(1) Employees An employer must ensure the health, safety and welfare at work of all the employees of the employer.
That duty extends (without limitation) to the following:
(a) ensuring that any premises controlled by the employer where the employees work (and the means of access to or exit from the premises) are safe and without risks to health,
(b) ensuring that any plant or substance provided for use by the employees at work is safe and without risks to health when properly used,
(c) ensuring that systems of work and the working environment of the employees are safe and without risks to health,
(d) providing such information, instruction, training and supervision as may be necessary to ensure the employees' health and safety at work,
(e) providing adequate facilities for the welfare of the employees at work.
(2) Others at workplace An employer must ensure that people (other than the employees of the employer) are not exposed to risks to their health or safety arising from the conduct of the employer's undertaking while they are at the employer's place of work.
3 The charges are constituted by amended applications for order filed in Court on 11 September 2007. The defendants pleaded guilty to the charges as set out in the amended applications for order and this judgment deals with the question of penalty only.
4 The charges, although different in the sense that they relate respectively to ss 8(1) and 8(2) of the Act, are substantially in similar terms. That against Clarence alleges that "on or about 12 July, 2004, being an employer, at Clarence Colliery, a place of work situated at Lithgow in the State of New South Wales, failed to ensure the health, safety and welfare at work of all its employees, in particular Ben Houlison, Darren Baxter, Richard Sharp, Bradley Gordon, contrary to subsection 8(1) of the Act." The charge against Centennial alleges that that defendant was an employer, that it had a place of work situated at Lithgow and that it failed to ensure that the same named persons who were not its employees were not exposed to risks to their health and safety arising from the conduct of its undertaking while at its place of work.
5 The particulars of each of the charges were in identical terms namely:
"(a) The Defendant failed to provide or maintain an adequate system of work for tasks related to the floor trenching task (sometimes known as "floor brushing") including the removal of electrical cable during the process of re-locating ("flitting") a continuous mining machine in 609D panel of the said mine as it failed to prevent workers working in unsafe locations on or about the said continuous mining machine whilst it was not isolated.
(b) The Defendant failed to provide adequate information and instruction to persons not in the employment of the Defendant for tasks related to the floor trenching task including the removal of electrical cable during the process of re-locating a continuous mining machine in 609D panel of the said mine.
(c) The Defendant failed to undertake an adequate assessment of risks arising from tasks related to the floor trenching task including the removal of electrical cable during the process of re-locating a continuous mining machine in 609D panel of the said mine."
6 The sentencing proceedings against each defendant were conducted concurrently with evidence in the one being evidence in the other.
7 There was tendered into evidence a statement of agreed facts which is in the following terms:
"1. Clarence colliery is an underground coal mine situated approximately 15 kilometres east of Lithgow (Clarence Colliery). Approximately 138 persons worked at the colliery in July 2004.
2. The following facts applied at all material times.
COMPANIES INVOLVED WITH CLARENCE COLLIERY
3. Centennial Coal Company Ltd (Centennial) was a corporation whose registered office was situated at BT Tower, Level 18, 1 Market Street, Sydney, NSW.
4. Clarence Coal Pty Ltd (Clarence Coal) was a corporation whose registered office was situated at BT Tower, Level 18, 1 Market Street, Sydney, NSW.
5. Clarence Colliery Pty Ltd was a corporation whose registered office was situated at BT Tower, Level 18, 1 Market Street, Sydney, NSW.
6. Clarence Colliery was owned by the participants in the Clarence Unincorporated Joint Venture (UJV). The UJV comprised Coalex Pty Ltd which had a 51% participating interest, Clarence Coal Investments Pty Ltd which had a 29% participating interest, Japan Energy Australia Pty Ltd which had a 5% participating interest and SK Australia Pty Ltd which had a 15% participating interest. All those companies except SK Australia Pty Ltd were wholly owned subsidiaries of Centennial. Through these companies Centennial indirectly owned an 85% interest in the Clarence Colliery.
7. Clarence Coal and Clarence Colliery Pty Ltd were wholly owned subsidiaries of Coalex Pty Ltd.
8. The UJV designated Clarence Colliery Pty Ltd as the operator of Clarence Colliery.
9. Clarence Colliery Pty Ltd did not employ any person at Clarence Colliery. The UJV paid the costs of Clarence Colliery Pty Ltd, including the cost of paying all of the persons who worked at Clarence Colliery who were employed by Clarence Coal. These employees included Jeffrey Savage, Paul Field, Darren Baxter, Richard Sharp, Bradley Gordon and Ben Houlison.
10. Centennial had interests in the following collieries through other companies: Angus Place; Anvill Hill; Awaba; Berrima; Charbon; Cook; Ivanhoe; Mandalong; Munmorah; Myuna; Newstan; Springvale; and Wyee (Centennial Group).
EMPLOYEES OF CENTENNIAL
11. The Managing Director of Centennial had responsibility for all aspects of the business of the Centennial Group, including safety and risk management .
12. The other directors of Centennial were involved in the promotion and monitoring of occupational health and safety (OHS) performance, across the Centennial Group.
13. Centennial employed and appointed the Mine Manager of Clarence Colliery. The Mine Manager had responsibility for all activities at the site including OHS, environment, production and employee matters. The Mine Manager, pursuant to the Coal Mine Regulation Act 1982 and its subordinate Regulations, controls the colliery site.
14. The Mine Manager of Clarence Colliery was also the General Manager of Clarence, Charbon, Berrima and Ivanhoe collieries. The General Manager in his position as Mine Manager was based at Clarence Colliery on a day-to-day basis. The other collieries each had their own Mine Manager with responsibility for all activities at the site including OHS, environment, production and employee matters.
15. The Centennial Group had several operational General Managers who each oversaw a number of collieries.
16. Centennial also employed the Chief Operating Officer (in July 2004 the position of Chief Operating Officer was designated as General Manager Operations) Manager Safety and Systems; and Group Coordinator OHS Systems. These employees visited Clarence Colliery, as well as the other collieries in the Centennial Group, as part of their duties.
17. The said Chief Operating Officer had Centennial Group wide responsibility for all aspects of operations including OHS, environment, financial performance, production performance. His duties included monitoring the implementation of, providing leadership for, and promoting OHS in the Centennial Group.
18. The said Manager, Safety and Systems had Centennial Group wide responsibility for promoting, advising and monitoring OHS performance.
19. The Manager, Safety and Systems and Group Coordinator OHS Systems carried out internal audits of all collieries against each individual colliery's implemented systems.
20. Under the Coal Mine Regulation Act 1982 (NSW) (CMRA) the duties and functions of the Mine Manager were extensive and of a high level of responsibility. They included the Mine Manager having full charge and control of all employees at the colliery and all operations at the colliery (section 37(1)(d)). The Coal Mines (Underground) Regulation 1999 also imposed duties on the manager of a colliery.
21. The Mine Manager had the highest level of on-site supervisory control of matters at Clarence Colliery and responsibility or control over all OHS matters at Clarence Colliery.
MEETINGS AND REPORTS OF CENTENNIAL
22. The directors of Clarence Coal and Clarence Colliery Pty Ltd were the same persons who were the directors of Centennial. The Boards of Directors of Clarence Coal and Clarence Colliery Pty Ltd did not have separate meetings from the Board of Directors of Centennial.
23. The Board of Centennial set policy on OHS matters, titled Safety and Risk Management Policy (Policy). The Chief Operating Officer applied the Policy through a strategy document, titled Health and Safety Risk Management Strategy (Strategy). The Policy and Strategy were provided to the collieries within the Centennial Group for implementation. Each colliery operated under different circumstances and as a result had to implement site specific systems.
24. The Board of Centennial required reports to be provided in order to monitor performance of the individual collieries in line with its Policy.
25. Centennial had a process in place to provide the Board with relevant information as to the operation of the collieries. Mine Managers were required to supply reports on a monthly basis (Mine Manager's Reports), to the Chief Operating Officer, who in turn prepared a report for the Board to review (Chief Operating Officer's Report).
26. The Mine Manager's Reports addressed:
a) safety and risk management (which includes positive performance indicators, safety activities, lag performance indicators and monthly injury and notifiable incidents);
b) environmental (which includes incidents/non-compliance and performance);
c) operations and production (which includes information on development and extraction panels);
d) process and engineering measurements (which includes information on process performance);
e) cost variance analysis (which includes information on budget compliance);
f) technical services (which includes information on strata control, ventilation and colliery planning);
g) employment (which includes information on numbers of employees, sick leave, etc.);
h) industrial issues (which includes information on enterprise agreement negotiations); and
i) statutory (which includes information on regulatory compliance).
27. The General Manager's Reports summarised the Mine Manager's Reports.
28. The Board of Centennial considered the General Manager's Reports at its monthly meetings and used them to monitor colliery performance against its Policy. The Managing Director and Chief Operating Officer attended the monthly Board meetings. The Manager Safety and Systems attended those meetings when requested to advise on strategic approaches to OHS.
29. The Board visited one of the Centennial Group's mining regions twice per annum. On each visit they would visit multiple collieries, conduct at least one underground inspection and hold their Board meeting at one of the collieries. In March 2004 the Board visited the Western district, conducted an underground inspection at Clarence Colliery and held their Board meeting there.
30. All budgets across collieries in the Centennial Group are generated by each colliery's Mine Manager and his team. The budget would then be presented to the Chief Operating Officer, finance and marketing who would then consider the budget and a budget document would then be produced and presented to the Board.
31. The Board was responsible for approving budgets for each colliery annually. The Board relied upon information and advice from Mine Managers and the Chief Operating Officer in approving the budget. The Centennial management team monitored the budget for Clarence Colliery.
32. The Chief Operating Officer provides a weekly report, which has information on safety statistics (positive and lag indicators) and incidents for all collieries within the Centennial Group, to the Managing Director (Weekly Report). The Weekly Report was prepared using information provided by operational General Managers.
33. The Group Coordinator OHS Systems also provided monthly reports to the Manager Safety and Systems who in turn provided monthly reports to the Chief Operating Officer. These reports covered all collieries within the Centennial Group and were used by the Chief Operating Officer in the Chief Operating Officer's Report to the Board of Centennial. Annexed and marked A is an example of the Manager Safety and Systems' report, which is titled "Centennial Coal Safety and Risk Management Report", dated June 2004.
34. The Chief Operating Officer received daily and weekly reports from the operational General Managers about safety and incidents at their collieries.
35. If there was an accident at a colliery a safety alert was put on Centennial's Wide Area Network (WAN), by the Mine Manager, which is then sent to each individual account on the WAN and is unable to be deleted until opened.
36. The Chief Operating Officer convened a meeting of all Mine Managers and operational General Managers of collieries within the Centennial Group quarterly. The first item of the agenda was safety. The Managing Director attended approximately one in every three of these meetings.
CENTENNIAL POLICIES AND ACTIONS
37. As previously identified, the Board of Centennial set policy on OHS matters. These policies included the Policy and an Occupational Health and Safety Consultation Policy. Both these policies were signed by the Board and provided to the collieries within the Centennial Group for implementation. When adopted by the collieries, they were signed by the Mine Manager. They were incorporated in the Clarence Colliery's Mine Safety Management Plan. Annexed and marked B is a copy of the policies applied at Clarence Colliery, dated 4 September 2003.
38. The Board of Centennial commissioned a modified OHS management systems audit. Annexed and marked C is a copy of audit titled "Final Report Occupational Health and Safety Management Systems Audit, Centennial Board of Directors", dated August 2003 (2003 Audit).
39. The Board considered the 2003 Audit and commissioned the preparation of an action plan. Annexed and marked D is a copy of This action plan titled "OHS Audit 2003 Action Plan".
40. Centennial commissioned audits specific to collieries. Annexed and marked E a copy of a Jim Knowles Group audit on Clarence Colliery.
THE INCIDENT
41. On 11 and 12 July 2004, miners were required to carry out tasks associated with lowering the floor level in "D" heading of the 609 panel of Clarence Colliery (609D panel). This job (also known as "floor brushing" or "floor trenching") involved the use of a remote-controlled continuous mining machine to cut a trench in the floor to a depth of about one metre. One of the tasks related to the floor brushing was the removal of electrical cable during the process of relocating ("flitting") a continuous mining machine in 609D panel. Cable-handling is a core risk of the continuous miner.
42. Mr Savage held the position of Undermanager in charge at Clarence Colliery, pursuant to s39 of the CMRA.
43. Mr Field held the position of Deputy at Clarence Colliery, pursuant to s. 42 of the CMRA. He had been appointed a Mine Deputy on 15 July, 2002. At the time of the events the subject of these proceedings, Mr Field had worked in the mining industry for approximately 12 years.
44. Mr Field was the Deputy in charge of 609D panel on the 11-12 July, 2004 pre-shift and night shift. Mr Field gave instructions to the work crew for the carrying out of the work, and allocated tasks to each of the miners.
45. In late June/early July, 2004, preparations were made for the carrying out of work in 609D panel, in order to remedy a problem involving water seepage, which if left unattended would have caused a ventilation hazard. This remedial work involved action to lower part of the floor in 609D panel, in the vicinity of "18 cut-through" in 'D' heading, so as to assist the drainage of excess water through the area.
46. On 29 June 2004, a surveyor inspected the relevant work site and painted a "grade line" on the rib (the wall) of the colliery, to assist mining personnel in grading the floor of the colliery to the correct level.
47. In the week prior to 11 July 2004, Undermanager in Charge visited the proposed work site and conducted an informal, on the job risk assessment of the work necessary to carry out the remedial task. In that week, the work site was also visited by Clarence Colliery's Mine Manager, who discussed the proposed work with the Undermanager in Charge, and day shift Undermanager. Floor brushing to the extent of cutting out a metre-deep trench was not an everyday task at the Clarence Colliery.
48. The Undermanager in Charge gave instructions for the carrying out of the work during the pre-shift of Sunday 11 to Monday 12 July, 2004. These instructions were discussed by the Undermanager in Charge and the Deputy on Friday 9 July. The instructions from the Undermanager in Charge were to cut an area of floor for 20 to 30 metres at a certain level (indicated by the grade line) to allow water to flow through. The undermanager in Charge also issued brief written instructions confirming the work to be carried out. The Undermanager in Charge left these instructions in his office written on a "pad" for the Deputy to tear off as his instructions. Relevantly to this job, they stated:
· "DEP - REQD FOR BRUSHING 18 - 19D 609D, GRADE MARX UP ON RIB TO SUIT HEAD HEIGHT, S/Cs TO STOW SPOIL SEE DIKS NOTE FOR LOCATION IN A/S 9/7 UMGRS REPORT
· SHARPY - SET UP CM4 FOR BRUSHING FLOOR 18 - 19D AND GO
49. The task involved the use of a remote-controlled continuous mining machine to cut a trench in the floor, approximately 4 metres wide and 1 metre deep. The pre-shift crew were assigned to the floor brushing task. As the task was not completed by the end of the pre-shift, Mr Sharp remained to assist the Deputy and oncoming night shift crew to complete the work task. Inexperienced miners Messrs Houlison and Baxter arrived with the night shift crew in 609D panel at approximately 1am on 12 July 2004.
50. The work task required the re-location of the continuous mining machine to the work site.
51. When the floor brushing was completed, the distance between the floor and roof, in the vicinity of 18 cut-through 'D' heading, had been increased by approximately one metre.
52. In order to relocate the mining machine to the next work location (for use by the day shift) it was necessary for the electrical cable to be retrieved from the roof-mounted "seagulls" upon which it had earlier been hung.
53. The usual method of cable retrieval using a handheld device, known as a "perch", was made more difficult due to the increased height of the roof.
54. Retrieval of the electrical cable was initially carried out by Mr Baxter, who climbed onto the "boom" of the continuous mining machine in order to reach the cable. Mr Baxter remained on the boom of the continuous mining machine while it was trammed to a location immediately underneath a "seagull". The boom was then raised (Mr Sharp operating the remote control machine, with Mr Baxter on the boom) to a height to enable Mr Baxter to remove the cable from its place on the seagull. Once this was done, the boom was lowered, and the machine trammed to the next seagull (with Mr Baxter still on it).
55. Mr Houlison climbed onto the machine to assist Mr Baxter in retrieving electrical cable from the roof. Messrs Baxter and Houlison made their own decisions to climb onto the mining machine and were not instructed to do so by Mr Field, or anyone else working in 609D panel.
56. Messrs Houlison and Baxter remained on the continuous mining machine while it was trammed from seagull to seagull, with the boom of the machine being raised and lowered to enable them to retrieve the machine's electrical cable. Electrician Mr Gordon also assisted by attending the cable to keep it from being pinched by mining machine tracks.
57. Use of the continuous mining machine as a "work platform" in this manner was contrary to safety rules applicable to those machines. Those rules required (inter alia) the enforcement of safety zones (known as "no standing" and "control" zones) around a continuous mining machine, during the operation of a machine.
58. Safety rules applying to the continuous mining machine required that it be correctly "isolated" prior to any person getting onto the machine, or entering a "no-standing" zone.
59. Messrs Houlison and Baxter remained on the mining machine as it was trammed from one seagull to the next. Mr Sharp, with Messrs Houlison and Baxter on the boom of the machine, was in the process of turning the continuous miner from 'D' heading into 18 cut-through. At this point the boom of the continuous miner was positioned under roof that was significantly lower as a result of geological faulting. Annexed and marked F is DWG No 7-135.2 plan, which depicts a cross section of the accident site. While engaged in this process, the mining machine pivoted, causing the boom of the machine to move suddenly towards the roof of the colliery where Mr Houlison was crushed. The accident was not caused by any defect in the continuous mining machine. Baxter took evasive action and was not injured.
60. As a result of the accident, Ben Houlison suffered spinal injuries, resulting in paraplegia.
61. At the time of the accident, four persons (viz, Messrs Houlison, Baxter, Sharp and Gordon) were located within the "no standing" zones of the machine, although only Mr Houlison suffered actual injuries.
62. Mr Field, was nearby, but not in the immediate vicinity, when the accident occurred. Mr Field was aware that the continuous mining machine was being used as a work platform to recover cable from the roof.
63. The unsafe handling of electrical cable using the continuous miner when not isolated had occurred on previous occasions at the mine."
8 It will be observed that [3] to [40] deal in essence with the respective functions of Clarence and Centennial. I shall return to this aspect of the matter after considering such evidence as is available with respect to the incident that gave rise to the proceedings. The description of that incident and other matters associated with it are contained within [41] to [63] of the statement of agreed facts.
9 There were two aspects of the incident that became significant for the purpose of these proceedings. The first involved the use of the boom, which was part of the continuous mining machine, to lift up the two employees concerned so that they could reach the cable and unhook it. It was submitted by the prosecutor and agreed by the defendants that there was other equipment available consisting of what, in effect, was a front-end loader with a basket replacing a bucket as a means of raising and lowering the employees which would have provided a far safer work environment. The second aspect was the fact that the continuous miner machine was being moved with the two employees situated on the boom at the time that the incident occurred. This of itself created a dangerous situation, especially in the circumstances of what in fact occurred. Superimposed upon these two aspects was the fact that procedures established by both defendants prohibited any person being in the near vicinity of the continuous miner machinery whilst it was capable of being operated, including the raising and lowering of the boom and its movement across the floor of the mine area. The defendants conceded that all of these matters were comprehended within the task of removal of electrical cable referred to within paragraph (a) of the particulars of the charges.
10 Some first hand account of what occurred is contained in an extract of evidence given in proceedings before the Chief Industrial Magistrate by Graham Collier, which was tendered into evidence in these proceedings. It was Mr Collier's evidence that he was able to observe the continuous miner machine moving. He saw a person on the back of the miner, presumably the boom, taking cable off a seagull and appearing to have trouble doing so. He then observed, "The other chap got up on to the miner to help lift the cable off and they lifted the cable off the seagull and dropped it down to the ground. The machine then appeared to start moving forward and started turning round to the left. At this stage, both men had either sat on the side of the boom or sat in the boom. As the miner went around, started to go around the corner I described it as the machine rocked up violently towards the back. One man dived into the boom and the other man wasn't quite quick enough to get down quick enough, and basically that's it."
11 Although Mr Collier did not observe the area on which the machine was moving at the time, he had an opportunity of doing so "later". He observed that the floor was uneven with the right-hand side of the cut having been made deeper than the left side. He thought that there might be "six inches, maybe a foot height difference in the floor." It may be inferred beyond reasonable doubt that this is what caused the boom of the miner to be suddenly propelled vertically so as to crush Mr Houlison as it moved over this uneven area.
12 For completeness, I observe as is made plain in the statement of agreed facts that the circumstances in which the work was being carried out at the time of the incident was in breach of established protocols requiring all persons to stay clear of certain "No Standing" and "No Go" zones around the continuous miner machine whilst it was "active".