As a result of the abovementioned failures, Paddy Aidan McGuire was placed at risk of injury and was fatally injured.
4 Each defendant has pleaded guilty to the charges.
5 Mr R.C. Pontello of counsel appeared for the prosecution and Mr P. Rowe of counsel appeared for the defendants. The prosecution relied upon an Agreed Statement of Facts, photographs of "Wirra", Bullarah-Bronte Road, Moree NSW 2400 and module builder taken by Inspector John Forster on 16 and 30 May 2006, depicting the view of incident scene; Mellor Enterprises Pty Ltd Induction Manual "Cotton Harvesting Operations" (Version 20 February 2006); Mellor Enterprises Pty Ltd Safe Operating Procedures Manual (Version 20 February 2006); Gunnedah Industries Suggested Safe Module Builder Operation Procedures; WorkCover Prohibition Notice No. 7-108357 issued by Inspector John Forster upon Mellor Enterprises Pty Ltd on 17 May 2006; Mellor Enterprises Pty Ltd Induction Checklist for Paddy McGuire dated 3 March 2006 and InterSafe Supplementary Report on "Risk Assessment of Hydraulic Controls" prepared by Roger Kahler dated 22 May 2006 and two Victim Impact Statements.
6 Mr Rowe tendered the affidavit of Jon Lloyd Mellor sworn 21 January 2009 and the affidavit of Gregory Shane Mellor also sworn 21 January 2009. A number of relevant documents were attached to the affidavit of Gregory Mellor relating to financial records of the company and proposed safety changes in the operation of the business.
7 The Agreed Statement of Facts relevantly reads:
4. At all material times, Mellor Enterprises was an employer.
5. At all material times, Mellor Enterprises' undertaking was the provision of picking and associated harvesting services to the cotton industry, including cotton module building.
6. At all material times, Mellor Enterprises was contracted to perform work at a property known as "Wirra", Bullarah-Bronte Road, Moree in the State of New South Wales ("the property").
The Manager - Jon Mellor
7. Jon Mellor was employed in the position of Manager and was Mellor Enterprises' senior representative at the property.
8. Jon Mellor's responsibilities, as Manager for the corporation, included:
(a) overall control of the work site - as it related to collection of cotton and associated tasks including, but not limited to, cotton module building;
(b) management of the corporation's staff at the site;
(c) advising employees of safe operating procedures; and
(d) providing training to new employees in relation to the safety, maintenance and operating procedures of plant, including cotton module builders.
The workforce
9. At all material times, Mellor Enterprises employed Paddy Aidan McGuire (date of birth: 9 January 1985).
10. Mr McGuire was engaged as a Module Builder Operator.
11. Mr McGuire commenced employment with Mellor Enterprises on or about 19 February 2006 and had been working for Mellor Enterprises for approximately 3 months at the time of the incident.
12. At all material times, Mellor Enterprises also employed (among others):
(a) Alexander Loram, as a Module Builder Operator ("Mr Loram");
(b) James Bright, as a Module Builder Operator and subsequently as Bole Buggy Driver ("Mr Bright");
(c) Luke Mellor, as a Leading Hand, Picker and Bole Buggy Driver;
(d) Daniel Wade Strickfuss, as Cotton Picker Operator ("Mr Strickfuss");
(e) Jon Mellor, as Manager.
The Cotton Module Builder
13. At all material times, Mellor Enterprises owned and operated a cotton module builder identified as Unit No.1 ("the Module Builder"), which had been manufactured by Gunnedah Industries. The module builder was purchased new from Gunnedah Industries during the 1996 season. The purpose of a cotton module builder is to compact harvested cotton into 'modules', which can then be covered with a tarpaulin. These modules are then ready for transporting elsewhere for processing (e.g. a processing plant known as a 'cotton gin'). Annexed hereto and marked ' A ' is a photograph showing the Cotton Module Builder.
14. The module builder supplied by Gunnedah Industries to Mellor Enterprises was supplied without a specific safety manual for the machine. Mellor Enterprises did not subsequently seek such a document from the manufacturer, when advised by the manufacturer in or about March 2005.
15. The Module Builder is operated by hydraulic power. Among the operating components of the Module Builder are:
i. the 'tramper' - a large metal object which, when activated, descends and acts to compact the cotton inside the Module Builder. The tramper can be operated in either automatic or manual mode. Annexed hereto and marked ' B ' is a photograph showing the 'tramper' (in a raised position).
ii. the 'monkey' - a metal bridge across the top of the module builder, which has the capacity to travel the length of the module builder. Annexed hereto and marked ' C ' is a photograph showing the 'monkey'.
16. The manual operation of the monkey and tramper were carried out from two control levers situated at a control platform at one end of the Module Builder. At the time of the incident, the levers protruded above the rim of the Module Builder. Annexed hereto and marked ' D ' is a photograph showing the state of the control levers at the time of the Inspector's visit to the site on 17 May 2006 (the day after the incident).
17. The left-hand lever operated the travel of the monkey. The lever is pushed to move the monkey away from the control platform and pulled to move the monkey towards the control platform.
18. The right-hand lever operated the tramper. The lever is pushed to lower the tramper and pulled to raise the tramper.
19. The operating pressure of the hydraulics to operate the monkey was approximately 300 psi (pounds per square inch). The operating pressure of the hydraulics to operate the tramper was approximately 2000 psi.
20. There is a pressure-regulating valve in the hydraulic circuit to reduce the pressure for the monkey. On the manual valve body there is also another diverter valve that takes the pressure off the monkey travel to the hydraulic levers and valves that operate the rear door and wheel 'raise and lower' hydraulic cylinders.
21. There is also an automatic control system that can operate the monkey and tramper. This is computer controlled and there is a diverter valve that is situated on the floor of the control platform to take the hydraulic supply, either to the automatic (computer) valve body or the manual valve body. This lever - separate to those that manually control the monkey and the tramper - is in auto mode when it is up, and manual mode when it is down.
22. A Coronial Inquest was held at Moree Local Court on 14 November 2007 and 6 December 2007. The evidence at the Coronial Inquest indicated that the Cotton Module Builder was in manual mode at the time of the incident.
The Incident
23. At about 8:00pm on 15 May 2006, in the course of his employment with Mellor Enterprises at the site, Mr McGuire was operating the Module Builder.
24. Mr McGuire had finished building a module of cotton and was in the process of placing a tarpaulin over the top of the module prior to removing the Module Builder from around the module.
25. Mr McGuire ran the tarpaulin out along the top of the module by tying the end of the tarpaulin to the device on the Module builder known as 'the monkey' and moving the monkey to the end of the Module Builder.
26. After running out the tarpaulin, Mr McGuire walked along the top of the module to the other end of the Module Builder, in order to undo it from the monkey and push the end of the tarpaulin down into the corner of the Builder.
27. It is apparent that, while Mr McGuire attempted to pull the tarpaulin down over that end of the module, either the tarpaulin itself or a rope attached to the tarpaulin caught on the levers (at the other end of the Module Builder) which controlled the tramper, causing them to move and, consequently, to activate the tramper.
28. Once activated, the tramper rapidly descended before coming into contact with Mr McGuire.
29. At the time of the incident, Mr Loram was on the ground near the rear of the Module Builder. Mr Loram was apparently in the process of preparing to remove the completed cotton module from the Module Builder and opening the rear door to allow Mr McGuire more room to push the tarpaulin down over the end of the cotton module.
30. While the tarpaulin was apparently being fed through to Mr Loram, he heard a scream. When Mr Loram heard the scream, he went up to the control platform. He lifted the end of the tarpaulin off the control levers and then used the controls to raise the tramper, which had descended on Mr McGuire.
31. Prior to the incident, another employee - Mr Bright - was driving another item of plant, known as a 'Bole Buggy' in the field and had observed Mr McGuire pulling the tarpaulin over his module. At the time of the incident, Mr Bright was approximately 200 metres away from Mr McGuire's Module Builder when Mr Loram called on the two-way radio to inform him of the incident.
32. Mr Bright approached the Builder and saw Mr McGuire on his knees in a crouched position with his head turned and his arms towards his back. Mr Bright observed that the tarpaulin was near the levers that manually operate the monkey and the tramper. He climbed on top of the module and went to render assistance to Mr McGuire.
33. Luke Mellor, Daniel Strickfuss and Jon Mellor also attended the scene of the incident. Mr McGuire died at the scene. The cause of death was "brain stem injury from extensive basal skull fractures".
The procedure for placing a tarpaulin on a cotton module
34. The company's usual procedure for placing a tarpaulin on a cotton module was to put the tarpaulin on top of the module and unravel it by hand while it was still in the module builder.
35. It was done this way to allow for the spreading of the tarpaulin while there was still fall protection available. If the tarpaulin were spread after the builder was removed, it would require someone climbing back on top of the module without having the sides of the builder available to prevent a fall.
36. During the course of Mr McGuire's employment with Mellor Enterprises, Mr McGuire and the other module builder operators had started to use another method of placing the tarpaulin over the module. The method was to use the monkey to pull the tarpaulin along over the top of the module by tying it to the monkey and running the monkey away from the control platform to the rear end of the builder.
37. As the monkey took the tarpaulin along, it was rolled out from the control platform and had to be undone at the end of the builder and manually pulled further down to go over the end of the module.
38. There was also another known method, used by other contractors and workers in the industry, to place a tarpaulin over a cotton module. This other procedure was to tie the tarpaulin onto the rear door of the builder and let it be pulled over the cotton module while the builder is being removed from the completed module.
Training/supervision
39. The method of manually spreading the tarpaulin over the module was developed by Mellor Enterprises a number of years ago. This procedure was demonstrated to Mr McGuire prior to him taking on the operation of the Module Builder. It appears to have also been part of the general work practices of other employees who assisted Mr McGuire when he began performing this work.
40. Employees were taken through Mellor Enterprises' safe operation procedures manual and induction manual.
41. Mellor Enterprises had two manuals to train their employees. One was an induction manual for "Cotton Harvest Operations" and a "Safe Operations Procedures Manual".
42. Mr McGuire apparently did not see these manuals until approximately two weeks after his employment with Mellor Enterprises commenced. Mr McGuire did not sign the employment induction checklist until 3 March 2006.
43. Mellor Enterprises did not undertake a risk assessment or warn employees of the hazards associated with the use of the monkey to pull the tarpaulin along the top of the module.
44. Following the incident, Inspector Forster issued the following Notices:
· Prohibition Notice (No. 7-108357) to immediately cease use of the Module Builder;
· Improvement Notice (No. 7-108367) in relation to risks associated with the operating controls of the Module Builder, including their inability to be locked 'off'; and
· Improvement Notice (No. 7-108363) in relation to the non-identification of the control levers on the Module Builder.
45. Following the incident, Mellor Enterprises engaged the services of Mr Roger Kahler of the InterSafe Group Pty Ltd (referred to hereafter as the 'InterSafe Report'] to:
(a) investigate and report on the cause of the incident giving rise to the death of Mr McGuire;
(b) provide a report as to the modifications to cotton module builders that would minimise the likelihood of personal entrapment in cotton module builders and advise on the system of work.
46. The InterSafe Report explored a number of possible scenarios including the possibility of problems with the hydraulics of the Module Builder. The investigation found that there was no apparent fault with the hydraulics of the Module Builder and that the scenario that the tarpaulin or the ropes attached to it had 'tripped' the control levers was the most likely scenario. WorkCover engineers reviewed the Intersafe Report and found its investigation and conclusions were plausible. Annexed hereto and marked ' E ' is a copy of the Intersafe Report.
(47. Intentionally blank)
48. Mellor Enterprises also provided a copy of the InterSafe Report to the Cotton Australia and Australian Cotton Harvesters Association for the purpose of informing the industry of potential dangers and how Module Builders may be modified, as well as advising of the system of work subsequently adopted by Mellor Enterprises in working with Module Builders.
49. Following the incident, Mellor Enterprises carried out a risk assessment on the method of placing the tarpaulin over the cotton module. Mellor Enterprises determined to fit a hinged barrier along the front of the operator's position that folds down and diverts all the hydraulic oil flow from the pump through a diverter valve to the storage tank when a person enters the Module Builder. This prevents any hydraulic power being able to be activated through the control levers until the hinged barrier is reset when the operator returns to the control platform.
Co-operation
50. Mellor Enterprises and Jon Mellor have co-operated with WorkCover throughout its investigations into this matter.
No Prior Convictions
51. Mellor Enterprises and Jon Mellor do not have any prior convictions under NSW occupational health and safety legislation.
Early Plea of guilty
52. Mellor Enterprises and Jon Mellor each entered a plea of guilty at an early stage of proceedings - namely, the second directions hearing on 8 August 2008.