this and had not checked the code in the PLC.
99Mr Spicer maintained that at no stage in his conversations with Mr Ciarelli did he admit that he had made a mistake. This was raised for the first time in the interview with Mr Willets.
100Mr Willets maintained that at no stage was the subject of Kevlar gloves and the accidental turning of pages ever raised by Mr Ciarelli. This explanation was only raised in by Mr Ciarelli in his witness statement. Mr Willets questioned the truthfulness of this explanation particularly when Mr Sharrock confirmed that he never saw Mr Ciarelli open the procedure.
101Mr Willets also maintained that Mr Ciarelli's suggestion that he was unfamiliar with this type of procedure was not supported by the training he had received nor his qualifications and duties as a Level 16 plus HSM Operator. Further if he was unsure of the procedure or what to do, he should have spoken to his Shift Team Leader for further assistance. An employee, and in this particular case Mr Ciarelli, should never proceed if they were in a situation where they had concerns or were not sure what to do.
102Mr Ciarelli also said that at neither of the meetings with Mr Spicer did he have a support person with him, nor was such offered to him. Mr Ciarelli did have a support person present in the interview with Mr Willets and Mr Spicer on Thursday 25 November.
103Mr Ciarelli drew attention to the fact that in Mr Willets' statement there was acknowledgement that in that interview he admitted that he made a mistake and that he should have taken more time to read the procedure.
104Mr Ciarelli believed that the manner in which the investigation was initially conducted had been prejudicial to his situation and that both Mr Munkman and Mr Willetts had formed opinions based on Mr Spicer's information that had brought into question his integrity and honesty.
105Mr Spicer generally confirmed, through his recollection, the main points of the interviews conducted with Mr Sharrock, Mr Tagliapietro and Mr Ciarelli
a set out in the notes made by Mr Willets. He further added that as soon as Mr Ciarelli entered the room for the interview, the first words out of his mouth were - "I fucked up". Mr Spicer said that he was very surprised to hear this as he had not admitted this to him during his earlier conversations. Mr Spicer said that Mr Ciarelli explained words to the effect of:
"I only flicked through the pages, I must have missed some pages and that's why the nitrogen was left isolated. I must have missed that page or they were stuck together".
106Mr Ciarelli considered that his record with respect to safety matters prior to this incident was very good. He had no previous indiscretions as confirmed by Mr Munkman in the HARMinIE Incident Report (ID 159332).
107Mr Munkman denied that he wrote in this Incident Report that Mr Ciarelli had no previous indiscretions or had very little exposure to this type of procedure, saying that what he wrote was:
"Joe Ciarelli was the Isolating Person on Friday Night Shift, many years of experience as a HSM Level 16 Operator."
108Mr Munkman in cross examination confirmed that he had rated the incident as a 'Safety Risk' level 2. He adhered to his belief that the scenario of the consequences if the furnace had tripped was a " major accident event". He denied that he had overstated the seriousness of the situation saying that the problem with a high-risk facility or major hazardous facility legislation was that it is designed about stopping multiple fatalities and the chance of multiple fatality is extremely small. So the work that they are doing is trying to achieve that scenario from occurring in less than one in every 10,000 years. Whilst it was really really low it can still happen. They were obliged to comply with major hazardous facility legislation was something they had to take care of and something they had to do.
109Mr Ciarelli also maintained that he had previously had very little exposure to this type of procedure in the past when carrying out both isolations and de-isolations in his role as Gas Safety Level 2 and Isolating Person.
110Mr Spicer maintained that this was a further reason why Mr Ciarelli was required to read the procedure through its entirety, particularly if he was unsure or not overly familiar with the process. All HSM employees were instructed that at any time while performing a task if they were not sure of any aspect, be it a safety, isolation or lack of knowledge, to stop the task and seek assistance from their Team Leader. He said that this was what Mr Ciarelli should have done on the night if he had concerns about using this particular procedure.
111Mr Spicer also maintained that Mr Ciarelli had made statements to try and cover up the fact that he did not read or refer to the procedure and did not admit that he had made a mistake or take responsibility for a mistake.
112Mr Munkman also believed that Mr Ciarelli has had exposure to both isolation procedures and gas procedures. He went on to say that most of the gas isolations performed by the HSM Operators were done in conjunction with a gas procedure and an isolation procedure.
113Mr Munkman had examined the gas isolations performed by Mr Ciarelli since 1 July 2007 for No.1 Walking Beam Furnace Soak Zone that involved a gas procedure and an isolation procedure (SP-SPS-SMI-10183, 1WBF06 Gas Isolation for Working in Front of the Discharge Doors and SP-HSM-RF-03-24, No.1 WBF Zone 8 Double Block & Bleed Procedure and SP-HSM-RF-03-25, No.1 WBF Zone 9 Double Block & Bleed Procedure). Mr Ciarelli performed this isolation on 3 November 2008, 24 February 2009, 21 May 2009, 10 November 2009 and 19 January 2010.
114Mr Ciarelli believed that the disciplinary action taken by the Company for a first offence, given his previous safety record, was both excessive and did not consider all of the circumstances and mitigating factors that led him to committing an unintentional violation. Further, when compared to similar and more serious breaches in the HSM department under the same Operations Manager over a period of four years where no such disciplinary action was taken, it was his opinion that he had been unfairly treated in this instance.
115Mr Willets considered the formal written warning and 2 day unpaid suspension given to Mr Ciarelli was appropriate for a number of reasons for this including that he had a high level of responsibility attached to his Level 16 Operator role and was accredited to assess other Operators. Added to this was the untruthfulness of his explanation that the procedure had pages missing. He was given plenty of opportunities to admit that the procedure was complete but had stuck to this story until the meeting on the 25 November.
116Mr Willets confirmed in cross examination that if Mr Ciarelli had acknowledged at the outset that he didn't read the procedure then it would have "absolutely" made a difference. That would still have involved some form of disciplinary action as in the role Mr Ciarelli fulfilled reading and following procedures was an part of that role. What had come out of this in his opinion was that "he just didn't read the thing". It was such a simple procedure to follow that it put a lot of doubt in his mind as to how well he was able to follow and execute some of the more complex procedures required under the Gas regulations and in his role as Furnace Operator.
117Mr Munkman also said that he was aware of the penalty imposed on Mr Ciarelli for the incident and considered it was appropriate in the circumstances.
118Whilst there was cross examination of Mr Spicer, it overwhelmingly concerned differences/conflicts between his evidence and that of Messrs Munkman/Willets/Ciarelli as to who said what or where something was said, and he generally confirmed and maintained his written evidence.
119Mr Punshon is also a level 16 Operator at the HSM who has achieved all necessary accreditations and competencies to carry out his role with the exception of Gas Safety level 2 for Furnace 2.
120His evidence generally concerned the difference between the procedures to be followed in gas and non-gas isolation procedures and the various regulations concerning such.
121Mr Punshon stated that he did not believe that the type of isolation procedure used by Mr Ciarelli and other operators should be used for the purposes of isolating sources of gases on the furnace. In this particular instance, those gases are Coke Ovens Gas and Nitrogen.
122He had reviewed isolation procedure SP SPS SMI 10816 and had noted a number of errors in the procedure. He had checked and cross referenced this procedure with the one that Mr Ciarelli was provided with when his incident occurred and they were the same. The errors in the procedure related to wrong identification of isolator labels, and an omission of what to do in the event that a verification test failed. In his experience all procedures that related to furnace work should have all steps identified for both isolation and de-isolation and what to do if a step could not be completed or performed. Mr Punshon annexed to his statement a copy of the procedure with the errors noted (Exhibit 2 -CP2).
123Mr Munkman disagreed with Mr Punshon's assertion and said that the isolation procedure used by Mr Ciarelli on 19 November was the correct procedure to use and follow in this situation. He went on to say that when following an Isolation Procedure if a verification step failed, or could not be completed or performed, then the Isolating Person should stop the isolation, notify the Work Owner, Plant Owner and contact the Isolation Coordinator. Mr Ciarelli was following an Isolation Procedure as the Isolating Person and if he had followed the Isolation Procedure correctly the isolation would have been lifted without incident.
124Mr Munkman did agree however that the isolation procedure in question did have errors, but the isolator labels in the procedure and on the furnace were correct. Further, the errors did not explain why Mr Ciarelli left the three isolators of the Nitrogen Key isolated. It was not an omission that the isolation procedure did not include what to do if a verification test failed. He reiterated that the Isolation Procedures relied on the skills of the isolating person to stop the isolation if an isolation could not be achieved, or if a verification step failed.
125Mr Munkman also disagreed with Mr Punshon's comments that all procedures that related to furnace work should have all steps identified for both isolation and de-isolation and what to do if a step could not be completed or performed. The isolations performed at the furnaces by the HSM Operators are done by following either a isolation procedure or a gas procedure in conjunction with an isolation procedure. The majority of these isolations are done by following a gas procedure in conjunction with a Isolation procedure. Gas procedures included written steps that must be followed if step could not be completed or followed.
126Mr Punshon acknowledged that when an employee was following a procedure they did that step by step, or line by line, and checked whether that was correct. He maintained that if an Operator was not familiar with a procedure they should be trained. He agreed that in such a circumstance an operator was entitled to raise with their supervisor that they hadn't been trained and what should they do. He also agreed that if they were not trained that they were required to "stop and take two". On the issue of whether either training would be arranged or someone else arranged to do the job, he maintained that whilst that would be expected to take place, it didn't always happen.
127In relation to the procedure used by Mr Ciarelli he agreed that the front page provided a summary and referred to the department and section where the work was to be carried out and also what the procedure was actually for. He also agreed that there were references on the page to 5 multi-locks and 5 padlocks and agreed, with reservation ("if you're familiar with it"), that it could be assumed from that information that behind that page would be a page dealing with 5 locks. He went on to agree that it was simple to read the first page and that even if one was not familiar with the procedure, it was fair to assume that behind that page was going to be a procedure to deal with 5 locks.
128Mr Punshon further agreed that if one had concerns with a procedure then that would be the time to raise it, and that it should be raised with the Team Leader.
129Mr Punshon agreed that it was BlueScope policy that if more than three locks were required then it was a complex isolation, but emphasised that they were not Locking Co-ordinators but knew what locks were for.
130Mr Punshon also indicated that in December 2010 he was reviewing a procedure dealing with skip bin removal from Furnace 2 basement with an accredited WBFRM Assistant (Jason Turnbull) and Mr Munkman. During the course of reviewing this procedure, the topic of discussion turned to the incident involving Mr Ciarelli. The outcome of those discussions resulted in Mr Munkman requesting that he and Mr Turnbull take on the task of developing the relevant procedures associated with the following:
a) Isolation and de-isolation of the Coke Ovens Gas ("COG") Bleeders and Nitrogen Gas Key system for Furnace 2.
b) Isolation and de-isolation of the Harbour Mast.
.
131They were also advised by Mr Munkman that the procedures to be developed would be categorised as 'non-gas procedures'. Mr Punshon had subsequently checked the Company's Isolation Regulations and Section 5 of the Gas Regulations and in his opinion, Mr Munkman's view of how the procedures would be categorised was in accordance with the Regulations as set out in Clause 5.1.2.
132Mr Punshon said that they had been unable to commence the development of both procedures as they were waiting for the relevant access to the lockout database.
133Mr Munkman maintained that he did not request that Mr Turnbull and Mr Punshon develop standard procedures for these two isolations. He said that they spoke to him about preparing standard operating procedures and he agreed that once completed and approved they could be used in conjunction with the isolation procedure, not that the development of such standard operating procedures would replace or amend the existing isolation procedure.
134Mr Punshon also said that he and Mr Turnbull had had a similar experience to that experienced by Mr Ciarelli in that they had arrived for night shift and were advised by the dayshift crew that the COG bleeders and Nitrogen Gas Key system for Furnace 2 were still isolated, the key to unlock the group isolation board resided with the shift electrician Mr Bland and that he would be acting as the Isolation Co-ordinator. Mr Munkman did ring them to advise of the situation and circumstances surrounding why the isolation had yet to be lifted.
135When they were given the procedure (SP SPS SMI 10816 WBF2) by the Isolation Co-ordinator, neither he or Mr Turnbull had previously carried out this task under such a procedure. The procedure was one with which they were not familiar, nor had they received any instruction on how to proceed. Mr Punshon said that normally, procedures used on the furnaces had greater detail and specified the scope of the work, the equipment required, and the sequential steps for both isolation and de-isolation of equipment with a requirement for the Operator to initial each step as it is completed. In contrast the procedure they were provided with had no such information with the exception of the isolation steps. Whilst they had carried out the procedure, they had concerns that it was not the type of procedure that Furnace Operators were regularly exposed to and also there was poor lighting where the de-isolations took place. Those concerns had not yet been addressed or corrected.
136Mr Punshon also annexed to his statement a copy of an example of the usual procedures used at the Furnace (Exhibit 2-CP4).
137Mr Punshon also agreed, in response to questions from the Commission that his main concern was with the format of the procedure and that he believed it wasn't adequate. He agreed that he was essentially saying that the procedure would be a lot easier if it had little boxes where you actually had to tick a box and then make sure you had actually done it . This was because when lifting this isolation you were not ticking anything or signing anything. You were given it and just removing the locks.
138Mr Spicer also indicated, in reply to Mr Punshon's assertion that there was an omission of what to do in the event that a verification test failed, that Section 03:07 of the Isolation Regulations clearly covered this instance, that being that the isolation must not proceed. The same rule applied to a situation where a step could not be completed or performed. This was all covered as part of their training in the isolation process.
139In response to Mr Punshon's claim that the procedure he had referred to was not one with which they were either familiar or had received any instruction on how to proceed, Mr Spicer reiterated that all HSM employees were instructed that if at any time while performing a task they were not sure of any aspect (safety, isolation or lack of knowledge) to stop the task and seek assistance from their Team Leader.
140There was also evidence and cross examination as to various HARMinIE reports concerning other incidents which the AWU maintained were relevant in relation to the harshness of the penalty imposed on Mr Ciarelli as well as evidence and cross examination as to Mr Ciarelli's training history. Mr Ciarelli could not recall any of the specific SAO Audits referred to in the relevant toolbox meetings.
141Mr Willets was not aware of the particular circumstances of those other HARMinIE Reports.
142Both Mr Ciarellli and Mr Punshon indicated that training was done in-house by the Company and generally by their peers, other Operators. Mr Ciarelli agreed that he had completed 'train the trainer' training and was accredited to asses other Operators but said that there was no formal training accreditation required to teach other Operators the skills and knowledge of his job. The majority of the training was now self paced training through the module training systems.