Inspector Maddaford (WorkCover Authority of NSW) v F.I.P. Pty Limited t/as FIP Brakes International
[2011] NSWIRComm 115
At a glance
Source factsCourt
Industrial Relations Commission (NSW)
Decision date
2011-08-24
Before
Backman J, Mr P
Source
Original judgment source is linked above.
Judgment (14 paragraphs)
Judgment 1The corporate defendant, F.I.P. Pty Limited t/as FIP Brakes International (FIP Brakes) pleaded guilty to a single contravention of s 8(1) of the Occupational Health and Safety Act 2000 (the Act). Chris Katakouzinos (Mr Katakouzinos), in his capacity as a director of FIP Brakes and by virtue of the operation of s 26(1) of the Act, pleaded guilty to the same contravention of s 8(1) of the Act. 2FIP Brakes carried on business manufacturing brake shoes and disc pads (friction material) for railway vehicles. It employed about 60 people in the business. Mr Katakouzinos was a director and managing director of FIP Brakes, having been appointed to both positions in July 2005. He was based at the corporate defendant's principal place of business in Wetherill Park and had overall control of the day-to-day operations, as well as overall responsibility for ensuring the development and implementation of FIP Brakes' occupational health and safety programme. 3Somsack Chantaboury (Mr Chantaboury) was employed by FIP Brakes as a machine operator. Some time between 11pm and 11.30pm on 18 March 2008, Mr Chantaboury, working alone, began the task of cleaning a piece of machinery at the premises known as blender 5. According to the Agreed Facts, Mr Chantaboury opened both access doors of the blender, but did not otherwise isolate or lock out the blender from the power supply. At some stage, he entered the hopper. Shortly before 1am on 19 March 2008, Albert Mando, who was employed by FIP Brakes as a production charge-hand, heard a noise and noticed smoke emanating from the electric motor that drove blender 5's mixing arms. He called to Mr Chantaboury to turn off blender 5. Upon receiving no response, he went to the blender and found Mr Chantaboury trapped by the machine's mixing arms. The electric motor driving the mixing arms was running. Mr Mando activated the emergency stop switch on the main control panel. The mixing arms within blender 5 had fatally crushed Mr Chantaboury. The star-shaped chopping blades had inflicted additional injury. 4An investigation into the cause of the accident revealed that the electrical power supply to blender 5 had not been isolated. Although the access doors were open, the limit switches had not operated to deactivate the machine. The main isolator switch on the control panel had not been turned off, locked out and tagged. The two 415 vault powerpoint switches for blender 5's two electric motors had also not been turned off, locked out and tagged and the power cords for each of those motors had not been removed. 5Blender 5 was located on the lower of two mezzanine levels at the premises. It was used to mix ingredients in the course of making brake pads. It had a mixing hopper which was U-shaped, one metre deep, and sat underneath the level of the mezzanine floor. Two outward-opening access doors were fitted immediately above the mixing hopper. When the access doors were closed, they completely covered the mixing hopper. Within the mixing hopper were two sets of mixing arms fitted to a shaft which was connected to a high ratio reduction gearbox and electric motor. Two star-shaped chopping blades were fitted within the electric hopper. These blades were connected to, and driven by, a separate electric motor. Both electric motors were located underneath the mixing hopper. The main controls for the blender were located on a control panel positioned above a dusthood. These controls consisted of various switches, lights and monitoring gauges. At the bottom of the control panel was a rotary switch labelled "Main Isolator" which was fitted with a spring-loaded lockout mechanism. Immediately above that was a rotary switch with two positions designated as "Mix 1" and "Mix 2" respectively. Above that switch was a red push operator's switch labelled "Emergency Stop". In addition, two small control panels were located on the ground floor underneath blender 5. These panels contained switches to operate the pneumatics for the covers of the discharge points and to move the mixing arms within the hopper in forward or reverse directions to facilitate discharge of material from the hopper. Blender 5 was controlled by an Allen Bradley SLC 500 programmable logic controller (PLC). 6Blender 5 was one of a series of five blenders operated by the corporate defendant at the premises. The other four blenders were known respectively as blenders 1, 2, 3 and 4 which were adjacent to blender 5. A further blender known as R11 was located on the ground floor, under the mezzanine level. This blender had been commissioned three to six months previously with the intention that it would replace blender 5. It was intended that the use of blender 5 would be phased out. Blenders 1 to 4 were used for different production purposes, but had similar hoppers, paddle mixers and access door configurations. When blender R11 was commissioned, FIP Brakes had used blender 5 and blender R11 to mix material as part of manufacturing brake pads, although blender R11 had been used the majority of the time. 7Problems were experienced with product mixed in blender R11 which resulted in the blender failing to meet quality control standards. Russell Davis (Mr Davis), employed by FIP Brakes as its production manager, decided that the use of blender 5 should be resumed given the problems with blender R11. Blender 5 had last been used on 25 February 2008 and required repairs due to a broken drive coupling which connected the mixing arm assembly to the gearbox. Those repairs had taken place on 18 March 2008 when a replacement coupling had been installed. Roy Stivala (Mr Stivala), employed by FIP Brakes as a maintenance charge-hand, had requested that the mixing hopper of blender 5 be cleaned prior to testing of the new coupling. Mr Davis authorised overtime in order for that and other work to be conducted. Mr Katakouzinos was not aware at the time of the accident that blender 5 had been recommissioned following problems with blender R11. This was so, notwithstanding that Mr Davies reported directly to Mr Katakouzinos.