4 An agreed statement of facts was tendered which relevantly reads as follows:
4. At all material times the defendant carried on the business of manufacturing lead acid industrial batteries trading as "GNB Technologies".
5. At all material times the defendant operated a lead alloy casting machine referred to as the "TBS Casting Machine" ( the " said machine ") in the conduct of its business.
6. At all material times the defendant employed William Andrianopoulos as a factory hand and labourer responsible, inter alia, for the operation of the said machine.
7. At approximately 10.15 am on 10 April 2000 Andrianopoulos sustained crush injuries and burns to his right hand and forearm when his gloved right hand was caught between a moving mould (or die) and the body of the said machine. As a result of the incident all four fingers of Andrianopoulos' right hand were amputated. Immediately preceding the incident Andrianopoulos placed his right hand into the machine, between the body and two stationary moulds of the said machine, in an attempt to remove a drip tray. The machine indexed and the moulds moved from their stationery position and, whilst in motion, one of the moving moulds caught the glove of Andrianopoulos's right hand and dragged it further into the said machine where it was caught between the moving mould and the body of the said machine and caused to come into contact with both the molten lead alloy bath and the hot mould (or die).
8. On 10 April 2000 the Prosecutor attended the Padstow premises and made an inspection of the said machine. A series of coloured photographs were caused to be taken and an Inspection Report recording the Prosecutor's observations subsequently compiled (a copy of the Inspection Report and series of coloured photographs are attached hereto - attachment " A " & " B " respectively).
9. The Prosecutor's inspection revealed the following matters:
(a) the said machine, a lead alloy casting machine, measured approximately 5 metres in length, 2.8 metres in width and 1.6 metres in height;
(b) the said machine incorporated a steel conveyor belt to which 10 steel moulds were attached (collectively referred to as the "feed line"). The feed line was driven by a 3 phase 5 horsepower electrical motor;
(c) the said machine incorporated a lead pot fitted with a heating element that operated to melt lead alloy ingots, a molten alloy feed pump and a molten alloy bath from which molten lead alloy was distributed to moulds. 2 square steel posts (approximately 0.03 metres) measuring approximately 0.15 metres in height supported the molten alloy bath by means of a horizontal bar;
(d) a drip tray, measuring approximately 0.25 metres in length and 0.15 metres in width, was accessible through a gap formed between each mould when the conveyor belt and moulds were stationary;
(e) a nip point was formed between each mould and the steel posts, horizontal bar and molten alloy bath when the moulds indexed and moved from one position to their next; and
(f) there was no impediment by means of guarding or otherwise to prevent access to the nip points formed.
10. Solid lead alloy ingots were placed into the lead pot that was fitted with a heating element, heated to a temperature of between 430 and 450 degrees Celsius, and converted to their molten state. Thereafter, the molten lead alloy was pumped from the lead pot by a feed pump and deposited into the bath. One of a number of moulds attached to the steel conveyor belt was indexed to a position beneath the bath where it came to rest. The said machine moves slowly. It moves by indexing forward for a set period of time and stopping for a set period of time, rather than moving continuously. During the rest period between indexing, a predetermined quantity of molten lead alloy was delivered to the mould from the bath before the mould was indexed away from its rest position beneath the bath. Another mould was then indexed to a position beneath the bath where the process was repeated. By the time the conveyor completed a full revolution the molten lead alloy was cooled and the finished solid product ejected from the mould into trays (not being the drip tray) beneath the said machine. A drip tray was positioned directly beneath the bath and was designed to collect residual lead alloy that did not find its way into the mould.
11. The operator of the said machine was required to ensure the level of the lead pot was maintained, remove impurities (dross) from the lead bath and periodically remove the drip tray from its position in order to discard residual lead alloy. The drip tray had attached to it a handle that was used by the operator to remove the drip tray from its position.
12. On the date of the incident the defendant charged Andrianopoulos with the responsibility of operating the said machine. In the course of operating the machine Andrianopoulos noticed the drip tray was full of residual lead alloy. In an effort to remove the drip tray and discard the residual lead alloy he reached into the said machine between 2 moulds that were then stationery and took hold of the handle connected to the drip tray. His attempts to remove the drip tray were hampered as the build up of residual lead alloy was such that it caused the drip tray to be "stuck" to the body of the said machine upon which it rested. While Andrianopoulos was in the process of moving the drip tray the moulds of the said machine indexed and moved from their stationery position as Andrianopoulos failed to stop the operation of the machine prior to removing the drip tray. One of those moving moulds, filled with molten lead alloy, caught the glove of Andrianopoulos's right hand and dragged it further into the said machine. As a result Andrianopoulos's hand was caught between the moving mould and the body of the said machine and caused to come into contact with both the molten lead alloy bath and the hot mould (or die) resulting in the stated injuries.
13. The said machine incorporated a 'START button', a 'STOP button' and an 'EMERGENCY STOP button' which were located at the side of the machine. Andrianopoulos reached over to press the 'STOP button' to stop the operation of the machine after his right hand was caught between the moving mould and the body of the machine.
14. There was no guard to prevent Andrianopoulos placing his hand into the machine and, at the time he did so, Andrianopoulos had not isolated the machine from its power source. This was contrary to the standard operating practice for removing the drip tray, as described in paragraph 16 below.
15. In the course of operating the said machine the drip tray was required to be removed from its position, in order to discard residual lead alloy, approximately 3 times per day when the machine was operating efficiently and approximately 6 to 7 times per day when the machine was not operating so efficiently.
16. Andrianopoulos had operated the said machine for a period of approximately 6 months leading up to the date of the incident and Andrianopoulos had operated the said machine during that period without incident. Andrianopoulos had worked for the defendant at the Padstow factory premises for a period of over two years prior to the incident. In accordance with the procedures adopted by the defendant, Andrianopoulos received "on the job training" in relation to the operation of the said machine. In this regard the operator of the said machine before him provided Andrianopoulos with verbal instruction concerning the standard operating practice in relation to the said machine, including removing the drip tray in order to discard residual lead alloy. The standard operating practice required stopping the operation of the said machine prior to placing one's hand between the stationery moulds and into the machine to remove the drip tray. On the date of the incident Andrianopoulos acted contrary to that instruction and, in his words, "neglected to stop the machine". He had adopted such a practice "on many other occasions" as he considered that in the ordinary course of events there was sufficient time in which to remove the drip tray before the moulds indexed and moved from their stationary positions. On the date of the incident, however, his attempts to remove the drip tray were hampered as the build up of residual lead alloy was such that it caused the drip tray to be "stuck" to the body of the said machine upon which it rested.
17. Prior to the occurrence of the incident the defendant retained Be Safe Resources Pty Limited, an Occupational Health and Safety consultant, to conduct audits of the Padstow premises. Audits of the Padstow premises conducted in late March and early April 1996 identified the need to investigate the suitability of a light beam guard for the top of the said machine. Audits conducted in September 1997 and on 03 & 04 April 2000 identified the need to guard the moving moulds of the said machine. The defendant was furnished with written reports compiled by Be Safe Resources Pty Limited subsequent to the conduct of the audits.
18. The 1996 and 1997 written reports were furnished to the defendant prior to the date of the incident involving Andrianopoulos. The absence of fixed guarding on the sides of the Machine and the suitability (after investigation) of a light beam guard for the top of the Machine were identified in the 1996 report. The report suggested as follows: " Provide fixed guarding to the sides of the machine and investigate the suitability of a light beam guard for the top of the machine" . The 1997 report identified the absence of a top guard on the Machine. The 1997 report stated as follows: " This machine was observed operating with all guards in place. Platform was clean and tidy. Despite the above, the moulder machine still requires a top guard to prevent access to the moving moulds ." As at that date of the incident the suggestions made in the reports had not been implemented on the Machine.
19. A written summary sheet compiled by Be Safe Resources Pty Limited subsequent to the audit conducted in 2000 identified various risks at the Padstow premises. The written summary sheet recommended a guarding assessment of the said machine be conducted. Whilst the 2000 audit was conducted prior to the occurrence of the incident the defendant was not furnished with the written summary sheet or the written report until subsequent to the date of the incident.
20. Subsequent to the incident the defendant caused an investigation to be conducted culminating in a written report. In accordance with recommendations of that report fixed guards were fitted to parts of the said machine not requiring regular access and an electrically interlocked guard was fitted to the machine in the vicinity of the moulds where regular access was required. The electrically interlocked guard operates such that in the event the said machine is in operation and the guard raised the machine immediately ceased operation and, as a consequence, access cannot be gained to the moulds whilst they are in motion (a series of coloured photographs depicting guards subsequently fitted to the said machine are attached hereto - attachment " C ").