8 The parties in the present proceedings reached agreement on a statement of facts that was tendered to the Court. Attached to the statement were: An Incident Investigation Report prepared by Mr R D Pearson of Testsafe Australia; an Injured Person's Statement by Carmel O'Neill; a Supervisor's Statement by Brian Shortall, an employee of Chubb; a response by Mr Pearson to a report by Dr George Crank for Supercut; and, Dr Crank's report on the subject incident. The statement contained the following facts:
14 On 18 February 2000, Zaccula [Frank Zaccula, supervisor for T Helsby & Sons] attended the premises and met with [Shannon] White [concrete cutting machine operator employed by the defendant], who was to operate the concrete cutting machine. At about 9:00am Zaccula left the premises before the concrete cutting operations commenced and did not return to the premises until about 3 pm.
15 White was the operator of the concrete cutting machine. Moore and 2 other persons, who were working on the refurbishment, were in and around the proposed canteen area, while White undertook the concrete cutting operations.
16 White commenced the concrete cutting operations at about 9.30am on 18 February 2000.
17 After approximately 15 minutes of cutting, White was asked to stop the concrete cutting machine by the plumber's assistant so that excess water from the concrete floor could be vacuumed up. The concrete cutting machine blade was cooled by a mechanism involving the use of water. White switched off the machine.
18 After the water was vacuumed up, White re-commenced the concrete cutting operation. White cut "another metre" of the concrete floor and had to stop the machine. The concrete cutting operations commenced again and stopped again at 10.15am for morning tea.
19 The concrete cutting operations re-commenced at 10.30am. At 11.00am the belts on the concrete cutting machine broke. White did not have a spare set and arranged to have a new set of belts delivered. The belts were delivered approximately 40 minutes later.
20 When the belts arrived, White had some difficulty fitting them to the machine. White called for assistance. White did not recommence cutting operations until about 12.30pm. At about 1.30pm White stopped the concrete cutting operations following instructions from the builder, Skyline.
21 At the time of the concrete cutting operations, employees of Chubb Security and other persons ( Chubb Security workers ) were working in an adjacent office area which included the accounts payable area of Chubb Security.
Concrete cutting machine
22 An internal combustion engine powered the concrete cutting machine. The engine could be either fuelled by liquefied petroleum gas ( LPG ) or petrol. The machine had been converted such as to permit the use of LPG or petrol by MED for Supercut in about 1999. The conversion was carried out such as to permit the machine to work in an indoor environment. At all material times on 18 February 2000 the fuel was LPG.
23 The exhaust gases of the machine included carbon monoxide.
24 The concrete cutting machine was not fitted with a catalytic converter or other carbon monoxide limiting device.
Events of 18 February 2000
25 There was a suspended ceiling within both the proposed canteen area and the adjacent office area, including the accounts payable area of Chubb Security. The suspended ceiling was 2.65 metres high. Above the suspended ceiling was a roof space. Within the roof space was air conditioning ducting. Within the proposed canteen area some 22 ceiling tiles had been removed from the suspended ceiling. The roof space was common as between the proposed canteen area and the adjacent office area. The concrete cutting machine at all material times was operated within the proposed canteen area but was also operated under the air conditioning ducting system and the exposed roof cavity.
26 Within the proposed canteen area there was a window with 2 openings and a door on the same side of the room. White opened the window and door prior to any cutting. Pearson in his first report expresses an opinion that "there may have been little air movement from wind induced drafts [sic]". In his second report (at page 9) Pearson makes an assumption that it may have been possible for natural ventilation causing air movement equal to the total volume of the proposed canteen area every 5 minutes. This is given in answer to criticism of his first report as made by Dr Crank and describes the extent of natural ventilation caused by external winds as "one major unknown variable".
27 Sometime between 10.50am and 12 noon a gyprock wall was constructed in the proposed canteen area by Skyline on the instructions of Peter Claydon. White understood this wall to have been constructed following complaints by Chubb about the noise. The area in which the concrete cutting machine was operating after that time was reduced. At no time prior to 1.30pm was he made aware of any complaint as to fumes.
28 The Chubb Security workers in statements to the inspector identify various times at which they experienced symptoms such as headaches, dizziness, blurred vision, shortness of breath ( symptoms ) ranging from 8.00am (Thompson) and 8.30am (Vranjkovic), 10am (O'Neill) to as late as 12noon (Cuna). Chubb Security workers were working in the accounts payable area and also in the payroll area which was located next to the accounts payable area and separated from the accounts payable area by a floor to ceiling glass wall. Vranjkovic gave evidence that Chubb Security workers working in the payroll area were affected by symptoms about half an hour after persons in the accounts payable area.
29 Some Chubb Security workers such as Vranjkovic complained to their supervisors and managers of a strong odour entering the accounts payable area. Brian Shortall Chubb Security Facilities Manager claims to have been told of fumes at approximately 11.38am by his "PA" Jacki Lawson and further claims to have inspected the area and advised Peter Claydon of Skyline Interiors "to sheet up the area to stop any fumes leaching into the department". Mr Claydon does not make any reference in his statement to any such conversation with Mr Shortall. Mr Clayton states that a complaint was made as to noise at "about 1.00-1.10pm and the major concern of inhalation of toxic substance at approximately 2.15pm".
30 Seventeen (17) Chubb Security workers were hospitalised due to carbon monoxide poisoning. In total, forty-seven (47) persons were affected to varying degrees as a result of exposure to carbon monoxide.
31 On 18 February 2000, the NSW Fire Brigade attended the site and undertook tests and recorded carbon monoxide readings of between 0 to 31 parts per million in the time period 14.51 to 15.32 (2.51pm to 3.32pm). The highest reading, 31 parts per million (0.031%) of carbon monoxide was taken at 14.56 (2.56pm).
32 On 18 February 2000 Inspector Henson issued Prohibition Notice 112910 to Skyline Interiors directing Skyline Interiors to ensure the health and welfare of persons by providing and maintaining a safety-compliant ventilation/extraction system or by other means.
33 On 18 February 2000 Inspector Henson issued Prohibition Notice 112911 to Chubb Security Holdings Limited, directing Chubb Security to ensure the health, safety and welfare by providing and maintaining a safety compliant system of extraction/ ventilation system or by other means.
Failure to conduct an adequate risk assessment
34 The Defendant did not undertake an adequate risk assessment process in relation to the risks arising from the work of concrete cutting to be performed at the premises.
35 The Defendant did not carry out the concrete cutting work in a manner as would satisfy the provisions of the Code of Practice "Cutting and Drilling Concrete and other Masonry Products" ( Code ). … Specifically, the Defendant failed to conduct an adequate process of hazard identification and risk assessment at the planning and preparation stage as set out in section 3.3 of the Code.
36 Exposure to carbon monoxide from internal combustion engines is known to constitute a risk to the health and safety of persons. The Defendant failed to take appropriate steps to prevent the risk of exposure to its employees and to non-employees.
Failure to provide adequate training and instruction in risk assessment procedures
37 White was aware that the work to be performed at the premises was an indoor job which meant that he had to use the LPG saw. White was aware that he had to use the LPG saw as a petrol or diesel saw could not be used because of the fumes.
38 White could not remember receiving any training on the Code.
39 White did not receive adequate training and was not aware of the Code and had not been trained and instructed in the Code.
40 The Defendant did not ensure that an inspection of the premises was undertaken before the concrete cutting operations commenced.
41 The Defendant's documented training and induction on risk assessment Training Session Plan allocated 10 minutes to the Code and concrete cutting and drilling. Mr Armstrong explained his understanding of the induction training given to employees including training in the Code … and White was able to describe the training given to him …
42 White was not adequately trained or instructed to inform or advise persons in the vicinity of the concrete cutting operations to leave the area or to warn them of the possibility of fumes from the concrete cutting machine prior to commencing the concrete cutting work.
43 White was not adequately trained or instructed to ensure adequate ventilation during the concrete cutting operations.
Failure to ensure employees and other persons on the premises
were adequately warned of the risk of exposure
44 White warned the plumber of the risk of fumes and told him "to leave the doors and windows open", White did not warn any other person at the premises on 18 February 2000.
45 Neither White nor any other person from the Defendant warned the Chubb Security workers about the possibility of exposure to carbon monoxide from the concrete cutting machine.
46 The Defendant did not provide any information directly to Chubb Security workers about the concrete cutting operations and the risk of harmful emissions from the concrete cutting machine, specifically carbon monoxide.
Failure to provide adequate ventilation
47 There was a window with 2 medium sized openings and a door in the proposed canteen area where the concrete cutting operations were being undertaken.
48 There was no forced air ventilation or extraction system utilised for ventilation for the concrete cutting operations at the premises as installed by the Defendant or any other person on 18 February 2000.
49 The Defendant failed to ensure adequate ventilation as set out in section 4.5 of the Code whilst using a concrete cutting machine powered by an internal combustion engine.
Failure to ensure employees and other persons were adequately protected from inhaling or being otherwise exposed to carbon monoxide at the premises
50 Until about 1.30pm no attempt was made by the Defendant or any other person to evacuate persons from the adjacent office area and premises prior to and during the concrete cutting operations.