4 The charge under s 16(1) was that the defendant failed:
Contrary to Section 16(1) of the Occupational Health and Safety Act, 1983, to ensure that persons not in its employment and in particular, Iv Try Kuoch ("the deceased worker"), were not exposed to risks to their health and safety arising from the conduct of its undertaking, namely, commercial poultry farming, including but not limited to the management of commercial poultry farming operations, in that the deceased worker sustained fatal injuries at the defendant's place of work, being the site, on 24 July 2000, when he became trapped between the right rear wheel of an orange coloured Kubota Tractor type L3010D, Serial Number: 72605, ("the tractor") and a water tank stand, by reason that the defendant failed:
(a) to prevent the deceased worker operating, the tractor at the site, whilst not being sufficiently competent to operate the said tractor, in other than its normal manner of operation.
(b) to ensure there was any, or any adequate, safe work method statement for the operation of the said tractor.
(c) to adequately ensure, that there was recorded confirmation that the deceased worker understood instructions conveyed to him
(d) to adequately assess its' training of the deceased worker to ensure his competency to operate the said tractor, in other than its normal manner of operation
(e) to adequately supervise the deceased worker:
(i) to ensure he at all times operated the said tractor in the manner he was trained; and.
(ii) such that should medical attention be required, it may be provided in a timely manner
(f) to carry out any adequate, documented site specific risk assessment of the tasks to be performed by the worker.
5 The defendant pleaded guilty to the charge. Agreement was reached between the prosecutor and the defendant on a statement of facts. The statement contained the following relevant facts:
8. At all material times, Bartter and Network had in place an agreement in respect of the provision of labour to perform functions at sites in the Newcastle/Hunter region for Bartter. There was a subsequent oral agreement between Bartter and Network for the supply of labour for the Luddenham site.
9. As a consequence of the distance of the Luddenham site from Network's Newcastle operations, Network relied upon a related company, Choice HR Pty Ltd (Choice) to recruit for the Luddenham site .
10. At all material times, Avtar Singh, Farm Manager and employee of the defendant, was the Supervisor of all employees at the site.
11. No site inspection was carried out by either Network or Choice prior to the deceased worker commencing work at the site.
12. On 19 June 2000, the deceased worker commenced employment as a Farm Hand at the Luddenham site, and was given the induction training that was then in place. The induction training was provided by Mr Avtar Singh, at the site, but the extent of this training was not documented at that time. However, according to Mr Singh the deceased worker was inducted into the system of work and training was given specifically about egg collection, the grading of eggs, the nesting boxes, the cleaning of the egg service room, the changing of foot dips and general cleaning and washing duties as well as the safe height to use the male feeder for when the chickens are fed. The induction training took a full day. Mr Singh states that he also provided the deceased worker with a copy of the induction program. The deceased worker was then supervised by and worked with an experienced egg collector on 19, 20, 21 and 22 June 2000.
13. On or about 3 July 2000, the deceased worker was first instructed and observed in the operation of an orange coloured Kubota Tractor type L3010D, Serial Number: 72605, ("the tractor"), by Mr Avtar Singh. Mr Singh was an experienced and appropriately qualified person to train the deceased worker in the operation of the tractor. The training provided by Mr Singh consisted of a practical demonstration of all the controls and the instruction and observation of the deceased worker operating the tractor.
14. The deceased worker operated the tractor under the direct supervision of Mr Singh on a number of occasions on 3 July, 7 July, 18 July, 23 July and 24 July 2000. The tractor was required for the movement of eggs used for breeding chickens to the fumigation room, the collection and removal of dead birds and other farm purposes.
15. During the above periods of operating the tractor, the deceased worker was not trained to use the hand throttle but was trained to use the foot throttle for the movement of eggs. The hand throttle was only to be used when a grass cutter was attached to the tractor. Mr Singh was the only person who operated the tractor to cut grass.
16. English was the second language of the deceased worker. According to Mr Singh it was for this reason that the deceased worker was not provided with a copy of the instruction and operation manual for the tractor.
17. Nor was the deceased worker provided with written instructions in how to operate the tractor in either English, or Cambodian his first language.
18. The deceased worker was provided with sufficient instruction in how to operate the tractor in normal conditions including the instruction of how to stop the tractor in an emergency.
19. On 24 July 2000, the deceased worker was operating the said tractor to transport eggs from the production shed to the fumigation area.
20. The job of transporting eggs from the production sheds to the fumigation area necessitated the undertaking of the following process:
(a) Carrying trays of eggs from the production shed to a dolly. A dolly is similar to a trolley that has a number of shelves;
(b) Appropriately stacking the trays of eggs on the dolly;
(c) Moving the loaded dolly onto the transportation platform that is attached to the rear of the tractor;
(d) Placing the safety chain around the dolly and attaching the chain to the side of the transportation platform to prevent the load falling off;
(e) Operating the tractor to lift the platform;
(f) Driving the tractor at low speed to the fumigation area;
(g) Lowering the platform and the dolly before moving the dolly off the platform;
(h) Moving the dolly and eggs into the fumigation room.
21. At approximately 3.00pm, the deceased worker left the vicinity of shed 4 to take a load of eggs to the fumigation area.
22. At approximately 3.40pm, a fellow employee, Thi Thu Thao Le ("Le"), noticed that the deceased worker had not returned.
23. At approximately 4.00pm, Le stepped out of shed 4 to ascertain the location of the worker. Le noticed the tractor adjacent to the water tank stand and the dolly loaded with eggs lying on its side some 20 metres behind the tractor. Le concluded that with the dolly overturned that the deceased worker would be clearing up the broken eggs.
24. At 4.30pm, Le again left shed 4 to check on the worker. Le noticed the tractor and dolly in the same location as at approximately 4.00pm.
25. Le and a fellow worker could not see the deceased worker and they proceeded to move towards the tractor. There, they discovered the deceased worker pinned between the right rear wheel of the tractor and a water tank stand. Mr Singh arrived at the area a short time later.
26. Mr Singh advised that the tractor was in first gear but the motor was not running
27. Mr Kuoch sustained fatal injuries as a result of the accident.
28. There were no witnesses to the accident and the exact cause of the accident is not known.
29. The road travelled by the deceased worker from the production shed no 4 to the fumigation room was a dirt road. It is believed that the dolly chain was not secured and at a point of the road the dolly loaded with eggs became unbalanced and overturned.
30. The tractor was being driven in first gear at a slow speed.
31. Subsequent examination of the tractor by Inspector Atkins and Test Safe Australia did not reveal any defects with the tractor that may have contributed to the accident.
32. At the conclusion of his examination of the scene of the accident Constable Donald Brett McLennan, of the New South Wales Police formed the opinion that:
"….the death was occasioned by the deceased jumping from the tractor…."