The Incident:
18. At the time of the accident on 24 July 2003, Mr Alley held Mr Pineda's training logbook. On 5 June 2003, Mr Alley assessed Mr Pineda's competency in the operation of forklift. As a result of the assessment Mr. Pineda was deemed " not yet competent ." After 5 June 2003, Mr Pineda continued to operate forklifts and stock pickers but he did not keep or maintain any training logbook. Mr Pineda's supervisors did not inquire or ensure that Mr Pineda kept a training logbook for forklifts or stock pickers in that time.
19. At the material time, on 24 July 2003, Mr Pineda was not a trainee stock picker under a training logbook system, although the defendant assumed (incorrectly) that Mr Pineda remained a trainee stock picker.
20. Since about November 2002 some employees of the warehouse played cricket during their lunch break on the driveway outside dock 15, batting from the southern Victoria Street end of the premises towards the northern end of the warehouse. The employees used tennis balls wrapped with insulation tape, a bat and a rubbish bin for stumps. The balls were often hit up onto the roof of the warehouse between docks 12 to 13 and docks 13 to 14. Mr Tuite or Mr Pineda would retrieve the balls from the roof about twice a week.
21. On 24 July 2003, Mr Pineda had driven the stock picker out through dock 12 along the outside eastern wall of the warehouse approximately 7 metres towards dock 13. Mr Pineda was operating the stock picker from within the cage, which consisted of an operator platform, and he used the controls to raise the platform. The concrete driveway sloped away from the wall at this point, and was not level. Mr Pindea was in the process of retrieving balls that were collected in the guttering of the warehouse roof.
22. At the time of the accident a strong gust of wind was blowing from the northerly direction over the 15m wide driveway between the warehouse and the next-door building on the left. Mr. Pineda had positioned the stock picker about 1.5m from the warehouse and about 4m from dock 13. The stock picker control end was facing south, towards Victoria Street, Wetherill Park. Mr Pineda then raised the platform of the stock picker up to reach the gutter of the warehouse. Mr Evangelista, who was operating a forklift at dock 15, observed this activity by Mr. Pineda.
23. As the platform reached a certain height, it appeared to become unstable and started swaying towards the driveway. Mr Evangelista saw the stock picker fall and crash down across the driveway with Mr. Pineda at the controls inside the stock picker. Mr Pineda suffered severe head injuries and died later that day as a result of his injuries in Westmead Hospital.
24. Mr Tuite stated he was aware that Mr Pineda, about twice weekly, retrieved tennis balls from the gutter of the warehouse using a stock picker. Mr Tuite stated that he had also retrieved balls from the roof on previous occasions using a stock picker, but only as far as dock 15 of the warehouse. He stated he had never taken the stock picker past dock 15 (i.e. to docks up to 14, including docks 12 and 13) because the ground was not level past dock 15. Mr Tuite stated that he had told Mr Pineda not to go past dock 15 with the stock picker, as the ground was not level past that point.
25. Mr Tuite stated that he did not know how many times Mr Pineda had previously retrieved tennis balls from the roof of the warehouse, but that Mr Pineda or Mr Tuite would collect the balls from the roof when they needed balls to play cricket. Mr Tuite stated when he (Tuite) went up to get the balls he would make sure that the ground was level by placing the stock picker about a metre out from the wall of the warehouse. He would also ensure that the front of the stock picker faced the Victoria Street side of the premises, and the gutter on the warehouse roof was on the right side of the cage. He would take the platform up to the maximum lift level (10.87 meters), so that the gutter was about level with head, neck and shoulder. If the balls were within reach he would grab them. If not, he would mark the location of the ball in the gutter, take the stock picker back down, move into position and then take the stock picker up again to retrieve the balls.
26. Mr Hunt stated that the supervisor, Mr Daley, and the Warehouse Manager, Jose Manio were aware of the cricket game being played during the lunch break and had warned employees to be careful of the company and client's properties, and not to hurt anybody or themselves.
27. On 24 July 2003 at about 2:15pm, Inspector Ken Kumar attended at the premises and observed as follows:
(a) The incident scene was located on the concrete driveway, leading from the Victoria Street, down towards the end of warehouse one. To the west of the driveway was warehouse one with 6 roller doors indicating dock numbers 12 to 17. The driveway was approximately 15 metres wide.
(b) The height of warehouse one (to the guttering) was approximately 8.67 metres.
(c) At the time of the inspection a strong wind was blowing over the driveway from the northerly direction.
(d) The area between dock 12 and 13 was cordoned off by Police tape, due to the wind. Some of the rubble was being blown outside the tape. Inside this area was the stock picker extended on its side, stretched across the driveway with the battery end of the equipment towards the warehouse, near dock 13.
(e) The second last doorway was closed. The last northern roller door was open. To the left of this roller door were two signs.
i. The top sign stated: - "Dock 12"
ii. The bottom sign stated: - "Inwards Goods"
(f) The cage of the stock picker was towards the boundary fence. Blood was observed from inside the cage down the driveway away from the building. A pile of rags with bloodstains was located inside the cage.
(g) The cage attached to the stock picker was 3.670m from the gutter of the driveway.
(h) The cage was 2.1m high, 2.06m deep.
(i) The operator's platform was 680mm wide.
(j) The cage was 1.30m deep over the pallet.
(k) Inside the cage yellow strapping was attached to the right hand side safety rail.
(l) The ring for the safety harness was attached to the overhead cage frame. To this ring was attached blue coloured harness, with a yellow lifeline.
(m) The outside safety guard for the cage was taped in open position with cellotape.
(n) The bottom steel frame of the operator's platform was broken.
(o) The control wheel was to the left of the platform, close to the concrete driveway.
(p) The stock picker was identified as "Crown" - electric order picker bar coded as SWADS SW02076 and with the following information on the load plate:
Actual Model SP3040-30TT276
Model SP3040-30
Serial Number 1A186087R
Max Lift Height 7010mm
Caps kg 800
"A" mm 7010
"B" mm 600
Alt Cap 1260
"A" mm 6096
"B" mm 600
Wt with battery max 3830kg
Truck weight with no battery 2968kg
Battery wt max 862kg
Max grade with 300mm max fork height 5%
CAUTION - Unit rated for use on hard level surfaces
This truck was released from the factory conforms to the mandatory requirements of AS 2359-1, 1995.
Crown Equipment Pty Ltd.
(q) The base of the stock picker (overall dimensions 1.8m long and 1.2m wide) was 2950mm from the wall of the warehouse and approximately 7 metres from dock 12.
(r) The concrete surface at this point was sloping away from the building towards the driveway.
(s) Two scratch marks were observed on the concrete floor adjacent to the base of the stock picker. One mark was towards the trail wheel of the stock picker was 2.210m from the warehouse wall and was 740mm long. The other scratch mark was 2.150m from the wall, towards the drive wheel of the stock picker, and was 760mm long.
(t) The drive wheel appeared to be in a straight position however there were circular scuffmarks on the wheel.
(u) The stock picker was extended up to the maximum height. The approximate length from the base of the stock picker to the top of the cage was 9.0m.
(v) On the cage, where the extension arms were attached, there were two micro switches identified. The safety switch for the first extension had a white wheel in a metallic casting. Timber was wedged between the wheel and the casting. Attached to the casting was some torn dirty but clear tape. This tape was level with the wheel however it did not cover the wheel mechanism.
28. The manufacturer's specifications provided that the maximum difference in ground gradient for the stock picker was 5% and that gradient was specified on the data plate attached to the machine (see par 27(p) above). The concrete driveway where the incident occurred sloped away from the wall.
29. According to TestSafe Australia Report No. 24765 dated 1 December 2003, the maximum grade allowed for the type of stockpicker involved in the accident, with load at 300mm fork height was 5%. This equates to 2.86 degrees of slope. The slope of the area where the accident occurred was found to be between 4 and 5.5 degrees. The TestSafe report noted that the data plate attached to the machine indicated " maximum grade with 300mm maximum fork height was 5% ." Consequently, at the time of the accident, the stock picker was being operated outside of its operational gradient limits.
30. The TestSafe Australia Report also noted that the maximum grade allowed for the machine was specified to apply with a fork height of 300mm, and that based on information provided to them by Inspector Kumar, the fork height at the time of the accident was in excess of 300mm.
31. A report prepared by Steve Barnes from Crown Equipment Pty Ltd dated 29 July 2003, but which was prepared to comply with a WorkCover Prohibition Notice served on the defendant on 25 July 2003, identified that the platform 600mm height limit switch of the stock picker was jammed closed with a piece of timber. This would have the effect of allowing the stock picker to have lateral travel once the platform was higher than 600mm. Mr Barnes also noted that there was a build up of tape on the switch body which indicated this was a previous practice. The Prosecutor noted that a piece of timber was jamming the limit switch at the time of his inspection on 24 July 2003 (see paragraph 27(v) above).
32. Mr Hunt said that no instruction had been given to the operators not to use the picker outside the warehouse and the operators had not been instructed about the dangers of operating a stock picker on an uneven surface.
33. At the time of the accident there did not appear to be a formal, documented operator-training program for stock pickers in place other than the training logbooks. Training logbooks did not indicate the relevant plant or equipment to which the training logbook related. However, verbal training was provided by certificated operators and included provision of information relating to machine capacity, use of harness, sounding horn when exiting aisles, maintenance of load and machine.
34. Mr Daley stated that while operator's manuals were available on the stock picker, employees were not specifically advised of their existence.
35. Prohibition Notice No 7-33491 and Improvement Notice No. 7-33538 were issued on the defendant in relation to the stock picker involved in the incident, and required the provision of information, instruction, training and supervision for the operation of industrial load shifting equipment.
36. Mr McLachlan stated that Mr Pineda was required to operate the defendant's plant and equipment of stock picker, reach truck and forklift in the course of his employment.
37. DECA conducted two training programs for the defendant's forklift operators including Mr Pineda. One program was conducted in February 2002 and the other in June 2003. DECA did not provide training for stock picker.
38. Mr McLachlan stated the defendant had been operating stock pickers in its business since 1992 - that is approximately twelve years. There were approximately 15 stock pickers operated by the defendant and, of these, four were at the premises.
39. Stock pickers operated by the defendant in its business operations were serviced and initially maintained by Crown Equipment Pty Limited and later, Task Australia Pty Limited.
40. Service Job Cards provided by Crown Equipment Pty Limited for the period 1999 to 2001 indicate 6 instances where the Service Technician noted tampering with a "24 inch switch" on a stock picker. The "24 inch switch" is a height limit switch on the stock picker. This was brought to the attention of Mr Daley, (Warehouse 1 Supervisor). When it was brought to his attention, Mr Daley investigated the circumstances and was advised by the operator that the intention was to operate the stock picker faster. Mr Daley stated he informed the operator the potential gravity of this illegal practice and informed that the action was subject to disciplinary action. All this was done verbally. The company had not put in place any system to ensure that the limit switches were not tampered with other than verbal warning by Mr Daley. The issue was not brought to the attention of higher management.
41. Mr McLachlan stated that the defendant was not aware that limit switches on some stock pickers were tampered with until after the incident of 24 July 2003.