Prosecutors evidence
15Mr R Reitano of counsel appeared for the prosecutor. Mr Reitano tendered an agreed folder of documents which included an agreed statement of facts which read:
Background
1.At all material times, the prosecutor was an Inspector duly appointed under Division 1 of Part 5 of the Occupational Health and Safety Act 2000 (Act) and empowered under Section 106 of the said Act to institute proceedings under the Act.
2.At all material times Transfield Services Engineering Group Pty Limited ACN: 076 861 615 (TSEG) had its registered office at Level 10, 111 Pacific Highway, North Sydney in the State of New South Wales.
3.At all material times TSEG was a corporation which conducted a business, trade or undertaking in the provision of project management services.
4.At all material times BlueScope Steel (AIS) Pty Limited (BlueScope) owned and occupied premises known as the Commonwealth Rolling Mills (CRM) site, Old Port Road, Port Kembla (the premises). At the premises, BlueScope operated a trial Sinter Cooler plant. BlueScope was undertaking a project known as the Ore Preparation Upgrade Project (OPUP) at the premises.
5.The OPUP Project commenced in March 2007. As part of the scope of works to be undertaken as part of the OPUP BlueScope commissioned a new Sinter Cooler which was manufactured in Korea.
6.To ensure that the new cooler functioned properly before its final installation BlueScope arranged to undertake a trial of the rail cooling system. The trial required the rail cooling system to be erected, tested and dismantled at the premises. The trial was also undertaken to reduce the shut-down time needed when the new Cooler was ultimately installed. The rail cooling system was installed and trialled at a remote location on the site approximately 3 kilometres from where the new Sinter Cooler was to be installed. The area was known colloquially as "Siberia". The area was completely fenced off and access to the premises was under the control of BlueScope, TSEG and Thomas & Coffey Limited ("T&C"). All visitors to the premises were required to sign the visitor's register before access was granted.
7.The Hatch Project Manager was Jim Fresh and the Construction Manager was Peter Hall. Both managers reported to Phillip Smith, the BlueScope Vice President for Capital Development and Engineering. BlueScope engaged Hatch Associates Pty Limited ("Hatch") to provide engineering personnel and project management personnel. The persons provided by Hatch for that role were Glen Stimson (Project Engineer), Sushil Rawat (Construction Engineer) and Bob Burke (Site Co-ordinator).
8.At all material times BlueScope had in place a safety management plan for the OPUP Project. The plan set out site safety rules, procedures and policies, including policies relating to contractors.
9.On or about 4 March 2009 TSEG entered into a contract with BlueScope for the last component of the Major Works (with Design Option) of Ore Preparation Upgrade Project (OPUP) Major Shutdown Installation - Sinter Plant (CM 006) (Contract).
10.Transfield Services Australia Ltd (TSA) provided labour to undertake work required under the Contract. Mark Sheldon (Mr Sheldon) was employed by TSA. The contract named Mark Sheldon, as Cooler Team Leader for the installation of the Sinter Cooler. The primary role of Mr Sheldon was to co-ordinate the works required to install the new Sinter Cooler, including the dismantling of the trial rail cooling system with the authority to direct work in relation to the sinter plant.
11.Under Schedule 7 of the Contract, T&C were nominated as the subcontractors to TSEG to provide the engineering services, supervision, labour, materials and equipment and overall management for the disassembly of the trial cooler at the premises. There was no separate contract between TSEG and T&C. The installation of the trial rail cooling system had been carried out by T&C under the direction of BlueScope and Hatch. T&C had access to the engineering drawing for the trial rail cooling system that had been provided by BlueScope and Hatch for the installation and subsequent disassembly of the plant. TSEG had no role in the installation and trial of the rail cooling system.
12.The scope of work to be undertaken by T&C was set out in the purchase order as "Provision of Labour, Materials and Equipment necessary for disassembly of the New Cooler generally as detailed in work portion 8.1 of target cost estimate." The purchase order also stated that "Work to be done under the direction of Transfield's Mr Mark Sheldon."
13.T&C employed Paul Rodgers (engineer), Peter Reinhardt (supervisor), Scott Rodgers (leading hand boilermaker), Joe Zappia (fitter), Frank Kerr (fitter), Alan Neves (rigger), Steve Ashton (boilermaker), and Vito Esposito (rigger). These workers formed the T&C work crew that was involved in the disassembly of the cooler.
14.For the disassembly of the trial rail cooling system Mr Paul Rodgers developed a time sequence and lift studies and trial lifts were conducted.
15.This planning work was carried out in consultation with TSEG, Hatch and BlueScope OPUP project teams. The majority of the disassembly work was completed by 29 March 2009. The work planned for 30 March 2009 was the removal of the inner and outer dip rails. The dismantling of the trial cooler system on 30 March 2009 required cranage. Allstate Cranes & Plant Hire Pty Ltd (AC) were contracted to TSA to provide crane services at the premises for the dismantling of the dip rails. Allstate Labour Hire Pty Ltd (ALH) provided labour to AC to assist with crane services provided for the disassembly of the new cooler at the site.
16.ALH employed David Wormleaton as a dogman, Dean Graham as a dogman, Darcy Rolfe as a crane driver and Wayne Fuller as a Supervisor (referred to hereafter at the "ALH Crew").
17.The company 24 Hour Cranes Pty Ltd were the owners of the crane that was used at the premises.
The Contract
18.Under the Contract TSEG was required to undertake work at the premises. The work that was required to be undertaken was set out in Technical Specification titled 'Engineering Specification for CM 006 - The Structural and Mechanical Installation of the Sinter Plant: Feed End, Discharge End and Cooler; Rev O, dated 14 March 2009, document number OPUP - TS - SP - CO - CM 006 - 00774. Under the contract TSEG and its subcontractors were required to carry out all of the work in accordance with the Contract.
19.Under the Contract access to the CRM premises conferred upon TSEG a right to use and control of the premises as was necessary to enable TSEG and its sub-contractors to carry out work under the Contract.
20.Under the Contract TSEG was obliged to comply with the Occupational Health and Safety Act 2000 (NSW) and with other advisory standards relating to occupational or workplace health and safety.
21.Under the Contract TSEG was entitled to subcontract any of the work required to be done by it to subcontractors nominated in the Contract including T&C. However, the subcontractors were to be approved by BlueScope pursuant to Schedule 7 of the Contract. Schedule 7 also provided BlueScope's list of preferred contractors. Under the Contract TSEG was responsible for the performance of its subcontracts (including T&C) and the management and supervision of their activities; was liable for the acts and omission of the subcontractors as if they were those of TSEG and was not, in the event that work was subcontracted, relieved of any of its obligations under the Contract.
22.Under the Contract TSEG was required to comply with BlueScope's site requirements. The site requirements required TSEG to develop, implement and administer a Site Specific Safety Plan ("SSSP plan"). Under the SSSP plan TSEG was required to conduct, review and audit any of its subcontractor's Health, Safety and Management systems prior to appointing the subcontractor. If the subcontractor's system failed to meet TSEG's requirements and the work was high risk the subcontractor was required to review its management system. Where the work was low risk the subcontractor was required to adhere to the TSEG management system. Under the Contract TSEG also had to comply with the BlueScope site safety plan in relation to subcontractors. Under the BlueScope site safety plans, BlueScope together with Hatch would review the subcontractors JSEA's for specific tasks and where BlueScope permits were required.
23.At all relevant times, BlueScope had in place a system for the issue of Authority to Work Permits. An "Authority to Work Permit" ("AWP") was issued to T&C for the disassembly of the trial rail cooling system for the period 26 March 2009 to 2 April 2009. Peter Hall issued the permit on behalf of BlueScope. Mr Jai Steele a Hatch engineer reviewed the JSEA's provided by T&C for the work. TSEG audited the safety systems of T&C on a regular basis. Under the protocols in place TSEG would from time to time review the JSEA's prepared by T&C for the disassembly work.
Sinter Cooling Plant Trial
24.Sinter is a hard wearing material manufactured at BlueScope Steelworks premises. Sinter is used to line the refractory surface of a blast furnace to minimise damage when the raw materials for the production of molten iron are added. It is produced by combining raw materials of iron ore, limestone and coke which are baked in a furnace and then left to cool on a circular conveyor type cooling bed. During the sintering process, when the sinter is cooled, it is discharged (tipped out) from the oven cars onto the cooling bed (revolving circular conveyor), then sent to the blast furnace for continuation of the process. The area where the discharge occurs is known as the dip-rail area.
25.The trial rail cooling system for the new Sinter Cooler was an elevated hollow circular structure. Two curved rail tracks formed part of the elevated track cars holding the sinter were to move along in a continuous sequence. The dip rail of the elevated circular track was a section in the rails which dipped down to allow discharge of the sinter from the cars onto a conveyor below. The culvert area below the track was used to access the inner area from the outer area of the track. The structure was supported by two steel frames in a horizontal position. A further two steel frames were positioned within the two beams in an inverted 'v' position and were bolted onto a concrete pad on the culvert floor by four hold down studs with nuts.
26.The trial of the Sinter Cooling Plant took place at a remote corner of the premises. The area was completely fenced off and access to the premises was controlled by TSEG and T&C. All visitors to the premises were required to sign the visitors register before access was granted.
The Incident
27.On the 30 March 2009 the ALH Crew arrived at the sinter cooler site Port Road, Port Kembla at about 7am. Lance Wise, an employee of TSA held a toolbox meeting outside the premises with the ALH Crew. The meeting covered the general site activities and hazards in accordance with the BlueScope safety management plan. Instructions were then given to the AC and ALH Crew to take the cranes to the work site where the dismantling of the trial rail cooling system was taking place ("Siberia"). The ALH Crew signed onto the TSEG attendance sheet.
28.The ALH Crew were assigned to work with the T&C crew to dismantle and remove the dip rail panels, rails and frames of the sinter plant cooling trial using a 100 tonne Grove Truck mounted crane.
29.The ALH crew were inducted by Peter Reichardt, Supervisor employed by T&C, into the specific site at which the work would be undertaken. The ALH crew attended the T&C job start and read through the JSEA. Following the job start session, the ALH crew together with Wayne Fuller conducted their own JSEA and lift study.
30.The ALH Crew together with T&C employees commenced work. As part of the dismantling process, the 7.5 tonne dip rail panels of the cooler were required to be removed from the dip rail pit area. The workers were then required to remove the side bracing of the dip rail structure which was comprised of two in situ beams and four beams lying in the work area. The two in situ beams were each secured separately to a concrete pad by four hold down studs with nuts. The dip-rail frame was made of fabricated steel measuring approximately 2.3 metres high by 8.1 metres long and weighing approximately 1.7 tonnes.
31.The dip-rail frame that had to be removed was situated under the top rail structure. Because of the minimal clearance between the frame and the top rail structure, the frame had to either be tilted over and then lifted clear by the crane or lifted slightly by the crane and the hold-down studs cut to allow it be moved sideways and then lifted.
32.Around 11am the removal of the outer dip rail panel commenced. However Peter Reichardt requested that the load be re-slung as he was not happy with it. He also instructed the fitters Joe Zappia and Frank Kerr to replace the bolts while the dogman re-slung the load. At around 12pm the removal of the inner dip rail panel was commenced. This job was completed successfully without incident. The removed panels were placed in a lay down area.
33.Around 1pm Scott Rodgers had a discussion with Alan Neves, David Wormleaton and Steve Ashton. Scott Rodgers gave instructions to Alan Neves and David Wormleaton to sling the top beans. He requested that once this had been done that the fitters, Joe Zappia and Frank Kerr, were to remove the bolts on the top beams and then the riggers - Alan Neves and Vito Esposito, were to remove the beams.
34.Alan Neves, David Wormleaton and Steve Ashton discussed how to remove the bottom support frames as there was not enough clearance due to the height of the threaded bar securing the frame to the ground and the minimum clearance of the structure/ledge it sat under.
35.It was decided that Steve Ashton, boilermaker, would cut the hold down bolts once Alan Neves and David Wormleaton had secured the frame. The frame would then be swung out then lifted. Scott Rodgers then left the area to check upon other works being undertaken at the premises.
36.At approximately 2:00pm, Joe Zappia and Frank Kerr made the unilateral decision to remove the hold down studs before the frame was secured, contrary to the verbal instruction given by Mr Scott Rodgers. They proceeded to loosen and remove the hold down nuts marked "1", "2" and "3" on the bottom beams of the structure which secured it to the concrete pads leaving the dip rail frame unsecured. Mr Wormleaton and other members of the ALH crew were not made aware of the decision.. The result of their actions was to leave the dip rails unsupported and therefore unstable.
37.David Wormleaton and Alan Neves were attempting to hook up one of the dip-rail frames to lifting chains that were attached to the crane. Dean Graham was standing in the pit area near David Wormleaton acting as a spotter. Alan Neves reached up and slung the chain over one end of the structure and hooked on. David Wormleaton threw another set of chains over the structure but was not tall enough to hook on.
38.Alan Neves commenced to step up onto the bottom beam of the structure to attach the chain sling. As he did so the structure started to sway. Dean Graham noticed the frame sway, yelled out and ran away from the area. Frank Kerr also observed the structure move and yelled out to everyone to clear the area. David Wormleaton commenced to run away from the area, as he was doing so the frame toppled over landed on his leg, causing crush injuries that resulted in the amputation of Mr Wormleaton's right leg just below the knee. Alan Neves was unhurt.
39.At the time that David Wormleaton and Alan Neves were performing the tasks ready to remove the panels they were unaware that the hold down nuts had been removed from the studs.
40.Following the incident, various persons inspected the concrete pads and the hold down studs and nuts of the two in situ beams. The inspection revealed that all eight nuts had been either loosened or removed from both in situ frames making the frames both inherently unstable. The remaining dip rail was immediately secured. The dip-rail frame that fell was secured using a synthetic webbing sling and a come along type rigging apparatus. The other dip-rail frame opposite was also secured using the same method. The frames were then removed by attaching a crane to the frames before the hold-down nuts were removed completely and the securing rigging equipment removed.
Safety at the Premises
41.TSEG had a SSSP plan for the OPUP work conducted at the premises. TSEG's SSSP required pre-project meetings to be undertaken to ensure a systematic work methodology was followed throughout the project. A representative from each workgroup or team involved in the project was required to attend each meeting. In addition it required a start up meeting to be held at the beginning of each shift which was to be used as a common means of communicating safety initiatives and or concerns to all personnel working on the project.
42.At the time of the incident T&C had in place a Safety Management Plan. The T&C Safety Management Plan required T&C to undertake toolbox meetings at the start each shift or when there was a significant change in the work to be undertaken. All people working at the premises where the trial rail cooling system was located were required to attend the meetings.
43.At the time of the incident T&C undertook site specific inductions for the work undertaken at the premises. In accordance with the site specific induction, T&C required JSEA's to be undertaken for all tasks. In addition it required its supervisors to undertake a tool box talk which included a discussion regarding the JSEA's with all personnel involved. On the day of the incident Peter Reichardt undertook a toolbox talk in relation to the dismantling of the cooler trial. It covered working at heights, mobile crane load and housekeeping. Frank Kerr, Joe Zappia and Alan Neves were in attendance at the talk.
44.T&C's Safety Management Plan required it to have in place a JSEA/ safe work method statement which identified and considered the risks and control measures for the specific work tasks to be undertaken at the premises.
45.T&C had a JSEA in place at the time of the incident which related to the task of the removal of the outer and inner dip panels.
46.The T&C JSEA contained four parts. Part 1 of the JSEA was a two page checklist. Mr Peter Reichardt completed the checklist on 30 March 2009. The second page identified that an AWP was required. Part 2 of the JSEA was a checklist for manual handling. Scott Rodgers completed the checklist on 30 March 2009. Part 3 was a prepared risk assessment for the task of removing the inner and outer dip rail panels dated 24 February 2009. Points 1 to 11 of the risk assessment identified the work sequence, hazards, risk and controls to be used for the removal of the Outer & Inner Dip Rail Panels. Points 7 & 8 of the risk assessment identified the work sequence to be: (7) "Rig Outer Dip Rail for lifting" and (8): "Break Outer Dip Rail Panel Bolted Connections".
47.Part 4 of the JSEA required a daily risk assessment that identified the work sequence, potential hazards, risk and control measures The JSEA identified the risk of "crush injury" and identified the control measure to be used as "* cut bolts after load rigged up". It was later revealed during the WorkCover investigation that Scott Rodgers had added this page to the document after the incident following instructions from Peter Reichardt.
48.Because no daily risk assessment was completed as required by the JSEA, the JSEA did not address the various tasks associated with the removal of the support frames and consequently did not identify the requirement to cut the hold down studs and bolts after the load had been rigged up. That risk and control measure was the ideal measure to eliminate the risk of being struck or crushed by the dip rail frame falling over. Had this control measure been implemented and followed before the incident, David Wormleaton would not have been injured.
49.ALH had in place safe work methods for both slewing and non slewing cranes. The ALH Crew attended the T&C job start and read through the JSEA. Following the job start session, the ALH crew together with Wayne Fuller conducted their own JSEA and lift study.
50.As a result of the T&C JSEA not identifying specific steps on the day of the incident, neither of the safe work method statements identified the steps to be undertaken in the task of dismantling the dip rail frames and consequently did not identify the risk of frames falling by the premature removal of the hold down nuts.
51.ALH and TSEG did not see the JSEA prepared by T&C for the removal of the outer and inner dip rail panels.
52.On the morning of the incident Mr Sheldon had rung Mr Wayne Fuller of ALH to check that the cranes had arrived. Mr Fuller advised that the cranes were on site and that he was conducting start up meetings and lift studies. At about 11.45am Mr Sheldon spoke to Mr Reinhardt to check on the progress of the work. Mr Reinhardt advised that the work was going "OK". TSEG did not make any inquiry of T&C before work commenced as to whether they had completed the daily risk assessment for the work.
53.At 1pm Mr Sheldon conducted a progress review meeting with Hatch, TSA and T&C representatives. The T&C supervisor, Peter Reinhardt attended the meeting. The meeting was held at a building adjacent to where the disassembly work was being carried out. At about 2pm the meeting concluded and the participants then conducted an inspection of the lay down (holding) area.
54.At the time of the incident Mr Sheldon was approximately 100 metres to the north of the worksite with Mr Bob Burke and Mr Jai Steele. On hearing a noise the group immediately went into the worksite and took control of overseeing assistance to Mr Wormleaton and the securing of the unsupported dip rail frame.
55.The T&C employees who had worked on the assembly of the cooler trial were not the same employees working on the dismantling on 30 March 2009. There was no hand over between the two crews to confirm the process and steps associated with the assembly of the cooler.
56.At the time of the incident, David Wormleaton, Alan Neves and Dean Graham were not aware that the hold down nuts had been removed whilst they were undertaking the work in question. It is usual practice when performing this type of work to secure the load before undoing the hold down bolts. As a result they did not check whether the hold down bolts had been removed prior to commencing to sling the frames to secure it to the crane.
57.There was no procedural or informal requirement in place for any of the ALH or T&C workers to check the state of the hold down bolts prior to rigging the frames to the crane. As such no one from either crew checked that the hold down nuts or studs were still in place before climbing on to or working in the vicinity of the dip rail frame.
58.The sequence of work specified in the T&C JSEA did not specify that the dip rail frames were to be inspected before slinging to ensure the dip rail frames were secure and suitable for slinging to take place. However, the ALH Crew had conducted a site inspection before commencing work. At the time of the inspection the dip rail frames were bolted and secure. The dip rail frames did not become unsecured and thereby unstable until Mr Zappia and Mr Kerr removed all of the bolts at about 2pm.
16The tender bundle also contained the following documents:
1.33 colour photographs taken by Inspector Wayne Cobbin on 30 March 2009 showing the northern frame mounting studs and hold down bolts with the 100 tonne crane.
2.Photographs supplied by Peter Reichardt.
3.Factual Inspection Report of Inspector Wayne Cobbin dated 28 April 2009.
4.Extract from Australian Standard 2601-2001 - Demolition of Structures, Section 2.
5.Incident Investigation 'Attachment 1: Sequence of Events'.
6.Thomas & Coffey Job Safety & Environmental Assessment (JSEA) dated 30 March 2009.
7.Thomas & Coffey Toolbox and Safety Talks for dates 25 February to 30 March 2009.
8.Thomas & Coffey Site Safety Audits.
9.Audit Report 2009 conducted on Thomas & Coffey by Transfield Services.
10.Thomas & Coffey Safety Management Plan.
11.BlueScope Steel minutes of meetings for dates 10 March 2006 to 30 March 2009.
12.Purchase Order dated 24 February 2009.
13.Prior Convictions Report, indicating no prior convictions.
14.Judgment: Inspector Cobbin v Thomas & Coffey Ltd [2012] NSWIRComm 46.
17Mr Reitano also tendered an Australian Securities and Investments Commission current and historical extract of the defendant under s 1274A of the Corporations Act 2001.