As a result of the abovementioned failures, Stanley Battersby was placed at risk of injury.
8 In respect of s 8(2) of the OHS Act, the defendant was charged with failing to ensure that people other than its employees, in particular Benjamin Pendergast and Jarrad Thornton, were not exposed to risks to their health and safety arising from the conduct of its undertaking while at its place of work. The particulars to the s 8(2) charge were in identical terms to those relied upon in respect of the s 8(1) charge as set out above.
9 The defendant pleaded guilty to the offences charged at its earliest opportunity. I am satisfied, on the evidence, that the defendant is guilty of the offences as charged, and that it was appropriate for the pleas of guilty to be entered. It follows, therefore, that this judgment is concerned only with the question of penalty.
Statutory provisions
10 Section 8(1) and s 8(2) of the OHS Act provide as follows:
8 Duties of employers
(1) Employees
An employer must ensure the health, safety and welfare at work of all the employees of the employer.
That duty extends (without limitation) to the following:
(a) ensuring that any premises controlled by the employer where the employees work (and the means of access to or exit from the premises) are safe and without risks to health,
(b) ensuring that any plant or substance provided for use by the employees at work is safe and without risks to health when properly used,
(c) ensuring that systems of work and the working environment of the employees are safe and without risks to health,
(d) providing such information, instruction, training and supervision as may be necessary to ensure the employees' health and safety at work,
(e) providing adequate facilities for the welfare of the employees at work.
(2) Others at workplace
An employer must ensure that people (other than the employees of the employer) are not exposed to risks to their health or safety arising from the conduct of the employer's undertaking while they are at the employer's place of work.
Prosecutor's evidence
11 Mr R Reitano of counsel, who appeared for the prosecutor, tendered agreed statements of facts, which provided:
3. At all material times the defendant was an employer conducting a business at 1 Forestry Road, Penrose ("the site") involving the manufacture of radiata pine timber products.
4. Wollondilly Mobile Engineering Pty Ltd ("Wollondilly Engineering") was a corporation conducting a business involving light engineering work. As at 22 March 2007 Wollondilly Engineering had about 10 employees.
5. Benjamin Pendergast ("Pendergast") was a 22 year old trade qualified boilermaker employed by Wollondilly Engineering. He had been so employed since 18 August 2004 and was Wollondilly Engineering's supervisor at the site.
6. Jarrad Thornton ("Thornton"), was a 17 year old second year apprentice boilermaker employed by Wollondilly Engineering since February 2007.
7. Stanley Battersby ("Battersby") was employed by the defendant as a leading hand. In that capacity he had supervisory responsibilities for the entire site including the wood shavings storage bin ("the shavings bin"). He had worked for the defendant for about 18 years.
8. Michael Cush ("Cush") was the managing director of the defendant and was present on the site on 22 March 2007.
9. Greg Blackburn ("Blackburn") was a self-employed occupational health and safety consultant engaged by Wollondilly Engineering. Blackburn had been engaged by Wollondilly Engineering in June 2006 to implement an occupational health and safety policy including the provision of training to its employees.
The Work
10. The defendant had a long-term (in excess of ten years) ongoing commercial relationship with Wollondilly Engineering in which the latter would perform various construction and maintenance tasks at the site. As at 22 March 2007 Wollondilly Engineering had at least four jobs in progress at the site.
11. On 22 March 2007 Wollondilly Engineering was conducting work on two jobs at the site for the defendant. The first involved enlarging the opening of a door to the moulding mill. The second involved extending a platform/ walkway and handrails on the shavings bin. The latter job was preparatory work for a wider project of installing a second access door to a filtration unit on top of the shavings bin. Both jobs required the performance of tasks that included welding and the operation of angle grinders.
12. Wollondilly Engineering had four employees present at the site for the performance of the above work. Pendergast and Thornton were two such employees. The other two were Tom Mortimer "Mortimer" (aged 18 years) and Paul Weatherley "Weatherley" (aged 46 years; employed by Wollondilly Engineering two weeks prior to the incident). Weatherley was a qualified boilermaker, rigger, scaffolder who had been in the industry since 1992.
The Wood Shavings Storage Bin
13. The shavings bin was a steel-framed structure approximately 12 metres in height. The top half of the structure was enclosed on all 4 sides and at the top by sheets of corrugated steel cladding. There were gaps in the cladding that formed the top of the shavings bin. Underneath the enclosed section were fitted hydraulically-operated clam-shell-style opening doors. These doors were positioned above a loading bay area designed to accommodate trucks which would be loaded with material from the bin for disposal as required. The bottom half of the structure was enclosed on 2 opposite sides by sheets of corrugated steel. Cylindrical exhaust ducting ran from the top of the shavings bin to the moulding building at the site. The moulding building housed a Weinig brand timber moulding machine/ planer that was used to manufacture timber products. The moulding machine was capable of processing about 7.5 cubic metres of timber per hour. In the course of its operation, the moulding machine would generate shavings and saw dust which was extracted from the machine by means of negative air pressure created by a high velocity exhaust fan located outside the moulding building and driven by a heavy duty electric motor. Each cutting head of the moulding machine had its own extraction duct. Wood shavings and saw dust were drawn into the ducting and after travelling along the length of the ducting were deposited into the shavings bin. The shavings bin had a storage capacity of 180 cubic metres (60 tonnes).
14. A series of three fixed metal ladders formed the means of access to the top of the shavings bin. The ladders were enclosed along most of their length. One ladder provided access from the ground to a platform ("the lower platform") located at a position approximately half-way between the ground and the top of the shavings bin. Another ladder provide access from the lower platform to a second platform ("the upper platform") located just beneath the roof of the shavings bin. A third ladder provided access from the upper platform to the roof of the shavings bin. The height of the roof of the shavings bin was approximately 10 metres. A series of hydraulic controls for the shavings bin doors were located on the lower platform.
15. Underneath the corrugated steel sheeting forming the top of the shavings bin was a screw augur powered by an electric motor located on the upper platform. The augur was designed to even-out the distribution of shavings and saw dust within the shavings bin. The augur was not in use at the time of the incident.
16. Attached to the side of the shavings bin was an air cannon. A series of outlet nozzles were affixed inside the shavings bin. When operated, the air cannon would discharge compressed air through the nozzles for the purpose of initiating the flow of wood shavings and dust adhering to the inside of the shavings bin when its doors had been opened to empty its contents.
17. The shavings bin had been constructed for the defendant by Wollondilly Engineering. The latter had also installed the air cannon and performed work on handrails on the shavings bin.
The Events of 22 March 2007
18. Pendergast and Thornton arrived at the site at approximately 6am. Pendergast attended the site office and reported to Battersby.
19. Pendergast subsequently climbed to the top of the shavings bin with Thornton. Pendergast and Thornton spent about one-and-a-half hours cleaning sawdust from the top of the shavings bin.
20. Blackburn was engaged by Wollondilly Engineering to conduct a surprise safety audit of its employees at the site and other locations. The audit proceeded by way of Blackburn covertly observing employees working and then discussing with them any unsafe work practices and alternative safe work methods.
21. Blackburn observed Pendergast and Thornton cleaning the top of the shavings bin. Upon Pendergast and Thornton descending from the shavings bin, Blackburn discussed with them the work they were undertaking. Blackburn noted the need for them to wear safety harnesses, to ensure that the work area was wet in order to prevent fires and to have a fire extinguisher with them.
22. When speaking to Pendergast and Thornton, Blackburn ascertained that no safe work method statement existed for the work being undertaken by them on the shavings bin and that no documented risk assessment had been performed. Blackburn did not inform Pendergast that the work on the shavings bin should not proceed until a safe work method statement was implemented but rather indicated that he would go back to his office to prepare one. After leaving the site, Blackburn did not return to his office but proceeded to conduct an inspection at another location. Blackburn understood that it was the practice of Wollondilly Engineering to prepare a safe work method statement for every job. Blackburn prepared a safe work method statement on 24 April 2007 in response to an improvement notice issued by WorkCover on Wollondilly Engineering.
23. Blackburn was aware that Wollondilly Engineering did not have a hot work permit system as he had previously been asked to implement one but had not done so. He was also aware that hot work would be conducted on the shavings bin on 22 March 2007 but did not access the shavings bin to inspect its contents or the roof working area. Blackburn did not discuss hot work procedures with the defendant and did not discuss with the defendant or Pendergast the contents of the shavings bin. He was however aware that the moulder extraction system was running and on that basis assumed that the shavings bin contained sawdust/ shavings. Blackburn identified no issues of major concern to him at the site on 22 March 2007.
24. Pendergast and Thornton then collected tools and materials including (at the request of Blackburn) a fire extinguisher before returning to the top of the shavings bin. Pendergast operated an electrically-powered angle grinder to remove the existing handrail. After a series of further climbs up and down the shavings bin to transport additional tools and equipment to the top of the shavings bin, they cut and welded metal at ground level. This metal was then transported to the top of the shavings bin using ropes to pull up a series of bundles of such material. Pendergast then operated an electric arc welder (with an output of 140 amps) on the top of the shavings bin for approximately one hour performing welding tasks associated with the work being undertaken.
The Fire
25. Pendergast and Thornton then smelled smoke. Pendergast used a water fire extinguisher, spraying initially underneath gaps in the roof of the shavings bin and then along the roof as the smoke increased. Pendergast then asked Thornton to descend for the purpose of seeking assistance from Battersby and getting him to open the shavings bin so that they could investigate the fire.
26. Battersby attended the shavings bin and climbed to the lower platform where he operated the hydraulic controls to open one of the shavings bin doors. When the shavings bin door opened, a fireball engulfed the shavings bin.
27. Pendergast who had begun to descend with welding equipment from the top of the shavings bin was at this stage located on the upper platform. Subsequent to the fireball engulfing the shavings bin, Pendergast was surrounded by flames. He then jumped from the upper platform to the ground, a distance of approximately 9 metres and received fatal head and chest injuries as a result. Battersby received burn injuries as a result of the fire and was unable to return to normal duties for a period of three months.
The Cause of the Fire
28. Radiata pine shavings are a well-known fire hazard in a timber mill. The shavings bin immediately before the fire contained a large quantity of such shavings.
29. Hot work involves electrical welding, cutting and grinding. These processes produce hot particles, sparks and hot surfaces and are a common cause of ignition for industrial fires and explosions.
30. The likely cause of the initial fire within the shavings bin was the ignition of wood shavings and saw dust by hot sparks or molten metal from the grinding and welding work being performed by Pendergast and Thornton. The material ignited may have been within the shavings bin or, alternatively, may have been on the roof of the shavings bin and have subsequently fallen into and ignited other material within the shavings bin.
31. Further, the conditions within the shavings bin were conducive to rapid spread of fire across the surface layer of shavings. This was due to the turbulence caused by the operating extraction fan and the low bulk density of the shavings resulting in an enhanced availability of oxygen to sustain combustion.
32. Finally, the opening of the shavings bin doors by Battersby allowed the shavings to fall to the ground, in the process greatly increasing the degree of mixing between burning shavings, unburnt shavings and oxygen in the air. These conditions resulted in an eruption of flame in the fireball that engulfed Pendergast.
Unsafe System of Work
33. The defendant had never been shown any risks assessments or safe work method statements ("SWMS") by Wollondilly Engineering in respect of work being performed on the shavings bin. No documented risk assessment/ job safety analysis was conducted for the work on the shavings bin. Pendergast and Thornton did not undertake a risk assessment before commencing work on the shavings bin. No SWMS existed for the work on the shavings bin.
34. Battersby did not review with Pendergast or any other Wollondilly Engineering personnel any safety aspects of the work to be performed at the site on 22 March 2007. Rather, he informed himself what work was to be performed and then handed over the shavings bin area to Pendergast and Thornton.
35. The defendant had a hot work procedure document, however no hot work permit procedure was in place at the site prior to the incident. Wollondilly Engineering did not have a hot work safety procedure. Accordingly, no hot work permit had been issued for the work on the shavings bin or in the moulding mill.
36. No confined space procedure had been put in place for the work on the shavings bin.
37. It was the defendant's usual practice when maintenance work was being performed on the shavings bin for the moulder and its extraction system to be shut down.
38. After the incident, Cush said that no agreement had been reached between the defendant and Wollondilly Engineering for the conduct of work on the shavings bin involving the installation of a second access door. He said that Wollondilly Engineering had been invited to discuss with him a safe procedure for the performance of such work before it was allowed to proceed.
39. Cush was the managing director of the defendant. As a result of this position he had the ultimate responsibility for the supervision of the site. However, his duties primarily did not involve the supervision of employees and contractors on a daily basis.
40. Cush had discussed with Turner that employees of Wollondilly would attend the site towards the end of the week to work on unfinished projects. Cush was aware that 2 employees from Wollondilly Engineering, Weatherley and Mortimer, were on site prior to the incident. Cush was unaware that Pendergast or Thornton were doing any type of work on the shavings bin. Cush was unaware that Blackburn was present on the site.
41. The operator of the moulder, Theo Jongsma, had not been informed and was unaware that hot work was being performed on the shavings bin on the day of the incident. He was aware that workers were present on the top of the shavings bin but assumed that such workers were taking measurements for work to be performed at a later date. Jongsma had understood that the work on the shavings bin was to have been performed the previous Saturday (17 March). The shavings bin had been emptied the previous Friday (16 March) so as to allow the work to be performed the following day.
42. Had Jongsma known that hot work was being performed on the shavings bin, he would have told the workers concerned that such work was not to proceed until the shavings bin was emptied.
43. On 22 March 2007 about 15 to 16 cubic metres of timber had been processed prior to the incident. At the time of the incident the shavings bin was more than half full.
44. Prior to the incident the defendant did not have any emergency procedure for a fire in the shavings bin.
45. A fire sprinkler system was not installed on the shavings bin.
Supervision
46. Battersby had been told by Cush a couple of days prior to 22 March 2007 that Pendergast would be coming to look at the shavings bin. On 22 March 2007 Battersby asked Pendergast what work he was going to perform and was informed by Pendergast that he would be installing a railing on the shavings bin. Pendergast explained to Battersby that he proposed to perform cutting work for the new railing on the ground and then use rope/s to haul the new railing to the roof of the shavings bin. Battersby was unaware that welding work was going to be performed on the shavings bin, did not notice the presence of welding gear and did not see Pendergast performing welding work on the roof of the shavings bin on 22 March 2007.
47. Battersby had never been to the top of the shavings bin.
48. Battersby was unaware whether the defendant had a hot work permit system. He had not seen the defendant's hot work procedure document.
49. As at 22 March 2007 the defendant did not have in place a sign-in register or other system for the identification and recording/ registration of visitors to the site and the purpose of their visit.
Instruction and Training
50. Pendergast and Thornton were not provided with any documented risk assessment or safe work method statement. No "tool-box" meeting was held in relation to the work on the shavings bin. hornton was unaware of any hot work procedure for the conduct of work on the shavings bin.
51 Wollondilly Engineering had not instructed Pendergast not to perform hot work on the shavings bin unless it had been emptied.
52 Pendergast received no training in hot work safety procedures from Wollondilly Engineering.
53 The defendant had not issued any written direction that work was not to take place on the shavings bin while the moulder and its extraction system were in operation. Prior to the incident Battersby had received no training in emergency procedures in relation to the wood shavings bin.
Australian Standard 1674.1 - 1997 Safety in Welding and Allied Processes
54. Australian Standard 1674.1 - 1997 entitled Safety in welding and allied processes ("AS 1674.1 - 1997") was published on 5 September 1997 and specifies precautions to be taken prior to and during hot work to prevent the possibility of fire or explosion which may result in harm to persons or property.
55. AS 1674.1 - 1997 identifies sawmills and woodworking plants as hazardous areas in which, among other things, combustible dusts or other flammable or explosive substances may be present.
56. Under the heading "Section 2 General Precautions", AS 1674.1 - 1997 states:
Off Cuts and Electrode Stubs Before any hot work commences, arrangements shall be made to prevent any work off-cuts, hot metal, slag or electrode stubs from lodging in places where there is any possibility of starting a fire.
Timber Where any hot work is to be carried out adjacent to or above timber, the timber shall be protected, by wetting or other suitable means, from the direct heat of any flame or arc and from sparks, slag and hot metal particles.
57. Under the heading "Section 3 Fire Protection", AS 1674.1 - 1997 states:
NOTE: Fires can be caused in locations remote from the actual working area by sparks or hot slag from hot-work operations or by transfer through metal walls or bulkheads.
58. Appendix A to AS 1674.1 - 1997 entitled "Guidelines for Hot Work" states;
Hot-Work Area The area within a radius of 15m from the point where the hot work is to be undertaken, including the space above and below that area, should be made safe by various techniques, preparation and testing, to ensure that any risk of fire or explosion resulting from the hot work is eliminated.
59. AS 1674.1 - 1997 prescribes the implementation of a permit system controlling the conduct of hot work.
60. Appendix B to AS 1674.1 - 1997 produces a precedent permit which requires various multiple sign-offs. One such sign-off is to be from the person in charge of the location where the hot work is to be performed.
61. The precedent in Appendix B to AS 1674.1 - 1997 requires responses to the following questions:
…
6.2 Have combustible materials been removed from the work area or made safe ?
…
6.14 Has product movement been stopped in the area of hot work ?
62. The defendant's documented hot work procedure did not comply with the requirements of AS 1674.1 - 1997.
Occupational Health and Safety Regulation 2001
63. Clause 62 of the Occupational Health and Safety Regulation 2001 (the OHS Regulation") provides:
(1) An employer must ensure that risks associated with fire or explosion at a place of work are controlled by:
…
(b) eliminating potential ignition sources, including naked flame, hot work and electrical equipment, and sources of static electricity, including friction, welding and slipping belts, from proximity to flammable substances, combustible dusts or waste materials, and
…
(d) removing waste materials and accumulated dust on a regular basis, and
…
(f) any other measures necessary to control the risks.
…
64. Clauses 209 and 227 of the OHS Regulation together operate to define the work performed by Pendergast and Thornton on the shavings bin as "high risk" so as to require that Wollondilly Engineering prepare a SWMS before the commencement of such work.
Alternative Work Procedures Available
65. The shavings bin could have been emptied prior to the commencement of hot work upon it, thus removing its contents as a source of potential fuel for a fire. The hot work on the shavings bin could have been scheduled to be performed when the moulder and its extraction system were not in operation, thus removing the oxygen-enhancing turbulence created by the extractor fan.
66. Cutting work could have been performed using a hacksaw rather than an angle grinder and the new hand rails could have been attached by bolts or other fastenings rather than being welded in place, thus eliminating hot work as a potential source of ignition.
67. Upon the identification in a risk assessment of the risk of fire, an emergency evacuation plan that provided for evacuation rather than opening the shavings bin doors should have been implemented.
Post-Incident Measures
68. Subsequent to the incident, the defendant ceased using the shavings bin as the means of storing wood shavings and saw dust.
69. The defendant commissioned a risk assessment for fire control at the site. Among other things, the risk assessment recommended the development of a hot work permit system.
70. In May 2007 the defendant introduced a hot work permit procedure. Among other things, this procedure required that a permit authorising the conduct of such work be issued by the sawmill supervisor before hot work could commence. Further, the supervisor was required to undertake a work site inspection to ensure that identified risk control measures were implemented.
71. Wollondilly Engineering prepared a SWMS in relation to the work to be conducted on the shavings bin. The SWMS adopted separate hot work procedure requirements.
72. In response to an improvement notice Wollondilly Engineering also implemented a hot work procedure and checklist and a confined space procedure. Both procedures implemented permit systems that, among other things, required signed authorisation before the conduct of hot work.
73. Wollondilly Engineering also employed a safety manager. Either the safety manager or Turner now visit intended work-sites to conduct risk assessments before the workers attend to conduct the work.
12 The prosecutor also tendered the following documentations:
(a) A Factual Inspection Report of Inspector Stephen Charles dated 30 March 2007;