1 Tomago Aluminium Co Pty Ltd ("the defendant") has pleaded guilty to a breach of s 8(1) of the Occupational Health & Safety Act 2000 ("the Act"). This judgment concerns the penalty to be imposed for that offence.
2 The defendant operates an aluminium smelter at its premises on Tomago Road, Tomago, New South Wales. On 14 February 2004, Mr N O'Connell, an employee of the defendant, sustained crush injuries when he was trapped between a suspended moving anode trolley and a fixed metal platform (known as the reject table), which was located in the cooling tunnel area of the Paste Plant within the Rodded Anodes Business Unit at the smelter. Mr O'Connell died on 25 February 2004, as a result of his injuries.
3 The charge under s 8(1) was that the defendant:
FAILED TO
Ensure the health and safety and welfare at work of all its employees, in particular Neil Maxwell O'Connell, contrary to section 8(1) of the Occupational Health and Safety Act, 2000.
4 The particulars of the charge are:
1. The defendant failed to ensure that the overhead power and free conveyor system in the cooling tunnel area of the paste plant in the Rodded Anodes Business Unit, (conveyor system) was properly guarded to prevent employees coming into contact with the moving parts of the conveyor system.
2. The defendant failed to ensure that the systems of work for the removal of reject and oversized anodes on the conveyor system were safe and without risks to health.
3. The defendant failed to ensure that employees isolated the overhead conveyor motor before performing the work of removing the reject and oversized anodes.
4. As a result of the said failure O'Connell was placed at risk of injury and in fact suffered a fatal injury.
5 The prosecutor tendered an agreed statement of facts. Annexed to the statement was a memorandum from the Carbon Plant Business Unit Leader to all Rodded Anodes Employees dated 6 February 2004, advising that the company intended to commence production of new green anodes, which were approximately 100mm longer and 80kg heavier than the standard anodes. Employees were encouraged, if they needed to manually intervene with the new anodes, to take extra care before commencing. Also annexed to the statement was the isolation procedures intervention matrix, as revised at 4 January 2002.
6 The prosecutor also tendered a factual inspection report by Inspector I Batty dated 17 February 2004. 52 colour photographs taken between 14 February 2004 and 9 July 2004 showing an anode carrier, the hydraulic reject pusher with reject table, diagram of main isolation points, permanently fixed physical barrier fence guarding and the site of the accident. There was a sketch (not to scale) of the accident site and the defendant's prior convictions which showed four prior convictions.
7 The prosecutor also provided the Court with a schedule of judgments involving moving conveyor lines or systems, and the wording of a s 115 order.
8 The agreed statement of facts excluding formal parts provided the following information:
Rodded Anodes Business Unity and Paste Plant operations
10. The Rodded Anodes Business Unit (RABU) is the part of the Smelter which makes anodes for use in the aluminium smelting process.
11. The RABU comprises the Paste Plant, Anode Storage Handling Area (ASH) and Bake Ovens. Anodes are manufactured in the Paste Plant, then stored in the ASH area before being sent to the Bake Ovens. Anodes are hardened or baked in one of the two Bake Ovens, after which they are transferred to the Rod Shop, where hardened steel rods are inserted into the anodes. Once fitted with a rod, each anode is ready to be transported to the potlines for use in the smelting process.
12. Anodes are principally made from a combination of petroleum coke and liquid pitch. The petroleum coke is crushed and combined with the liquid pitch to form a thick paste, which is moulded into a specific block-like shape by one of two vibro-compactors. Each anode weighs approximately 1.3 tonnes.
13. Once moulded, each anode is transferred onto a trolley. Trolleys are suspended from an overhead power and free conveyor system, which is described below.
14. Once transferred onto a trolley, each anode must be cooled. In order to do this, the Conveyor System transports each anode on its trolley through two cooling tunnels. At various stages along the Conveyor System, there are sensors, which weigh the anode and detect whether it is the correct size and shape. Anodes, which do not conform to the weight, size and shape specifications cannot be used in the smelting process and are automatically rejected by the Conveyor System.
The Overhead Power and Free Conveyor System
15. The overhead Power and Free Conveyor System (Conveyor System) was designed by Jervis B Webb Company and installed at the Smelter by the Conveyor Company of Australia Pty Limited in approximately 1983.
16. The Conveyor System was designated as a 4/6/6 type Power and Free (Wide Wing Conveyor - Conveyor No. 3220-61390). It involves dual trolley carriers, which transport anodes on suspended trays (trolleys) around the Paste Plant. Trolleys run on a free track and can engage and disengage on a continually moving overhead powered chain.
17. The Conveyor System consists of:
a) an overhead conveyor of approximately 360 metres comprising;
i. a free or unpowered track (Free Track); which is located below and parallel to
ii. a mechanised chain (Powered Chain);
b) 104 disengagable trolleys each equipped with an anode carrying tray (Trolley). Each Trolley weighs approximately 420 kgs (tare);
c) loading station at each of two vibro compactors;
d) one anode weighing station;
e) one density control station;
f) all electrical equipment for Pro-Logic Control of the Conveyor System; and
g) a Radio Frequency (RF ) tagging system.
18. The overhead conveyor moves at a rate of approximately 13.55 metres per minute, which is approximately the speed of a slow walking pace.
Trolleys
19. In order for a Trolley to move around the Plant, it must either engage directly with the Powered Chain or with another Trolley, which has engaged with the Powered Chain. In many respects, the movement of the Trolleys around the Conveyor System is similar to that of a train in that only the front carriage of the train is powered and it draws the subsequent carriages along the Free Track after it.
20. In practice, the first Trolley attaches to the Powered Chain by way of a device which consists of an operating link (or 'duck bill') and 'retractable dog', both of which are located on the Trolley's leading edge. When the duck bill is lowered (by gravity), the retractable dog is raised and a connection is made with the Powered Chain. Once connected to the Powered Chain, the Trolley moves along the Conveyor System.
21. At the rear of each Trolley, there is a 'cam tail' (Cam). The Cam of the first Trolley can attach to the duck bill on the leading edge of the next Trolley and so on. When the duck bill makes contact with the Cam, the duck bill is raised, which forces the retractable dog on that Trolley down. This causes the second Trolley to disengage with the Powered Chain. The result of this is that the Trolleys become joined to each other but only the first Trolley is engaged with the Powered Chain.
22. The first Trolley is powered by the Powered Chain when it makes contact with a 'pusher dog'; which is attached to the mechanical drive shaft of the Powered Chain. Pusher dogs are located at regular intervals along the Powered Chain. As the Powered Chain moves, the pusher dogs travel around the Plant with it. A pusher dog will make the contact with the retractable dog of the first Trolley as it passes that Trolley.
Stops
23. There area number of 'stops' that are located at various points along the Free Track. Each stop is an air operated device which, when closed, places a blade in the path of a Trolley to prevent it from moving forward. The blade causes the dog on the front Trolley to retract, which releases it from contact with the pusher dog on the Powered Chain. Opening the stop causes the blade to retract from the path of the Trolley and allows the Trolley to re-engage with the next available pusher dog on the Powered Chain. The Trolley then moves forward. The stops can be manually closed or opened at local push button stations which are positioned around the Plant.
Anti-rollback device
24. Trolleys are prevented from moving backwards along the Conveyor System by a series of anti-rollback devices, which are positioned at various points along the Free Track. Each anti-rollback device comprises a small metal bar or latch which hangs below the Free Track at an oblique angle. When a Trolley moves along the Conveyor System in the direction of the Powered Chain, the Trolley pushes against the device and causes it to flatten and become flush with the Free Track. The Trolley is then able to move past the device. However, if a Trolley rolls against the direction in which the Powered Chain moves, it becomes jammed against the device and is stopped. An anti-roll back device can be deactivated as to allow a Trolley to move backwards by manually depressing (ie, pushing upwards) the latch.
Quality Control
25. There is an electronic grading and sizing system for the purpose of ensuring product quality measure the height and weight of each anode. The grading and sizing for each anode is recorded on a programmable radio frequency (RF) tag, which is mounted on each Trolley. The information contained on the RF tag is read by the electronic equipment, which forms part of the overall Conveyor System. This information. allows the Conveyor System to identify which anodes meet the quality standards and which ones do not.
26. After passing through two cooling tunnels, each Trolley is stopped at Stop 16.
27. By this point, each anode has either been identified as a 'good' anode (that is, an anode which has met the quality control standards) or as a 'reject' anode. If it is a good anode, the Conveyor System directs it onto the 'green line' at Stop 17. If an anode has been rejected, the Conveyor System directs it onto the 'reject line' at Stop 19. The process of directing each anode onto the green line or reject line is automated and there is usually no need for human intervention.
Green line and reject line
28. The green line and reject line are situated at right angles to the Conveyor System. In this context, 'line' means a ground-mounted conveyor belt. In the case of the green line, the conveyor is mechanised; and in the case of the reject line; gravity causes the reject anodes to run along it (downhill).
Green line
29. A radio frequency antenna (RF antenna) and an ultra sonic height-sensing device are permanently fixed above the 'green line' unload station at Stop 17.
30. As the Trolley arrives at the green line, the RF Antenna reads the information contained on the tag mounted on the Trolley. As a secondary measure, the ultra sonic height-sensing device also measures the height of each anode,
31. If the anode is acceptable, it is pushed onto the green line by a hydraulic ram (the green line pusher).
32. The green line pushed works by extending from its position at the top of the green line to push the anode off the Trolley and onto the line itself. The green line pusher than (sic) retracts and is ready to repeat the process with the first good anode.
33. If an anode has been pushed onto the green line, it is moved a distance of approximately 2 metres to a 'turn over device'. The turnover device turns the anode onto its side to facilitate its handling in the ASH area.
Reject line
34. In the event that the sensing device at Stop 17 identifies that an anode does not meet the required quality standard, the Trolley is carried past the green line to the junction of the Conveyor System and the reject line (Stop 19). The distance between the green line and reject line is approximately 4 metres.
35. Once at Stop 19, a second hydraulic ram (in this case, the reject line pusher), which is located at the top of the reject line, pushes the reject anode off its Trolley and onto the reject line itself. An anode which has been pushed onto the reject line rolls along the line to a holding area. Reject anodes are crushed and recycled through the Plant.
Events leading up to the incident
36. Prior to the incident, the Smelter was undergoing an upgrade known as the 'AP22 Project' (the Project). Essentially, the Project involved increasing the Smelter's overall production. The Project required the integration of changes to plant and equipment in the RABU in early 2003 and February 2004 to accommodate the production of larger anodes.
37. On 6 February 2004, the Paste Plant commenced the production of larger anodes. These anodes were approximately 100 mm longer and 80 kg heavier than the anodes which had previously been produced.
38. On 6 February 2004, Mr Gawthrop, Rodded Anodes Business Unit Leader, forwarded a memo to all RABU employees concerning the manual handling of anodes. A copy of that memo is annexed and marked 'A'.
39. At Paste Plant No. 1 (in the transfer car area) there is an item of plant referred to as the 'chandler baffle'. A chandler baffle is an oscillating blade which is designed to ensure that the paste which is poured into each mould is spread evenly from back to front. In the days before the incident there had been a defect with the chandler baffle, causing it to be less effective.
Details of incident on 14 February 2004
40. At approximately 7 am on 14 February 2004, five of the defendant's employees (C Crew) commenced work on the day shift in the Paste Plant. On that shift, C Crew comprised:
a. Neil Maxwell O'Connell (Mr O'Connell), who was an experienced Paste Plant Operator, having been employed by the defendant in that position since 1982. Mr O'Connell was the operator of Paste Plant 1 at the time of the incident;
b. Edward John Bingham (Mr Bingham), who was an experience (sic) Paste Plant Operator, having been employed by the defendant in that position since March 1990. Mr Bingham was acting as 'third man' (that is, providing additional assistance in Paste Plants 1 and 2 as required) at the time of the incident;
c. Lance Richard Skinner (Mr Skinner), who was an experienced Paste Plant Operator, having been employed by the defendant in that position since 1999 and otherwise in the Rodded Anodes since 1997. Mr Skinner was the operator of Paste Plant 2 at the time of the incident;
d. Joseph Edward Fitzpatrick (Mr Fitzpatrick), who was an experienced Senior Paste Plant Controller, having been employed by the defendant in that position since 1984. Mr Fitzpatrick was the Senior Paste Plant Controller at the time of the incident; and
e. Mark Alan Joseph Westbury (Mr Westbury), who was an experienced Team Leader in the Rodded Anodes, having been employed by the defendant in that position since 2002.
41. In addition to C Crew:
f. Scott Hargreaves Gawthrop (Mr Gawthrop), was the Business Unit Leader of the Rodded Anodes, having been employed by the defendant in that position since 2002 and otherwise at the Smelter since 1983. Mr Gawthrop was not duty at the time of the incident; and
g. Troy Maurice Evans (Mr Evans) was a contractor who was hired by the defendant through Chandler MacLeod / Ready Workforce. Mr Evans was working as an Assistant Anode Storage Handler in the ASH area for Bake Oven No 2 at the Smelter at the time of the incident.
42. Prior to the incident, Mr Evans, who was working the ASH area, observed that an oversized anode (that is, an anode that was too tall), which should have been rejected by the Conveyor System, had been pushed onto the green line rather than the reject line, and was jammed in the turnover device (Defective Anode).
43. In addition to the Defective Anode becoming jammed in the turnover device, two good anodes had, by that time,. been pushed onto the green line and were behind the Defective Anode (that is, between the Defective Anode and Stop 16).
44. The Defective Anode had been pushed onto the green fine rather than the reject line because both of the defendant's anode height and weight detectors had failed.
45. Mr Evans informed Mr Skinner of the problem via two-way radio and Mr Skinner went to investigate the Defective Anode. Mr Skinner attempted to clear the green line by using the green line pusher to force the Defective Anode through the turnover device, but this was unsuccessful.
46. Mr Skinner returned to the Control Room of the Paste Plant and notified Mr Fitzpatrick of the problem via two way radio. At the time, Mr Fitzpatrick was with Mr Westbury in a different part of the Plant. Mr Fitzpatrick instructed Mr Skinner to notify Mr O'Connell and Mr Bingham of the problem. At that time, Mr Westbury indicated that he would investigate the Defective Anode shortly, as he continued on his supervisory rounds of the Rodded Anodes Business Unit.
47. Mr Skinner notified Mr Bingham and Mr O'Connell as request (sic) and they subsequently went to investigate the problem. Mr O'Connell and Mr Bingham arrived that the green line and turnover device and started to dear the line prior to the arrival of Mr Westbury.
Steps taken by Mr O'Connell and Mr Bingham
48. The only practical way of clearing the Defective Anode from the turnover device and to move it to the reject line was to intervene manually on the Conveyor System in the vicinity of the green line and reject line. Mr O'Connell and Mr Bingham needed to manoeuvre the Defective Anode and the two good anodes back onto Trolleys so that they could be moved from the green line to the reject line. The only way that this could be done was to:
a) bring an empty Trolley to Stop 16 and lever the nearest (good) anode onto the Trolley; then
b) move that Trolley to the reject tine at Stop 19 and push the anode onto the 'reject line using the reject line pusher; then
c) return the Trolley to Stop 16 so that the process could be repeated for the second good anode and finally the Defective Anode.
49. Mr O'Connell and Mr Bingham set about clearing the green line and turnover device in this way.
50. Consistent with the way Mr Bingham had performed this task in the past, the overhead Chain was not isolated prior to accessing the area.
51. However, contrary to the defendant's isolation procedures (isolation Matrix), Mr O'Connell and Mr Bingham did not isolate the Powered Chain before accessing the Cooling Tunnel and commencing their manual intervention. To 'isolate' the Powered Chain means to stop it moving by turning it off. A copy of the Isolation Matrix is annexed and marked 'B'.
52. To remove the first (good) anode, Mr Bingham manually closed Stop 16 via a local control push button station. This stopped any other Trolleys from moving out of the cooling tunnel and into the area in which Mr O'Connell and Mr Bingham were working. Mr O'Connell and Mr Bingham then positioned themselves on either side of the first good anode and used a crow bar to move it onto an empty Trolley positioned at Stop 17.
53. Mr Bingham then walked out of the southern side of the building, around the end of the reject conveyor and back into the building to position himself near to Stop 19. Stop 19 is located at the intersection of the Free Track and the reject line. Mr Bingham caused Stop 19 to be closed and Mr O'Connell caused Stop 17 to be opened by operating the local control stations respectively. By opening Stop 17, the next available pusher dog on the Powered Chain engaged with the Trolley which was carrying the first good anode and transported it to Stop 19. The closure of Stop 19 ensured that the Trolley did not move beyond that point. The first good anode was pushed from its Trolley onto the reject line by the reject line pusher, and it rolled along the reject line to the holding area outside the building as intended.
54. Mr O'Connell then operated the same local control station again to cause the reject line pusher to retract it to its original position. The empty Trolley moved a distance of approximately one metre from the reject table, against the normal flow of the Powered Chain, toward the green line.
55. Mr O'Connell then positioned himself on the northern side of the empty Trolley. Mr Bingham walked around the end of the reject conveyor and, on his way, picked up a broom handle which he knew would be needed to de-activate the anti-roll back device and the Free Track for the purpose of moving the Trolley back to Stop 17. Mr Bingham positioned himself on the south Western corner of the empty Trolley. Together, Mr O'Connell and Mr Bingham moved the empty Trolley in a westerly direction against the direction of the Powered Chain until the Trolley struck an anti-roll back device at Stop 18.
56. To move the Trolley back past the anti-roll back device, it was necessary for Mr Bingham to cause the device (being a small metal bar which hung down from the Free Track) to become flush with the Free Track. The only way to achieve this was to depress the device (ie, push it upwards). There was no specific device to undertake this task and Mr Bingham used the broom handle he had previously collected. Mr Bingham caused the device to flatten and become flush with the Free Track and the Trolley moved back towards the green line as intended.
57. However, while doing this, the Trolley engaged with the Powered Chain and Mr Bingham realised that, as a result of this, the Trolley had begun to move towards the reject line (ie in the opposite direction to where it was intended to be moved). However, given that Mr Bingham was looking upwards while he was attempting to hold up the anti-roll back device with the broom handle, he did not notice that Mr O'Connell had moved from the side of the Trolley and was standing in its path (that (s, between the Trolley and the reject table).
58. It is not known why Mr O'Connell stepped into the path of the moving Trolley at that time. It is also not known why Mr O'Connell did not depress the duck-bill of the Trolley to prevent it from making contact with the pusher dog on the Powered Chain.
59. As a result, Mr O'Connell became trapped between the Trolley and the reject table at Stop 19.
60. Mr Bingham, on realising what was happening, used both hands to try to hold the Trolley away from Mr O'Connell by raising it to about his chest or shoulder height. Despite his attempts, Mr Bingham could not prevent the Trolley from trapping Mr O'Connell against the reject table.
61. As this was occurring, Mr Westbury arrived at the scene, having entered the area through the southwestern opening of the building near to the green line pusher. Mr Westbury observed that Mr O'Connell was trapped by the Trolley.
62. Within a few seconds of his arrival, Mr Westbury hit the emergency stop button, which caused the Powered Chain to stop. This emergency stop button was located adjacent to the green line pusher. The Trolley immediately moved back (towards the green line) a distance of about one metre, which allowed Mr O'Connell to be released.
63. Mr Westbury used channel 3 of Mr Evans' two-way radio to contact the smelter's security office and requested urgent outside medical assistance. Security directed Michael Lewis (Fire and Emergency Coordinator) to the scene. First aid was rendered by the defendant's first aid officers prior to the arrival of the NSW Ambulance Service.
64. NSW Ambulance arrived on the scene at approximately 4.16 pm and departed at approximately 4.40pm, transporting Mr O'Connell to the John Hunter Hospital.
Details of the systems of work prior to incident
Guarding of Conveyor System
65. At the time of the incident, fencing on the southern and northern sides of the cooling tunnel area of the Paste Plant consisted of a permanently fixed metal post and rail fence/handrail approximately one metre high with a mid-rail positioned approximately 470 mm above ground level, with a number of open sections to facilitate access and egress. A metal chain could be placed across the open sections of the fence for the purpose of preventing unauthorised access. On the external southern side of the building, there are two openings allowing access/egress to the cooling tunnel area and a walkway adjacent to Stop 17.
Standard Operating Procedures in the Rodded Anodes Business Unit
66. Prior to the incident, the defendant had a documented system in place in relation to isolation procedures for the Conveyor System (isolation Matrix). This document outlines the areas which are required to be isolated for a number of interventions in the Cooling Tunnel. The Isolation Matrix stipulates the isolation of the overhead conveyor motor is required before general access to the Cooling Tunnel.
67. The system of work utilised by Mr O'Connell and Mr Bingham in the events leading up to the incident was inconsistent with the requirements of the defendant's Isolation Matrix.
68. The Isolation Matrix stipulates that the isolation procedures for intervening in the Paste Plant includes, but is not limited to:
a) in all cases, the standard isolation method prior to carrying out the manual intervention is to:
(i) isolate; then
(ii) attach a danger tag; then
(iii) test isolation.
b) area access isolation is required when working in any of the areas listed in the Isolation Matrix.
c) in the case of an anode jammed at Stop 16, employees are to isolate stops 16/17.
d) in the case of general access to the cooling tunnel, employees are to isolate:
(i) the overhead conveyor motor;
(ii) 'Cooling Tunnel No. 1 Pump No. 2 Isolator';
(iii) 'Cooling Tunnel No. 1 Pump No. 1 Isolator'; and
(iv) 'Cooling Runnel (sic) No. 2 Spray Pump Motor Isolator'.
e) for activities not listed on the isolation Matrix, 'full isolation is required unless otherwise approved by your relevant foreman'
69 The defendant also required its employees to implement the 'danger tag' system whenever a piece of equipment was isolated for the purpose of ensuring that no person would reactivate the equipment while the tag was in place. This requirement was reflected in the isolation Matrix under the heading of 'Job Procedure'.
70. At the time of the incident, the defendant had in operation a Job Safety Analysis scheme, whereby employees would undertake a risk assessment before commencing to perform a task. Mr O'Connell had completed JSA training on 13 January 2004. Mr Bingham had not been trained in the JSA system prior to the incident.
71. Neither Mr O'Connell nor Mr Bingham completed a JSA for the work activities they were undertaking leading up to the incident.
Practices of Paste Plant Operators in Cooling Tunnel Area
72. Contrary to the requirement that the conveyor system be isolated prior to entry into the Cooling Tunnel (as set out in the Isolation Matrix), at the time of the incident, it was a common practice for Plant Operators to enter the Cooling Tunnel for the purpose of 'manipulating' Trolleys. In this context 'manipulate' means to assist a Trolley to continue to move in the same direction as the flow of the Powered Chain. This common practice was known to supervisors and management.
73. Typically, such `manipulation' would occur when a Trolley failed to engage with the Powered Chain (in which case an Operator may have manually depressed the duckbill on that Trolley to connect the Trolley to the Powered Chain) or when a gate on the Free Track failed to open (in which case, an Operator may have manually depressed the gate to open it so that a Trolley could pass through the gate and into Cooling Tunnel No. 1).
74. However, it was not a common practice for Plant Operators to attempt to cause a Trolley to move against the flow of the Powered Chain without first isolating the Conveyor System. Mr O'Connell's and Mr Bingham's practice of undertaking this type. of intervention was singular to them and not known to, or in any way approved of, by the management of the defendant, including the Team Leader of C Crew.
Steps taken by the defendant to improve safety after the incident
75. As an immediate interim safety measure, the defendant erected a wire mesh fence to prevent access to the Cooling Tunnel and signage which stated that no person was to access the cooling tunnel area without a completed job safety analysis, authorised by the Carbon Plant Foreman and isolated following the correct standard operating procedure.
76. By 17 February 2004, the defendant had established a task force to review the operations in the Paste Plant. The task force identified a number of issues and recommended actions during the period 17 February 2004 to 19 March 2004.
77. A further revised access procedure was developed on the 18 February 2004.
78. The defendant developed an Action Plan in response to WorkCover Improvement Notices issued on 19 February 2004. The Action Plan details the immediate response by the defendant following the incident and then outlines the steps that it intended to (and did) take to improve safety over the medium and long term.
Implementation of the Action Plan
79. In order to implement the Action Plan, the defendant undertook the measures which are set out below.
(a) The defendant retained the services of an independent external safety and engineering consultant to assist with the safety review and implementation of the Action Plan;
(b) The defendant networked with other plants and industries for the purpose of inspecting their overhead conveyor systems and safeguarding in general;
(c) During the period between February 2004 and December 2004 permanent perimeter guarding to the full length of the Conveyor System was designed and installed to prevent unauthorised access to the Cooling Tunnel and uncontrolled 'live' operator interventions. The perimeter guarding has been designed with particular access provision via sixteen controlled gates. Key and interlock logic has been implemented to allow controlled, authorised access to the Cooling Tunnel and to ensure the safety of people required to undertake existing work activities;
(d) a specific tool was designed which can be inserted into the duckbill to hold it open;
(e) A review of operating procedures and practices was carried out which identified 51 required interventions, for which a new and/or revised JSA and SOP were developed and implemented in consultation with relevant personnel;
(f) A review of preventative maintenance schedules and practices was carried out during March and May 2004. Implementation of the improved maintenance practices (in accordance with Phase 2 of the Action Plan) was completed in August 2004. The preventative maintenance schedule and practices have improved the reliability of anode measurement devices and the RF tagging system, reducing the likelihood of a reject anode being pushed onto the green line. In the event that a large anode is pushed onto the green line, a physical gauge that will jam the anode before if gets fully off the Trolley has been installed immediately adjacent to Stop 17. This gauge ensures that in the. event of a jam only one anode need be dealt at a time,
(g) The defendant carried out a review of emergency stops and isolation facilities in the Paste Plant, including signage. All emergency stops were replaced with new 60mm diameter units;
(h) A Competency Development Plan (CDP) for the operation of the Cooling Tunnel was developed by the defendant, authorised by management and issued to operators. All supervisors and operators have now completed the CDP training;
(i) The Isolation Matrix for interventions requiring isolation of the Conveyor System was revised on 28 May 2004;
(j) A major plan was designed after the incident which focussed on compliance with Regulations, safeguarding, risk assessment and behavioural compliance; and
(k) A project titled the 'Man Machine Interface Project' (MMIP) was launched by the defendant following the incident to review the entire Smelter for the purpose of identifying and controlling hazards associated with the interface of personnel with equipment. As a result of the MMIP and WorkCover Improvement Notices, entry into the Cooling Tunnel is now restricted by the installation of full perimeter guarding. The Installation of an isolation and interlocking system which allows for safe entry into the area after automated isolations have been completed.
Co-operation with WorkCover
80. The defendant has co-operated with WorkCover in relation to its investigation into the incident.
9 The defendant tendered and read an affidavit of Arthur Gilbert Hunt. Mr Hunt was not required for cross-examination. The defendant also tendered a photograph showing an overview of the accident scene.
10 Mr Hunt is employed as the Business Unit Leader Liquid Metal, with the defendant. Prior to this position, he held the position of Business Unit Leader for the Rodded Anodes Business Unit ("RABU") and was in that role at the time of the accident. Mr Hunt described his duties as Business Unit Leader of the RABU, the production of aluminium and the manufacture of carbon anodes, stating that the defendant's Paste Plant manufactures approximately 200,000 anodes per year. As a result of extensions to the aluminium smelter, which was built in 1981, it now has a capacity to produce 460,000 tonnes of aluminium.
11 Mr Hunt stated that the defendant currently has approximately 1,000 employees and utilises the services provided by a large number of local contractors. It is one of the largest employers in the Newcastle/Hunter region.
12 Mr Hunt described the procedures for entering the Cooling Tunnel at the time of the incident as follows:
32. At the time of the incident, all employees were required to isolate the overhead conveyor in the Cooling Tunnel area of the Paste Plant prior to attempting to undertake any manual intervention in that area. Such interventions included attempting to clear the conveyor system of a blockage, such as that caused by an oversized anode becoming jammed in the turnover device on the green line in circumstances where an employee needed to manipulate trolleys against the flow of the overhead powered chain.
33. The Isolation Matrix, which was clearly displayed at various locations around the Paste Plant, including in the vicinity of Stop 19, plainly stated that equipment was to be isolated in the circumstances described in paragraph 32 above. Annexed to this affidavit and marked 'B' is a copy of the Isolation Matrix which applied at the time of the incident and was displayed in the vicinity of Stop 19 of the Paste Plant.
13 In referring to the improvements introduced by the defendant since the incident, as set out in paragraphs 75 - 79 of the agreed statement of facts, Mr Hunt stated that these improvements had cost in excess of $20 million and had taken three years to implement. It was common ground that the specific improvements introduced at the accident site had cost approximately $1.2 million.
14 Mr Hunt then set out the extensive assistance provided to Mr O'Connell's family. This included a cash payment of $25,000 soon after the incident, which was in conjunction with the provision of a further $25,000 from the Tomago employees; all costs relating to Mr O'Connell's hospitalisation, including emergency accommodation for family members, meals, psychological and counselling support; all costs relating to Mr O'Connell's funeral; assistance in securing an apprenticeship for Mr O'Connell's son; provisional ongoing counselling services to Mrs O'Connell and her children and continual telephone contact with them by members of senior management; assistance with workers' compensation insurer and the presentation of a memorial shield to commemorate Mr O'Connell.
15 Mr Hunt described the installation of the overhead conveyor system in the Paste Plant in 1991. He stated that on 9 September 1992, a senior Inspector of the WorkCover Authority of NSW inspected the conveyor and issued an Inspector's Notice. The notice required certain measures to be taken to meet safety standards, including securely fencing all nip points and installing handrailing to prevent normal access into the area swept by the suspended anodes, as they were transported on the conveyor.
16 Mr Hunt described the occupational health and safety management at the defendant, which is comprised of a number of separate but related safety programs. These include standard operating procedures ("SOPs"), which are prepared in consultation with the defendant's operational employees. Following the incident, the SOPs were comprehensively reviewed and in many instances, new procedures documented. Copies of the many new SOPs were annexed to Mr Hunt's affidavit. All employees undergo induction training when they commence employment with the defendant. Ongoing training is then provided by means of monthly safety meetings and a competency development program. One module in the competency development program is focused on the correct method of isolating equipment.
17 Since 1997, management have been required to undertake a number of safety observations each year. This requires management to visit the production areas and talk to operators about safety issues.
18 In 1999, the defendant developed a hazard management system. This system requires every employee to record any hazard in his or her hazard notebook so that corrective action is taken. A permit to work system was introduced in early 2000 to ensure the safety of contractors working at the site. A contractor must seek written approval to perform any work, in any area, at the defendant's site. A risk assessment is an integral part of the process by which permission is provided.
19 Towards the end of 2000, a job safety analysis ("JSA") initiative was introduced. A similar system, known as ActSafe was introduced from September 2001, for all operators, including those in the Rodded Anodes Business Unit. This system was ultimately replaced in January 2004 by the JSA. Employees are required under the JSA to record risks associated with the following tasks: any activity involving isolation; manual handling activities; any task involving the use of lifting equipment and any non-routine task, such as one which the employee has not undertaken for some time (more than one or two months) or a task for which there is no SOP. The JSA, which applied to all Plant Service employees, was designed to ensure employees undertake risk assessments before commencing a task. An employee must carry a pocket JSA notebook at all times and prior to commencing a task, must list any possible risks in the notebook, together with the control measures that are used to reduce or remove the risks.
20 Mr Hunt stated that Mr O'Connell was trained in the use of JSAs on 13 January 2004. A copy of Mr O'Connell's training records was annexed. A Safety Action Plan was introduced for each Business Unit in early 2002. The Plan identifies the top 10 hazards for that Business Unit and how those hazards will be addressed. The safety performance of each Business Unit is assessed each quarter against its Safety Action Plan. Regular safety audits were also introduced in mid 2001.
21 A scheme known as "Safety. Always Your Choice" was introduced in late 2002. This program was introduced to reinforce the role that each employee has to play in their own safety and the safety of the people with whom they work. The Safe Start program was introduced in late 2002. This program requires team leaders to meet with their crew members during each shift to discuss compliance with the ActSafe Program, the safety results from the previous shift, how the tasks are to be undertaken on that day could be performed safely and any injuries or near-misses of which the team leader is aware, both at the defendant's plant and any other aluminium smelter around the world.
22 Mr Hunt stated that safety meetings are held with each crew of production employees for one to two hours each month. The purpose of these meetings is to review the safety performance of the Plant. Department and crew; review the Business Unit Safety Action Plan to educate the employees about safety-related issues. A serious incident review meeting is held each week to review the investigations and action plans following any serious accidents or near misses. The CEO, Production Manager, Service Manager, Health and Safety Manager and the Chairman of the Occupational Health and Safety Committee attend these reviews.
23 The defendant has acquired ISO accreditation in respect of its safety systems.
24 Mr Hunt gave evidence that the major safety initiatives at the defendant's plant are currently aimed at significant improvement in four key areas, being:
(a) an audit has been conducted of plant across the site to identify man/machine interface hazards which may pose a risk to employees. These risks are assessed and recorded in a risk register. Actions are then taken according to the magnitude of risk, with the aim of reducing risks through the introduction of appropriate controls. These projects are the priority for capital expenditure at the site;
(b) minimisation of risks in identified specific risk areas through the use of improvement teams sponsored by a member of the site's senior management team. These teams develop and implement best practice solutions. For example, Tomago's CEO is the sponsor of the Crisis Management/Emergency Preparedness team. The Traffic Management team is sponsored by the site's Production Manager. The Permit to Work/Isolation and Contractor Safety Management team is sponsored by the site's Services Manager;
(c) enhancement of the current TAC Safety Management System. As part of this process, Tomago has taken on board the ALCAN EH&S First Safety Management System, adapting it so as to ensure that it conforms with applicable legislation, Australian Standards, and Codes of Practice; and
(d) continuation of the Business Unit safety planning process.
25 Mr Hunt stated that there are two main categories of expenditure on safety - operating expenditure and capital expenditure. Mr Hunt set out this expenditure which relates to calendar years as follows:
Safety operating expenditure
(a) The information supplied below relates to the 2003 to 2006 calendar years. Operating expenditure covers annual spend on items such as the purchase and maintenance of Personal Protective Equipment, safety consultants, and the wages & salary cost of employees involved in safety.
Actual Y/E Actual Y/E Actual Y/E Actual Y/E
31/12/03 31/12/04 31/12/05 31/12/06
Safety Coordinators $0.594m $0.619m $0.645m $0.528m
Safety Health & Hygiene Department Costs $1.037m $1.076m $1.433m $1.458m
Supplies and expenses - (PPE etc) $1.968m $2.289m $2.472m $2,501m
Total $3.599m $3.984 $4,550m $4,487m