Prosecutor's evidence
22Mr A Casselden tendered an agreed statement of facts, which provided:
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(1)(c) of the said Act to institute proceedings in the within matter.
2. At all material times Harry Schwarz Consulting Pty Limited [ACN 130 783 372] (HSC) was a corporation whose registered office was situated at 10 Caroline Chisholm Drive, Camden South in the State of New South Wales and was an employer. Background3. J.I.T. Offset Pty Limited (JIT Offset) was a corporation which undertook the business of lithographic box printing and manufacture. JIT Offset had approximately 35 direct employees working at the premises. It conducted the business at 5 Williamson Road, Ingleburn.
4. At all material times, Zac's Packs Pty. Limited (Zacs) was a corporation which undertook the business of paper and corrugated cardboard box manufacturing and printing. Zacs was registered with ASIC on 24 July 1992. Zacs employed approximately 20 people.
5. At all material times Zacs conducted its business at premises located at 5 Williamson Road, Ingleburn in the State of New South Wales and was an employer.
6. J.I.T. Box Pty. Limited (JIT Box) was a corporation affiliated with JIT Offset and Zacs and performed the management and administrative functions for Zacs and JIT Offset. JIT Box had approximately 20 employees.
7. Zacs is the ultimate holding company of JIT Offset and JIT Box. Mr Edward Zacaropoulos and Mr John Zacaropoulos are the directors of all three companies. All three companies were run as a single group, and they shared management. Management was responsible for the employees of all three companies.
8. The three companies operate from the same premises located at 5 Williamson Road, Ingleburn in the State of New South Wales. The premises are owned by Jobema Investments Pty Ltd [ACN 051 461 244] (Jobema). Zacs is owned by Jobema, of which Mr Edward Zacaropoulos owns 27 of 36 shares and Mr John Zacarapoulos 3 of 36 shares.
9. Mr Paul Manning Foran (Mr Paul Foran) was employed by JIT Box as the General Manager and was responsible for day to day management of the Zacs factory and J.I.T. Offset. Mr Paul Foran attended the factory 5 days per week.
10. Mr James Alexander Foran (Mr James Foran) was employed by JIT Box as the Operations Manager and was responsible for carrying out the practical operations of the company. Mr James Foran attended the factory 5 days per week.
11. Zacs and J.I.T. Offset are family run businesses. Mr Edward Zacaropoulos is the grandfather of Mr Paul Foran and Mr James Foran. Mr John Zacarapoulos is Mr Edward Zacaropoulos' son.
12. The Skulski Family Trust (Skulski Trust) is a discretionary trust established in 1995 and provided skilled labour to Zacs. There was no written contract with Zacs, and arrangements with Zacs were verbal.
13. The members of the Skulski Trust included members of the Skulski family, including Mr Paul Skulski (Mr Paul Skulski), Ms June Skulski (Ms June Skulski) and Mr Alexander Skulski (Mr Alex Skulski). Mr Paul Skulski and Ms June Skulski are the parents of Mr Alex Skulski. Ms June Skulski works at Zacs in payroll and on the switchboard.
14. Mr Paul Skulski is a qualified Printer Machinist and has been working as a contractor at Zacs for approximately 16 years. Mr Paul Skulski was the senior operator of the Varimat and was the direct supervisor of Mr Alex Skulski and Mr Lance Shiels (Mr Shiels).
15. Mr Alex Skulski was a 17 year old first year apprentice Printer Machinist employed by JIT Offset and was also attending Ultimo Tafe. Mr Skulski commenced his apprenticeship with JIT Offset in November 2008
16. Harry Schwarz Consulting Pty Ltd (HSC) was a labour hire company providing skilled and unskilled labour to commercial clients. HSC had approximately 8 employees, with 2 employees working at Zacs. Harry Schwarz was the sole director of Harry Schwarz Consulting.
17. Mr Shiels completed his Higher School Certificate at the end of 2008. In July 2009 he was employed by HSC. At that time he was 18 years old and had limited work experience.
18. Mr Shiels was engaged to work at Zac's as an unskilled factory process worker. Prior to working at Zac's Mr Shiels had been engaged for a short period of time as an unskilled process worker at another factory.
19. Harry Schwarz attended with Mr Shiels on the first day of his engagement at Zac's. Mr Shiels was engaged at Zac's to work at the end of a process machine stacking processed cardboard onto pallets.
20. HSC did not provide its own site-specific induction training to Mr Shiels. HSC worked off Zac's inductions. Mr Shiels received a basic induction from the Production Manager of JIT Box Pty Ltd, Peter Doherty. Copies of the induction records were available to Harry Schwarz.
21. Harry Schwarz would visit Mr Shiels at Zac's about once a week to see and ask him how he was going. He would also telephone him from time to time to enquire about his wages.
22. In early 2009 James Foran and Harry Schwarz discussed HSC finding a printers offsider.
23. Harry Schwarz was not informed by the Production Manager of JIT Box Pty Ltd, Peter Doherty that Mr Shiels had changed roles from process factory worker to a printers offsider.
24. HSC failed to instruct its employees (including Mr Shiels) or Zac's that its employees (including Mr Shiels) were prevented from undertaking any work at Zac's other than the work they were trained to perform. HSC did not have any procedure that prevented its employees (including Mr Shiels) from undertaking any work at Zac's other than the work they were trained to perform.
25. HSC did not have any procedure that required Zac's to notify and seek HSC's permission of any changes to the work to be performed by its employees (including Mr Shiels) before the employee commenced different or other work.
The Printing Press
26. At the premises there was a KBA 142 Varimat printing press; serial number 349217. The Varimat is a large format commercial offset printing press which produced a range of printed paper card finishes used in the manufacture of paper box products. The press prints external box decals and signage.
27. The Varimat range of presses was first manufactured in 1967 and the model ceased to be manufactured in 1995 when it was superseded by the 'Rapid' model printer. The press at the Zacs factory was manufactured in 1995 in Germany. Zacs purchased the press second hand from a German company, VossWinkle, specialising in the international sale of used industrial printing machinery. The press was imported into Australia in July 2004 by Finish and Binding Machines Pty Ltd, trading as Quigley Graphics.
28. The press and associated equipment was shipped to Australia in 9 shipping containers. A team of German technicians were contracted to come to Australia to install and commission the printer at the Zacs factory. The press was re-assembled in the same configuration as used in its previous location.
29. Mr Holzkamp, an employee of the previous owner of the press, had worked on the press for 9 years since it was purchased new by his employer. Mr Holzkamp travelled to Australia and spent 3 weeks providing training and instruction to employees at the Zacs factory.
30. The press works by loading cardboard into a vertical stacker that raises the cardboard as it is dispensed into the printer. The cardboard passes through a bank of up to 5 colour presses, depending on the job. After passing through the colour presses the cardboard goes into the coating unit, which provides a clear varnish coating. The cardboard then goes into the dryer and powder applicator to dry and set the ink.
31. A work order provides operators with detailed specifications for each print run. There can be up to 6 print runs each shift, depending on the size of each job. The machine operator checks for quality as the press is working, and sets up the press for each print run. The specifications are loaded into the press via the computerised panel, and the machine is also set up manually, including fitting colour plates, inks, paper and coating or varnish plates.
32. The press consists of a paper feed module, 5 printing towers, a coating unit and a counter/collector module. The printing towers and coating unit are mounted on a raised platform approximately 1.5 metres high. The coating unit has two rollers between the left and right sides of the unit, known as the varnish cylinder (or plate cylinder roller) and applicator roller (or coating roller). The varnish cylinder is located toward the front of the coating unit at floor level, and the coating roller is positioned above the varnish cylinder.
33. The coating unit has a varnish plate measuring 1430mm by 1170mm, and 1.4mm in thickness. The plate is fitted around the circumference of the varnish cylinder. The varnish cylinder is 1570mm long and 430mm in diameter, and is a 'C' shape rather than round, with a section of the circumference cut out. The cut out section of the cylinder has a pair of screw clamps located on either side, used to secure the varnish plate to the cylinder. The clamps operate in the opposite direction to one another so that when the varnish plate is fitted there is a gap between the two sets of clamps.
34. The applicator roller above the varnish cylinder is approximately 1440mm long by 265mm in diameter, with a gap between the varnish cylinder and the applicator roller, creating an in-running nip point. There is a two piece hinged Perspex cover on the front top and upper front of the coating unit known as the front flip cover, and a Perspex cover on the rear top and upper rear of the coating unit known as the rear flip cover. There is an interlock switch on the left hinge of the front and rear flip covers. There is plate cylinder guard consisting of a hinged metal cover on the lower front of the coating unit, with a plunger style safety switch on the left side of the plate cylinder guard. The metal guard can be lifted up and secured to allow access to the varnish cylinder.
35. To reach the nip point between the two rollers an object or body part would have to travel between 20 - 30cms around the top circumference of the varnish cylinder, also passing through a gap between the bottom edge of the Perspex cover guard on the applicator roller and the varnish cylinder that partially restricted the pathway to the nip point.
36. Opening the coating unit guard isolates the press and prevents it being operated. The isolation allows the varnish cylinder to be operated in 'inch' or 'crawl' mode so that the cylinder can be rotated at a reduced speed. The crawl mode is a slow continuous speed, while the inch mode rotates the cylinder a short distance before stopping. The varnish applicator roller, above the varnish cylinder, is not isolated by the lifting of the guard but rotates at slow speed on a default mode. The applicator rollers need to keep moving so as to ensure the aqueous varnish material remains in liquid form. Control buttons are located on either side of the coating unit for the crawl and inch functions of the varnish cylinder. When the control buttons are activated an audible alarm sounds, however if the inch button is pressed and then immediately pressed again, the cylinder will rotate without the alarm resounding. If there are a few seconds between pressing the inch button, the alarm will resound.
37. The process for loading a new varnish plate into the press is that varnish plate is laid out on the machine deck area in front of the varnish cylinder roller. The cylinder guard is removed, and the cylinder is rotated to expose the first set of plate clamps. The physical size of the plate means that two operators are required to support the plate on either side as it is slid into the clamp housing. The holding clamps are tightened with a specialist tool to secure the plate to the cylinder. The plate remains in a flat, horizontal position, projecting out from the coating unit, obstructing the cylinder, which means the persons replacing the plate must stand side on to the unit, on either side of the plate. The cylinder is then rotated to allow the plate to be wrapped around the circumference of the cylinder. One operator applies light pressure to the plate, with a hand, whilst it is being rotated to ensure the plate maintains tight contact with the cylinder. Once the plate is fully rotated around the cylinder, the operator feeds the leading edge of the varnish plate into the second set of clamps, which are then tightened to secure the plate to the cylinder. The guard is replaced and the coating unit is ready for operation.
The Incident
38. Printing operations at the premises usually commence around 6:00am and finish around 4:00pm. On Tuesday 20 October 2009 the factory was busy, and printing commenced at approximately 5:00am.
39. Mr Paul Skulski, Mr Alex Skulski and Mr Shiels were operating the press and had done two print runs that day. At approximately 11.00am Mr Alex Skulski and Mr Shiels were loading a new varnish plate onto the machine in preparation for the next print run. Mr Alex Skulski was instructing Mr Shiels in the process. Mr Paul Skulski attended to other work on the press, and left Mr Alex Skulski to supervise Mr Shiels. Mr Paul Skulski determined that the task was routine and repetitive and that Mr Alex Skulski was competent to work unsupervised. Mr Paul Skulski was performing another task on the printer, and could not see Mr Shiels and Mr Alex Skulski whilst they were changing the varnish plate. Mr Shiels had changed the varnish plate approximately 20 times since working with the press.
40. Mr Alex Skulski and Mr Shiels had clamped the plate to the cylinder via the first set of clamps. Mr Shiels was on the right side of the coating unit, adjacent to the walkway alongside the printer. Mr Alex Skulski was on the left side of the coating unit, the inner side, operating the control switches in order to rotate the cylinder so that the plate would wrap around it. The varnish plate did not fit correctly, and there appeared to be an air bubble between the varnish plate and the cylinder. Mr Alex Skulski rotated the cylinder again whilst he and Mr Shiels pushed against the plate.
41. Whilst the cylinder was being rotated, Mr Shiels' hand became entangled in the rollers. The plate was not entirely wrapped around the cylinder when Mr Shiels pulled his hand free. The details of how, and in which part of the press, Mr Shiels' hand became trapped are not certain.
42. Mr Shiels says that the cylinder had been entirely rotated and he was trying to fit the edge of the varnish plate into the second set of clamps. He was applying pressure to the plate with his left hand to force it into position and says the end of the plate was a little damaged and he was having difficulty getting it into the clamps. Mr Sheils' right hand was on the cylinder, above his left hand, applying pressure to the plate to ensure it stayed in position against the cylinder. Mr Shiels says it was at this moment the cylinder rotated inwards and his right pinkie and tips of his fingers became entangled between the varnish plate cylinder and the applicator roller.
43. Mr Skulski says that after securing the varnish plate into the first set of plate clamps he commenced rotating the varnish cylinder in order to wrap the varnish plate around the cylinder. Mr Shiels placed his hand over the edge of the second set of plate clamps and as the cylinder rotated his hand became entangled between the inrunning nip point between the applicator roller and the second set of clamps.
44. Mr Shiels' hand became entangled either in the nip point between the varnish cylinder and the applicator roller, or between the applicator roller and the plate clamps. In either case there was no guard in place at the time of the incident over the exposed nip point.
45. Mr Shiels pulled his hand away and saw exposed bone on his right pinkie finger and the tips of his middle finger and ring finger were crushed. He called to Mr Paul Skulski who was 10-15 metres away. Mr Paul Skulski assisted Mr Shiels to the first aid room and an ambulance was called.
46. Mr Alex Skulski and another printer, Mr Troy Young, were instructed to look for Mr Shiels pinkie finger in the press. They drained and removed the varnish tray at the rear of the machine in order to remove the severed part of Mr Shiels' pinkie, with the tendon still attached. The ambulance had already taken Mr Shiels to hospital, so Mr Troy Young drove the severed digit to the hospital.
Injuries
47. Mr Shiels suffered partial amputation of the small, or pinkie finger, and crush injuries to the tips of his ring and middle fingers on his right hand. Mr Shiels remained in hospital for two days and underwent a number of medical procedures. Mr Shiels underwent reconstructive surgery to his ring and middle fingers, including a skin grafts using skin from his upper thigh.
48. Since the incident Mr Shiels has not returned to work. He is studying Human Resources at Liverpool TAFE and considering university studies.
Systems of Work Prior to the Incident
49. J.I.T. Offset and Zacs permitted Mr Alex Skulski to work on the press without supervision in the task of changing the varnish plate, although he was only a first year apprentice. Zacs did not ensure that suitable and appropriate training was given to Mr Alex Skulski and relied on Mr Paul Skulski to train Mr Alex Skulski and assesses his competency for the task of changing the varnish plate. Mr Paul Skulski decided that Mr Alex Skulski was competent to change the varnish plate without direct supervision.
50. J.I.T. Offset and Zacs allowed Mr Alex Skulski, a first year apprentice, to directly instruct another inexperienced worker, Mr Shiels in the task of changing the varnish plate. Mr Shiels said that he did not understand the functions of the press, and had no clear knowledge or understanding of the audible alarm function on the press. Mr Alex Skulski, as a first year apprentice, was not in a position to determine the level and appropriateness of Mr Shiels' understanding of the functions of the press.
51. J.I.T. Offset and Zacs had a system for inducting new staff at the premises that consisted of an induction package with a selection of Zacs policies and procedures, and a walkthrough of the factory. The induction package contained different polices and procedure documents depending on the specific requirements of the inductee. There was no system in place to check that the inductee had read or understood the policies and procedures at the factory. There was no verification or assessment made of the inductee to affirm they had actually read and understood the documents provided to them.
52. J.I.T. Offset and Zacs had developed safe work instructions for particular activities or use of plant at the factory. The 4 page safe work instruction relating to the press was 'Safe Work Instruction 18", and consisted mostly of quality control issues rather than hazard identification and risk control measures.
53. J.I.T. Offset and Zacs relied on a system of on-the-job training to instruct workers at the factory. This approach relied on qualified and/or experienced workers instructing less experienced workers by a combination of instruction and demonstration. Mr Paul Skulski provided training to Mr Alex Skulski and Mr Shiels. There was no mechanism to check that task specific procedures had been completed and there was no documented assessment of Mr Shiels' competency on the press.
54. J.I.T. Offset and Zacs had workplace training instructions and checklists in place. However Mr Paul Skulski did not complete these documents in relation to the training of Mr Alex Skulski nor Mr Shiels.
55. When Mr Shiels commenced work on the press Mr Paul Skulski did not make any enquiry as to the level of training and instruction Mr Shiels had received in relation to the press or the safe work instruction. Mr Shiels was not provided with training in relation to safe work instruction 18 on the operation of the press before commencing work on the press. Zacs relied on Mr Paul Skulski to provide training and induction to Mr Shiels, and did not make any enquiries to ensure that training had taken place.
56. The press is manufactured with a guard over the coating unit nip point. However this guard was not supplied or installed with the press. Zacs had never fitted the guard to the press and were not aware there was a guard for this section of the press. It is unclear if the guard was fitted to the press when it was operating in Germany, or if it was lost or overlooked during the installation of the press at the Zacs factory. The English version of the operators' manual identified the guarding on page B2 at item 39 and page B6.
57. J.I.T. Offset and Zacs conducted two risk assessments on the press after it was installed at the factory. The first assessment on 16 January 2007, two years after the press was in production, fails to record who conducted the risk assessment and fails to identify any hazard in relation to unguarded nip points on the coating unit. The second risk assessment, on 11 February 2008, did not identify any concerns with the unprotected nip point in the coating unit. Neither risk assessment identified the need to guard the unprotected nip point.
23An agreed statement of facts, in identical terms, was relied upon in respect of the charge brought against the personal defendant.
24The prosecutor also tendered the following documents:
1. Factual Inspection Reports of Inspector David Young dated 13 November 2009.
2. WorkCover Photographs taken by Inspector David Young on 20 October 2009 and 13 November 2009 (21 pages). The photographs show the KBA Lithographic printing press, the "Coater Unit" showing the "Plate Cylinder Roller", rear hinged guard in the closed position and the front hinged guard in the open position.
3. 7 WorkCover Photographs taken by Inspector Stephen cooper on 24 February 2010. These are photographs taken by Inspector Cooper on 24 February 2009 showing a new Pivot Bar Guard having been installed on the printer between the lower Varnish Plate Roller and upper Application Roller.
4. Zac Pac Job Description - Process Worker.
5. Company Search of Harry Schwarz Consulting Pty Ltd (ACN 130 783 372) printed 12 September 2012.
6. Prior Conviction Report of Harry Schwarz Consulting Pty Ltd (ACN 130 783 372) printed 12 September 2012, showing no prior convictions.
7. Prior Conviction Report of Harry Schwarz printed 12 September 2012, showing no prior convictions.
8. Safety equipment and safety instruction booklet for KBA 142 Varimat printing press. Under the heading "safety equipment of machine" which sets out all of the individual components of the machine, component 39, which is directed to what would appear to be two rollers and a nip point provides:
39 Run-in guard in front of varnish application roller and blanket cylinder
- Machine stops at any operating mode
- Varnishing device motor stops at contact and if varnishing device guard (37) opened at the same time
25Mr Casselden submitted that it was the run-in guard referred to in the booklet that was missing from the printing press.