8 There was tendered into evidence an agreed statement of facts with a large number of annexures, some of which I shall refer to. In addition, affidavit and oral evidence was given on behalf of each of the defendants by Benjamin Charles Taylor, Christopher Wilks and an affidavit of Domenico Antenucci tendered.
9 The statement of agreed facts was as follows:
"1. At all material times the Prosecutor was an Inspector duly appointed under Division 1 of Part 5 of the Occupational Health and Safety Act 2000 and empowered under Section 106 of the said Act to institute proceedings in the within matter.
2. At all material times BBC Hardware Ltd [ACN 000 003 378] was a corporation whose registered office is situated at Wesfarmers House, Level 11, 40 The Esplanade, Perth, in the State of Western Australia.
3. At all material times Bunnings Group Ltd [ACN 008 672 179] was a corporation whose registered office is situated at Wesfarmers House, Level 11, 40 The Esplanade, Perth, in the State of Western Australia.
4. At all material times BBC Hardware Limited ("BBC") and Bunnings Group Limited ("Bunnings") operated a Bunnings hardware shop located at The Homemakers Supa Centa, Shop 7148, Corner of Bryant Drive and Wyong Road, Tuggerah, in the State of New South Wales ("the premises").
5. At all material times BBC was an employer at the premises and employed Bruce Miller as a gate keeper. Mr Miller had been an employee of BBC, working at two locations that trade under the brand 'Bunnings', since October 2003.
6. At all material times Bunnings was an employer at the premises. Bunnings employed the management staff at the premises.
7. Wesfarmers Limited (ABN: 28 008 984 049) is the Ultimate Holding Company for both BBC and Bunnings. The entity that is now Bunnings Group Limited commenced as a public company in June 1948. The name BBC Hardware Limited commenced in June 1994, and the ASIC records disclose that the company was incorporated on 27 November 1906. Wesfarmers Limited acquired what is now Bunnings Group Limited in 1994, and then acquired BBC Hardware Limited during 2001.
8. The assets, roles, responsibilities and employees at the Tuggerah premises have been divided between BBC and Bunnings since 2001 and the two defendants operated the premises jointly at the time of the incident.
9. On 10 December 2005 Mr Miller commenced work at 8am. He was undertaking his usual employment as a gate keeper. This role involved checking that dockets match goods, checking vehicles for goods that customers have not paid for, filling LP Gas cylinders by decanting and other duties as required. Mr Miller had undertaken these duties at the premises 5 days per week, for approximately 10 months prior to the incident.
10. Several hours after starting work, Mr Miller, in the course of his normal duties, dealt with an LP Gas cylinder that had been given to him the previous day by a co worker, Michael Ferguson. Mr Ferguson had been instructed by Ms Pescud, the store's Claims Administrator, to remove the 9kg LP cylinder from the dock area of the store to the yard area because the 9kg LP gas cylinder was faulty and leaking. The procedure in place at the Tuggerah premises was for leaking or faulty gas bottles to be given to the gatekeeper. On this occasion and on two previous occasions Mr Miller dealt with the faulty bottles given to him by venting the gas from the bottle into the atmosphere without utilising a water spray to disperse the gas.
11. Mr Miller commenced to release the gas from the cylinder into the atmosphere, with the intention of emptying it's contents. Mr Miller undertook this task in an area in the vicinity of the gate keepers wooden shed. There was a concrete wall enclosing three sides of the area. The concrete walls were approximately 7 metres, 6 metres and 8 metres long. The lowest of the three concrete walls was approximately 2.4 metres high and the other two sides were approximately 6 to 8 metres high. There were numerous items in and about the area. The biggest item in the area was the gate keepers wooden shed that was approximately 4m x 3m. In addition there was a portable workbench, 15 LP Gas cylinders ranging in size from 9 kg to 144 kg, eight x 1.5 metre diameter rolls of black flexible tube, two shopping trolleys, and a 4 burner barbeque in and about the area.
12. At approximately 11.20am on 10 December 2005 the LP Gas Mr Miller was venting into the atmosphere ignited explosively and Mr Miller was caught in the middle of a fireball that was estimated by a customer to be at least 10 metres high and 6 metres across.
13. Mr Miller's injuries were the result of a flash fire caused by the ignition of a dense cloud of propane vapour in which he was standing. The origin of the propane was from the cylinder which was venting. The precise source of the ignition is unknown. Given that Mr Miller was venting gas from the 9kg LPG cylinder, there were a number of possible ignition sources in the area in which Mr Miller was venting the gas including vehicles, electrostatic discharge and electrical equipment.
14. The venting process undertaken by Mr Miller was unsafe for a number of reasons, including that the particular area in which it was undertaken was unsuitable as it had enclosed walls and a number of items in the close vicinity.
15. A customer who was standing in the yard area when the gas ignited heard "a percussion boom and caught an orange fireball out of the corner of his eye. It was a self-engulfing ball of orange with black edges". As the customer ran to the area, he met with Mr Miller running out from behind the shed and screaming.
16. The Fire Brigade, Ambulance and Police attended the incident scene. Mr Miller was taken from the scene by ambulance to Gosford Hospital, prepped and then air lifted to Concord Repatriation Hospital Burns Unit. There he was diagnosed with 38% burns to his body, consisting of face, ears, both lower arms and lower legs. He remained in hospital for just under 4 weeks.
17. As of March 2006 Mr Miller was still required to wear pressure dressings on both arms. Mr Miller was also taking anti-depressants to stop flashbacks and help him sleep. In additional, Mr Miller was still regularly attending appointments with his doctor, specialist and physiotherapist with respect to ongoing monitoring and treatment of his burns. Mr Miller was certified fit for suitable duties consisting of mainly sedentary office work for 2 hours per day, 3 days per week from 20 March 2006.
18. Mr Miller had vented gas from leaking or faulty gas cylinders on two other occasions prior to the incident in the ten month period he had worked at the Tuggerah store. There is no suggestion that there was any similar incident on these occasions however the defendant did not adequately promulgate or enforce its systems for identifying and/or reporting incidents, near misses or hazards involving leaking LP Gas cylinders at the Tuggerah store.
19. The Code of Practice for Storage and Handling of Dangerous Goods 2005 and Australian Standards AS 4332:2004 "The Storage and Handling of gases in Cylinders" and AS 1596:2002 "The storage and handling of LP Gas" provide guidance material for dealing with LP gas cylinders. Appendix D of AS 4332:2004 specifically deals with appropriate procedures for management of leaks. The process of venting leaking consumer LP Gas cylinders which Mr Miller followed at the time of the subject incident was not in accordance with the guidance material.
20. Appendix M of AS 1596:2002 The storage and handling of LP Gas, recommends that emergency procedures be in place in the event of an LP Gas leak.
21. Mr Miller's work for BBC and Bunnings at their Dural and Tuggerah stores had involved LP Gas for 18 months at the time of the incident. His duties included gas cylinder exchanges and the filling of gas bottles for Bunnings customers. Mr Miller filled approximately four to five gas small gas cylinders per day from Bunnings' large gas cylinders. Mr Miller handled LPG cylinders in the course of his duties ranging from 190kg transfer bottles, customer gas bottles, forklift gas bottles and heater bottles. Mr Miller was also responsible for dealing with any faulty or leaking gas bottles that Bunning's staff located at the premises.
22. Mr Miller received training in relation to decanting LP Gas when he was working for the same employer at Bunnings' Dural store in about May 2004.
23. After his transfer to the Tuggerah premises, Mr Miller was listed at that site as an "authorised person" for the decanting of LP Gas from bulk storage gas cylinders into consumer cylinders for that site. It is not clear who determined that Mr Miller should be on the "authorised persons" list for LP Gas decanting at the Tuggerah premises, or who added Mr Miller's name to the list of "authorised persons" at those premises.
24. Mr Miller was not provided with any training with respect to LP Gas handling whilst he was working at the Tuggerah premises and no-one assessed whether Mr Miller was competent to work safely with LP Gas whilst he was at those premises.
25. At the time of the incident Mr Miller was unaware of how to deal safely with a leaking LP Gas cylinder and he did not fully appreciate the risks associated with the venting of a consumer LP Gas cylinder into the atmosphere.
26. Steve Kolletti, Lifestyles co-manager/co-ordinator was Mr Miller's direct supervisor from his commencement at the premises until mid 2005 when a trade co-ordinator was appointed whose role included directly supervising the gate keeper. Mr Tony Jones was appointed as the trade co-ordinator at the premises. He was not working on 10 December 2005. Mr Kolletti and another Lifestyles co-manager/co-ordinator Mr Bolger were responsible for supervision of the staff at the premises on 10 December 2005.
27. Mr Kolletti was involved in the recruitment of Mr Miller to the role of gatekeeper and had instructed him in his duties when he commenced work at the premises. Mr Kolletti was not trained in and had no experience with LP Gas.
28. Mr Jones had undertaken a course in LP Gas decanting and exchange with Elgas in approximately 2002 during his employment at Bunnings Budgewoi store. Mr Jones had not provided any training to Mr Miller in relation to working with LP Gas nor had he assessed his competency for working with LP Gas.
29. There were no systems in place at the premises to check that Mr Miller and his supervisors had any knowledge or training in LP Gas safety.
30. During the course of the investigation BBC and Bunnings provided WorkCover with a training and procedures manual for decanting LP Gas from the LP Gas supplier, Kleenheat that is dated prior to the incident. There are no records of that information being provided to anyone at the premises prior to 10 December 2005.
31. BBC/Bunnings had OHS policies/procedures/systems that they called B.S.A.F.E. This was already in place at the Tuggerah premises prior to Mr Miller commencing at the premises in February 2005, but did not cover anything in relation to LP Gas. This is the core OHS guidance the BBC and Bunnings Board of Directors developed and distributed to the management at each Bunnings work premises. The January 2004 version of the manual was current at the time of the incident and it contained two sections: 'overview' and 'safe work procedures'. The Safe Work Procedures (SWP's) cover approximately 19 topics. The January 2004 BSAFE manual did not incorporate a general provision, separate to the specific procedures outlined above, that set out the formal principles and formal processes of hazard management to be applied in the identification, assessment and control of any risks not specifically covered in the BSAFE manual.
32. BBC and Bunnings advised that the following information relating to the handling of LPG, including its status as a dangerous good, was available at the time of the incident:
1. a dangerous goods risk assessment on retail storage and handling of dangerous goods in consumer packages dated 22 May 2005.
2. a system of dangerous goods quarterly self assessments with a quarterly self assessment checklist dated 28 September 2005,
3. an annual health and safety/dangerous goods audit program including an audit completed on 8 December 2005,
4. Kleenheat Gas decanting LPG training and procedures manual,
5. a standard operating procedure for gas cylinder filling by decanting; and
6. a list of persons authorised to refill consumer LP Gas cylinder by decanting,
Mr Miller was not aware of the contents and did not have a personal copy of the documentation at points 1 to 5 at the time of the subject incident. The complex manager at the premises was not aware of nor had a copy of the documentation at points 1, 4 and 5, at the time of the subject incident. Mr Kolletti had received no information or training in relation to LP Gas procedures.
33. Since the incident, the company has made the following changes:
a) Company-wide:
BSAFE now includes procedures for LP Gas decanting and managing emergencies. A computer-based training/assessment module for employees who perform LP Gas decanting has been developed and implemented. The emergency procedure was developed after the incident and laminated copies are on display throughout Bunnings Stores and cards containing the procedure have been given to each employee for quick reference. BSAFE now includes better systems for keeping training records.
b) Incident Site:
The 190kg LP Gas decant vessels (cylinders) that were used for filling customer's LP Gas cylinders have been removed from the premises and no decanting has been done at the premises since 10 December 2005. Decanting has been replaced by 'swap & go'. LP Gas 'authorised' persons and the site managers have been trained by Kleenheat about working safely with LP Gas. All team members have been trained one-on-one, what to do with a leaking gas bottle. "LP Gas leaks" is now a topic that is regularly discussed at morning tea talks. LP Gas has been included in the monthly hazard checklist that is completed by the OHS committee.
34. The following supporting documentation is annexed:
a) 6 Colour photographs taken by Inspector Trotter 12 December 2005 and 8 February 2006 numbered 4, 9, 14, 24, 33 and 46;
b) Factual Inspection Report of Inspector Trotter dated 14 December 2005;
c) Testsafe Report dated 6 April 2006
d) B.S.A.F.E document dated January 2004
e) Kleenheat Gas Safe Decanting of LP Gas Training Procedures Manual dated August 2005
f) Bunnings Tuggerah Refill Listing (Nov 05)
g) MSDS for commercial propane
h) AS 4332-4004 - The storage and handling of gases in cylinders
i) AS 1596:2002 - The storage and handling of LP gas
j) Code of Practice for the Storage and Handling of Dangerous Goods
k) Placarding on Kleenheat bulk cylinders
l) Prior convictions certificates."
10 The evidence of Mr Taylor supplemented [22] of the agreed statement of facts in that Mr Taylor carried out training at the Bunnings Dural store between 2003 and January 2006. It was the evidence of Mr Taylor that his training involved showing a video recording produced by the Kleenheat organisation, which became evidence in the proceedings. That video deals predominantly with the operation of decanting LP gas from a large storage cylinder into smaller domestic cylinders. A manual produced by Kleenheat also contains a number of instructions in dealing with a leak in a cylinder where there is no fire. The instructions include closing the valve on the leaking cylinder if possible, keeping hands and face away from the escaping gas and trying to move the cylinder to the most open space away from buildings, people, drains and sources of ignition, standing the cylinder upright with the valve at the top, dispersal of the gas with a water spray and disposal of the empty cylinder.
11 The evidence of Mr Wilks covered in part the interrelationship between the two defendants and the occupational health and safety regime of each of the defendants and the Bunnings Group as a whole. Mr Wilks is Group Health and Safety Manager for Bunnings Group Limited. That group as at May 2008 operated 226 hardware stores throughout Australia and New Zealand, 14 trade centres and 8 frame and truss manufacturing plants in Australia. It currently employs approximately 27,000 people in Australia and New Zealand. In New South Wales, there are 64 stores and 6,513 employees.
12 The evidence given by Mr Wilks and the documentation annexed to his affidavit demonstrate an overall commitment to occupational health and safety matters and a comprehensive occupational health and safety regime.
13 However, as Mr Wilks properly conceded, there were deficiencies at the time of this incident in the documentation, training and procedures generally dealing with the handling of faulty gas cylinders.
The circumstances of the breach