3 The statement of agreed facts is in the following terms:
1. At all material times the Informant was the assistant director of performance improvement at the Department of Mineral Resources and person who has received the written consent of the Director General of the Department of Mineral Resources to institute the within proceedings.
2. At all material times the defendant, Cumnock No. 1 Colliery Pty Limited [ACN 051 932 122] ("the defendant") was a company duly incorporated with its registered office at Level 5, National Australia Bank House, 255 George Street, Sydney in the state of New South Wales.
3. At all material times the defendant conducted its business of coalmining from an underground coal mine known as the Cumnock No. 1 Colliery at Pikes Gully Road, off the New England Highway, Ravensworth in the state of New South Wales ("the mine").
4. At all material times the defendant was an employer and employed Mr Eugene Borkowski as a fitter/welder to work for it at the mine.
5. Mr Borkowski had been employed as a fitter/welder at the mine for approximately 25 years prior to the incident.
6. Situated at the defendant's premises was continuous miner known as the CM3 ("CM3"). (refer attached photographs 1.34 and 1.35).
7. CM3 was supplied to Cumnock No. Colliery in September 1995.
8. CM3 was manufactured by Joy Manufacturing Pty Ltd ("Joy") and was used for the development of roads prior to the extraction of coal.
9. CM3 was originally supplied to the former owners of the mine, Elcom Collieries Pty Ltd as a Joy 12 HM7 miner.
10. In September 1995 the 12HM7 was converted into a 12 CM29 continuous miner by Joy and returned to Cumnock. CM3 was supplied to the defendant with hydraulic roof bolting machines manufactured by Hydramatic Engineering Pty Ltd ("Hydramatic") ("the drill rig").
11. The CM3 was originally supplied to the defendant with a hydraulic roof-bolting machine ("the drill rig") attached to it. (refer attached photograph 1.33)
12. The roof bolting machines are designed to drill holes into the roof of the mine in order to install roof bolts to secure the roof of the mine and prevent collapse.
13. On each side of the continuous miner there are valve banks with three handles which operate the functions of the drill rigs. (refer attached photographs 1.26,1.27 and 4.7)
14. The three handles on the value bank control different aspects of movement of the drill rig including the movement of the drill rig towards the face of the mine, away from the face of the mine, towards the rib of the mine, towards the machine itself and to raise and lower the drill pot mounted to the drill rig. The drill pot is the portion of the drill rig which holds the drill steels etc and provides upward and downward movement and rotation
15. At 7.00am on 23 August 1999 Mr Borkowski attended work at the mine and was assigned to work as the fitter in Main Gate 15 development panel
16. Main Gate 15 panel consisted of two adjacent headings being driven. The heading on the left hand side when looking inside is referred to as 1 heading and the heading on the right hand side is referred to as 2 heading.
17. Mr Borkowski was given two work orders (numbered 3302 and 33152) by his supervisor, Les Ross, which set out maintenance tasks to be performed in the panel. The tasks set out in these work orders included "grease all points" and "grease drill pots" and included a direction that the machine be isolated at the main isolator and personal danger tags attached.
18. The work order required that all work, including isolation and tagging, should be carried out in accordance with the Cumnock safety procedures.
19. Mr Borkowski was not the normal fitter assigned to Main Gate 15 but had worked there on several prior occasions including three other shifts in the month of August 1999.
20. The panel was set up with a continuous miner and one shuttle car in each heading. The continuous miner in 1 heading was known as CM1 and the continuous miner in 2 heading was known as CM3
21. At approximately 12.00pm Andrew Buchan, surveyor, attended the face of 2 heading to carry out some survey work with a laser. A laser is a device mounted on the roof of the heading and projects a beam along the heading into the face. Its purpose is to ensure that the headings are driven in a straight line. CM3 was in close proximity to the face and the shuttle car was parked just outbye of it. The driver side drill rig mounted on CM3 was fully tilted back towards the driver's cabin and outwards towards the rib.
22. As Andrew Buchan was arriving to set up, the mining crew left the face and went to crib. At this stage there were no other persons present in the vicinity of CM3.
23. In order to carry out his work it was necessary for Andrew Buchan to climb onto the top of CM3. Prior to carrying out the survey work, he isolated the electrical power to the continuous miner by turning the circuit breaker handle in the driver's cabin to the off position and removing the handle. He kept the isolation handle on his person whilst he was on top of CM3. (refer attached photographs 2.1 and 4.12).
24. Whilst Andrew Buchan was carrying out survey work on top of CM3 Mr Borkowski walked to the face carrying two tins of oil and proceeded to pour the oil into a port located on the continuous minor.
25. A short time later Andrew Buchan completed his work on top of CM3 and placed the isolation handle on the driver's seat of CM3. He did not restore power to CM3.
26. Andrew Buchan then borrowed a shifting spanner from Mr Borkowski so that he could use it to move the laser. The laser was situated approximately 60m outbye of CM3.
27. Andrew Buchan then left the face area and moved the laser just outbye of the shuttle car at the rear of CM3.
28. Whilst he was aligning the laser Andrew Buchan noticed Mr Borkowski's silhouette. He appeared to be leaning over near the drill rig on the driver's side in towards the body of CM3.
29. Andrew Buchan did not notice whether Mr Borkowski appeared to be moving or not at this stage.
30. After completing setting up the laser Andrew Buchan walked up to CM3 so that he could return the shifting spanner to Mr Borkowski. He then noticed that Mr Borkowski was pinned between the hydraulic roof-bolting machine mounted on the driver's side of CM3 and the control valve bank lever for drill rig. Andrew Buchan checked Mr Borkowski for signs of life but could not detect any.
31. Andrew Buchan estimated that from the time he last saw Mr Borkowski alive to the time he discovered Mr Borkowski pinned at approximately 12.50pm, was ten to 15 minutes.
32. Mr Borkowski had greased the grease nipples of the drill rig on the driver's side. It is not known when CM3 was re-powered. Mr Borkowski inadvertently moved the control lever situated on the forward driver's side of CM3 with the result that the mast of the right-sided hydraulic roof-bolting machine (drill rig) moved so as to reduce the space between the main body of CM3 and the said mast. In addition, a part of the machine known as a drill pot rose in height, coming into contact with Mr Borkowski's body Mr Borkowski was, as a consequence of these two actions, pinned between the mast of the driver's side of the hydraulic roof bolting machine and the main body of CM3 with the driver's side drill pot pressuring his body.
33. At the time Mr Borkowski was found by Andrew Buchan there was power to the hydraulic bolting rigs, the machine was not isolated and tagged off and Mr Borkowski's body was blocking the drill rig control valve bank. This prevented Andrew Buchan from being able to move the hydraulic roof bolting machine and free Mr Borkowski.
34. There was a grease gun lying on the ground near where Mr Borkowski was pinned. Later inspections revealed the presence of fresh grease on some of the grease nipples on the drill rig.
35. Andrew Buchan then contacted Paul Langley by radio and informed him of the emergency. Paul Langley then informed persons who were in the crib room of the situation and Bruce Moore, Shane Gover, Lee Courtney and Paul Langley then attended the scene of the accident.
36. On arrival at the scene Bruce Moore observed Mr Borkowski was pinned between the mast of the drill rig and the control valve bank mounted on the continuous miner. His chest area was pressed against the cover plate over the control valve bank and his feet were suspended approximately 450mm from the foot. The drill pot was thrusting against Mr Borkowski's body at approximately hip height and the timber jack was at full extension.
37. Two continuous miner operators were able to free Mr Borkowski by lifting his lower body between them whilst Shane Gover reached in with his right hand and operated the control valve bank causing the drill rig to tilt away from Mr Borkowski.
38. After Mr Borkowski's body was freed, CPR was administered by the persons present in the panel and later by ambulance officers but they were unable to revive him. Mr Borkowski's body was then taken to the surface.
39. Each continuous miner had a separate crew assigned to it but the mine deputy, Mr Bruce Moore and the fitter, Mr Borkowski, had responsibility for both of the headings and the machinery in them.
40. The CM3 was examined at the request of the Department of Mineral resources following the incident. The report found that:
(a) The functions of the continuous miner and the machine mounted drill rigs were found to operate as designed and without fault.
41. There was an accident at the Tower Colliery on 8 July 1991 where a miner was trapped between the body of a Joy 12CM20 continuous miner and the machine mounted drill rig, following inadvertent operation of the control levers which caused the drill rig to move.
42. The Department of Mineral Resources had issued an industry wide safety alert to all mine managers, including the defendant with respect to machine mounted drill rig injuries in Departmental Circular C93/0298 dated 19 September 1995. (see attached appendix 5.1)
43. The Department of Mineral Resources had issued an industry wide safety alert to all mine managers, including the defendant, with respect to the risk of inadvertent operation of the controls of the same type of continuous miner as the CM3 due to the failure to isolate the machine, in Safety Alert SA 99/12 dated 14 July 1999. (see attached appendix 4.10)
44. The defendant failed to move the control valve bank for drill rigs to a position higher and further away from the drill rigs so that persons performing the work performed by Mr Borkowski on 23 August 1999 could not inadvertently operate the control valve bank handles with their belt or any other attachments to the belt.
45. Following the incident the defendant re-located the control valve bank for drill rigs to a position higher and further away from the drill rigs so that persons performing the work performed by Mr Borkowski on 23 August 1999 could not inadvertently operate the control valve bank handles with their belt or any other attachments to the belt. (refer attached photographs 1.36 and 1.37)
46. The Defendant cooperated with the Department of Mineral Resources.