1 This is an appeal by the Director of Public Prosecutions against the sentences imposed upon the respondent in the County Court, at Melbourne, on 28 October 2004, on two counts of failing to provide and maintain, as far as practicable, a safe working environment for its employees, contrary to section 21 of the Occupational Health and Safety Act 1985[1].
2 The respondent, a company that has operated in Australia for many years was, on 25 March 2003, engaged in the manufacture of paper products from pulp at premises in Fairfield, Victoria. At about 3.30 p.m., on that day, one of its employees, Darren Moon, was working, in the ordinary course of his duties, in close proximity to a set of very large unguarded rollers on a paper manufacturing machine, when he was drawn against them and fatally injured. The machine, which was capable of manufacturing a number of different grades of paper, was extremely large and occupied the entire floor of the building. The base material used in the process was passed into it as a liquid pulp, and then taken through a series of supported rollers where it was drained, pressed, dried out and eventually rolled onto a reel and cut according to client specifications. When manufacturing light paper, the machine would process at 470 metres of material per minute. Heavier product would pass through it at between 160 and 200 metres per minute.[2] Mr Moon was working at a part of the machine known as the fourth dryer section. One of his duties was to ensure that the material being processed, which was described at the particular stage of the operation as a "tail", was positioned so that, guided by felt and ropes, it passed properly between the rollers. Sometimes, in order to achieve this, operators would use an air hose, the nozzle of which would be manually held very close to the rollers. Mr Moon was performing this duty when he was caught and drawn against them.
3 Surprisingly, the machine, which had been in use since 1966, had never been fitted with a relevant guard and it is, as we understand the position, accepted that there was little, if any, meaningful instruction or supervision of employees designed to address what, to an external viewer, would be regarded as an obvious and long standing risk of injury. The training of operators, such as it was, was predominantly conducted "on the job", with the process of achieving competency being documented in the company's training records. However there was no safety manual for the machine, nor was there any documented standard operating procedure.
4 Two risk assessments had been undertaken covering the fourth dryer section. The first was conducted in 1998 by Paul Moon (the father of the deceased) and Phillip Edwards, both of whom were long term employees of the respondent. That assessment identified entanglement, crushing, shearing, striking and ergonomic risks, amongst others. The second, a plant risk assessment, identified the nip points of the rollers as presenting entanglement risks. An associated work sheet stated that, because operators at one section needed to hand feed paper tail into a nip point, this presented obvious entanglement hazards. It also contained the statement that some operators, in retrieving 'broke' (torn product) attempted to reach into the moving machine. This was recognised as creating an obvious hazard and it was pointed out that if they were to be caught, crushing and/or shearing injuries could result. The next recorded comment was 'History would suggest however that this is a remote possibility, hence the low [risk] rating.' In the 'current risk control' column of the report it was stated that 'it is felt that the entanglement risk is also very prevalent when the machine is on crawl' and recommended that this be incorporated in the calculations. An additional note was made, however, that, 'Justification score card suggests automatic feed for the machine is of doubtful value.'
5 An incident report form relating to an occurrence on 14 July 2002 tendered before the sentencing judge contained the following passage: