7 An agreed statement of facts was tendered in matter Nos IRC6718 and 6721 of 2001 and relevantly reads as follows:
4 At all material times the Defendant
4.1 carried on business as a producer of bread products, particularly pita bread, at the Premises; and
4.2 employed Yan Zhong Zhu as dough maker at the Premises.
5. On 4 August 2000 Yan Zhong Zhu was working in a factory by himself at 4 -6 Boola Avenue, Yennora ( the Premises ) on a multilevel inclined conveyor ( Conveyor ) on the Bread Improver Line No. 2. His left arm was drawn into the Conveyor whilst he was attempting to remove and adjust a jammed teflon cover flap/guard on the Conveyor. He was unable to stop the machine himself.
6. Other workers came from another area of the factory to assist however they could not find a stop button. He was trapped in the moving Conveyor for approximately 30 minutes before the Conveyor was shut off. He then remained trapped in the stationary Conveyor for about another 30 minutes.
7. Mr Zhu sustained severe injuries to the left forearm, lacerations on the left upper arm, stomach and groin/penis. He was off work for 3 weeks.
8. Usually dough moved along the top belt of the Conveyor then transferred to the one below and went through all 13 levels until it reached the last belt, where it then went into the oven and on to the packaging area. The Conveyor was approximately 12m long (incline length) x 750mm wide x 2m high at the highest point which was the exit end of the Conveyor. On each end of the Conveyor was rubber cover/flap guard that covered the in-running belts.
9. It was while Mr Zhu was reaching into the area of the cover flap/guard while the Conveyor was running that his hand and then his arm was dragged into a 60mm gap between 2 running conveyor belts. Mr Zhu recently informed WorkCover that during his shift he noticed that one of the two screws holding the cover that fell was missing. However, it would appear that he did not report this to anyone at the time.
10. Mr Zhu had first commenced employment with Seda in January of 1991. On the first day he was shown the safety of the machines. He left the company and started his own business for approximately 12 months. He returned to work for Seda on 1 July 2000.
11. Mr Shimon Dahari made it clear in his interview statement that he had not provided Mr Zhu with any special training. He also made it clear that he had assumed that Mr Zhu would know all about the safety procedures, as he had already himself run a business and should have known about that without any additional training. Mr Dahari stated that "I use (sic) to just tell him when he was doing something wrong. Don't do this, don't do that. This is my nature, I do it all the time." Mr Zhu has stated to WorkCover that he worked on the Lines for some 10 to 12 years and that he knew everything (at least, insofar as the adjusting of the covers) and that other bakers had shown him what to do.
12. At 2.30 pm on 4 August 2000, in response to a verbal accident notification that was received from NSW Police, the Prosecutor attended the Premises to investigate the accident.
13. On arrival at the Premises, the Prosecutor was met by Constables Tracey Duncan and Andrew Quinn from Merrylands Police Station, who then accompanied him for an inspection. The Prosecutor was subsequently met by Mr Shimon Dahari, Managing Director of the Defendant, Mr Mark Nelson, owner of Angelo Engineering Pty Limited, and Mr Matt Ryan, a contractor employed by Angelo Engineering.
14. The Prosecutor observed the following:
14.1 Within the factory there were 3 Bread Improver Lines. Each started adjacent to the eastern roller door and progressed north, then west along the factory's length and then south to the packaging area.
14.2 Constables Duncan and Quinn took the Prosecutor between the second and third Bread Improver Lines to an area where the lines went from a northern direction to a westerly direction. They identified the feed end of the Conveyor as the area where Mr Zhu was removed.
14.3 In the corner where the No. 2 line changes direction from north to west was a transfer machine that was fed by a 4-belt telescopic conveyor. The transfer machine fed the top loop feed belt of the multilevel inclined fixed belt conveyor, which travelled 2m to the top of the Conveyor, then up along the approximate 750mm wide x 12m inclined length of the Conveyor.
14.4 Each of the 13 levels had loop belts which changed direction at each level until the last level that went out from the Conveyor's frame at the non-feed end to the conveyor that fed the oven on the western end.
14.5 On the feed and non-feed end and on the southern side of the Conveyor were drive motors, sprockets and drive chains attached to the ends of each of the 13 rollers. On the northern side were gears with no drives.
14.6 The guarding of the drive sprocket and chain on the feed end were on the floor adjacent to the side of the Conveyor. The guard on the gears was also removed and on the floor. Both guards did not have any rear guarding.
14.7 The guarding of the non-feed end was such as to leave the motor's drive sprockets and chain exposed. There was also no rear guarding of the 13 drive chains and sprockets, although the front was mostly covered.
14.8 The area identified by Constables Duncan and Quinn on the feed end south side had the mounting bolts removed from the bearing housing of the top roller. The second roller had the bearing housing's mounting bolts removed and the bearing housing and sprockets were removed from the roller's shaft. The third roller down also had the mounting bolts removed.
14.9 The drive chain had also been removed from between 1 and 2 rollers and 2 and 3 rollers.
14.10 There was an approximate gap of 60mm between each of the 13 drive rollers and belts.
14.11 On each end of the Conveyor were cover flaps that covered the inrunning belts. These measured approximately 90mm high x 750mm long x 4mm thick. The one covering the inrunning belts between rollers 2 and 3 had been removed and was on the floor adjacent to the Conveyor.
14.12 There was no motor isolating switch for the 2 drive motors for the Conveyor.
14.13 There were no emergency stops for the Conveyor.
14.14 There was no safe working load and identifying number displayed on the Conveyor.
14.15 There was no indication as to where the electrical isolation switch of the Conveyor was located.
15. On 4 August 2000 the Prosecutor identified the following deficiencies in machinery at the premises:
15.1 Bread Improver Line No 1 was deficient in the following respects:
15.1.1 no safe working load was displayed on conveyors;
15.1.2 no permanent identification number was displayed;
15.1.3 controls and switches were not identified to indicate their function;
15.1.4 emergency stop switches were not fitted to conveyors;
15.1.5 adequate motor isolation switches were not fitted;
15.1.6 there was no adequate labelling of motor isolation switches;
15.1.7 no rear guards were provided on conveyor drive chains and sprockets;
15.1.8 there was no adequate guarding of the chain and sprockets of the drive system for the oven.
15.2 Bread Improver Line No 2 was deficient in the following respects:
15.2.1 no safe working load was displayed on conveyors;
15.2.2 no permanent identification number was displayed;
15.2.3 controls and switches were not identified to indicate their function;
15.2.4 no emergency stop switches were fitted to conveyors;
15.2.5 no adequate motor isolation switches were fitted;
15.2.6 there was no adequate labelling of motor isolation switches;
15.2.7 no rear guards were provided on conveyor drive chains and sprockets;
15.2.8 there was no adequate guarding of the chain and sprockets of the drive system for the oven and on the flattening roller machine and the mixing machine;
15.2.9 nip points between driven rollers and conveyor belts on the multilevel inclined conveyor were not adequately guarded;
15.2.10 nip points between driven rollers and conveyor belts on the multilevel inclined conveyor were not adequately signed to warn the operator of the potential of being drawn into the nip point;
15.2.11 cover flaps/guards on the entry side of the multilevel inclined conveyor were not adequately secured.
15.3 Bread Improver Line No 3 was deficient in the following respects:
15.3.1 no safe working load was displayed on conveyors;
15.3.2 no permanent identification number was displayed;
15.3.3 controls and switches were not identified to indicate their function;
15.3.4 no emergency stop switches were fitted to conveyors;
15.3.5 no adequate motor isolation switches were fitted;
15.3.6 there was no adequate labelling of motor isolation switches;
15.3.7 no rear guards were provided on conveyor drive chains and sprockets;
15.3.8 there was no adequate guarding of the chain and sprockets of the drive system on the flattening roller machine and the mixing machine.
15.4 An inclined conveyor adjacent to an Agridy Dryer was deficient in the following respects:
15.4.1 no safe working load was displayed on conveyors;
15.4.2 no permanent identification number was displayed;
15.4.3 controls and switches were not identified to indicate their function;
15.4.4 no emergency stop switches were fitted to conveyors;
15.4.5 there was no adequate labelling of motor isolation switches.
15.5 A packaging machine identified as UBE model 67-2P, serial number R67, was deficient in the following respects:
15.5.1 there was no adequate guarding of the chain and sprockets of a number of drive systems;
15.5.2 a top cover was not fitted with an electrical interlocking device.
15.6 A packaging machine identified as UBE model 67-8BT, serial number 756 was deficient in that there was no adequate guarding of the chain and sprockets of a number of drive systems.
16. On 9 August 2000 the Prosecutor issued the company with 10 Improvement Notices ( Notices ) concerning deficiencies identified on 4 August 2000. Two of the Notices, Improvement Notices Nos. 198711 and 198712 concerned plant and equipment involved in Mr Zhu's accident on 4 August 2000.
17. On 15 August 2000 the Prosecutor received a facsimile from Mr Dahari of the Defendant, providing details of the injured person and a quote for the electrical work that was to be carried out as a result of the Notices.
18. On 12 September 2000, the Prosecutor received a call from Mr Dahari, a director of the Defendant, requesting an extension for the compliance with the requirements imposed by the Notices until 15 October 2000 due to the fact that two contractors that the Defendant has engaged to do the work could not complete the work on time. The Prosecutor accordingly granted the Defendant an extension to comply with the Notices until 15 October 2000.
19. On 6 December 2000, the Prosecutor visited the Premises to assess the Defendant's compliance with the Notices. A second factual inspection was undertaken by the Prosecutor. On arrival, the Prosecutor was met by Mr Eran Me-Tal, Manager of the Defendant and Mr Karwin Hamman, who then accompanied him during his inspection of the Premises. The Prosecutor observed that the Defendant had not yet complied with requirements imposed by Improvement Notices Nos. 198711 and 198712 in the following respects:
(a) Improvement Notice No. 198711 issued in respect of the conveyors on the Bread Improver Line No. 2:
(i) there was identified safe working load displayed on the conveyors;
(ii) there was no permanent identification number displayed;
(iii) the control switches were not identified to their function;
(iv) there were no emergency stop switches fitted to the conveyors;
(v) there were no rear guards on the conveyors' drive chains and sprockets.
(b) Improvement Notice No. 198712 issued in respect of the guarding of machines on the Bread Improver Line No. 2:
(i) there was no guarding of the chain and sprockets of the drive system on the oven;
(ii) there was no guarding of the flattening roller machine;
(iii) there was no guarding of the mixing machine
20. On 12 December 2000, the Prosecutor visited the Premises with the intention of assessing the level of compliance with the Notices. Present on that day was Mr John Buttriss, sole trader electrician, Mr Mark Nelson of Angelo Engineering, Mr Matt Ryan a contractor employed by Angelo Engineering, Mr Kirwin Hammam and Ms Vicky O'Brien of The Environmental Health Consultancy and Mr Eran Me - Tal, Bakery Manager of the Defendant.
21. On 15 December 2000, the Prosecutor issued two further Improvement Notices which required the Defendant to comply with the requirements imposed by the Notices by 8.00am on 8 January 2001. Present on that day was Mr Matt Ryan of Matt Ryan Engineering and a contracted party with Angelo Engineering.
22. On 5 January 2001, Mr Dahari of the Defendant requested that the Prosecutor attend the Premises to give advice and to see if anything further was required before the compliance date expired for the Improvement Notices issued on 12 December 2000.
23. On 12 January 2001, in the company of WorkCover Inspector Raj Garg, the Prosecutor visited the site at 4-6 Boola Avenue, Yennora, to assess the level of compliance with the two further Improvement Notices that were issued. On this day, Mr Eran Me-Tal, Bakery Manager of the Defendant, was present and it was identified that there were a small amount of additional items that were overlooked by the Defendant.
24. On 23 January 2001, the Prosecutor received a letter stating that the Defendant had completed the work as requested. On 31 January 2001, the Prosecutor visited the Premises and noted that the Defendant had complied with all Improvement Notices he had issued.