SafeWork NSW v Silver Raven Pty Ltd

SafeWork NSW v Silver Raven Pty Ltd - [2025] NSWDC 8 - NSWDC 2024 case summary — Zoe

[6]

The incident

On 1 September 2021, Mr Notaras and Mr Anderson were undertaking high pressure water jetting works on pier 3 of the bridge.
Access to the work location on the pier was via a barge, provided and operated by John Holland. The barge was anchored to the bridge footing located west of the bridge in the river. On the barge, Mr Notaras and Mr Anderson set up the water pressure gun and pump. They were wearing a double face protection helmet, glasses, a mask, steel capped boots, general non-gauntlet gloves and a life vest. The life vest was a requirement of John Holland for working in close proximity to the river.
Mr Notaras walked onto the pier from the barge. From the pier he was operating the gun/lance to high pressure wash timber at the base of a 3.6m deep, 300mm diameter core hole within the concrete caisson of the bridge. Mr Notaras was kneeling whilst operating the gun and placing his body weight on the gun.
Mr Anderson was operating the pump from the barge. Adam Johnstone, a leading hand from John Holland was also present observing the works.
Due to the depth of the hole and the steam coming out, Mr Notaras could not see the bottom of the hole.
At approximately 4:22pm, the metal connector between the gun assembly and the hose failed. The hose blew away from the gun. The stainless steel nuts stayed on the hose and flicked around for a short period of time until Mr Anderson was able to hit the emergency stop button. The metal joiner from the hose to the lance was damaged in the process and sheared off.
Mr Notaras dropped the gun and the hose struck him, resulting in serious injuries to his right arm. Mr Notaras' arm was wrapped up by Mr Johnstone and emergency services were called.
Following the incident SafeWork NSW seized the plant and equipment involved in the incident and conducted an inspection which identified: 1. that the safety shroud was worn, and there were no cam buckles to attach the strap of the safety shroud to; 2. the male plug in the connector was damaged during the high-pressure jetting operation and broke off through mechanical force; and 3. the high-pressure connector failed at the maximum operating pressure of 2500 bar, which was below the 4000 bar pressure rating of the connector.
Inspector Li opined that the black strap on its own could not secure the safety shroud in the event of a hose failure. The whip socks could not be restrained to any opposed shackle points.

[8]

Systems of work prior to the incident

The offender had a documented health and safety management system which included a master Safe & Environmental Work Method Statement (SEWMS). In addition, the offender had documented Plant and Equipment Risk Assessments, inspection checklists, toolbox talks and pre-start risk assessments.
On the day of the incident, Mr Notaras was not wearing Kevlar blast gloves or gaiters or any other Kevlar personal protective equipment (PPE) such as a jacket and pants. PPE was stored in cabinets in the work trucks, however, workers were not required to wear the Kevlar PPE on the day of the incident.
The offender had a site specific Safe Work Method Statement (SWMS) dated 13 August 2021 that made reference to AS4233. The SWMS: 1. addressed the risks of pump failure during high-pressure jetting works and identified all components shall be inspected, serviced and generally maintained in accordance with the manufacturer's specifications; 2. identified the risk of incorrect PPE for flex lancing works resulting in injury; 3. in relation to "working in or around water" noted "barricade areas unsafe to access" and "risk assess if workers are safe to carry out task"; 4. identified as a potential hazard "incorrect hose assemblage and failure to perform visual inspections prior to use, resulting in high-pressure hose or equipment failure causing serious injury or death". The SWMS also listed control measures for this risk including to conduct pre-start visual assessment of equipment for damage, fit hose stockings and hose restraint to all viable hose connections and check all hose joiners are the correct type and hoses are rated for the correct pressure.
The SWMS specified the following PPE to be worn by the high pressure gun work operator: 1. Kevlar Blast pants; 2. Kevlar Blast jacket; 3. Steel cap gum boots with Blast gaiters or Blast boots; 4. double eye protection; 5. helmet with face shield; 6. adequate gloves; and 7. hearing protection.
In the weeks leading to the incident, Mr Notaras and Mr Anderson raised an issue with the offender's HSEQ Manager, Kirby Mugford, regarding the weight of wearing the Kevlar suit whilst performing the works. Undated handwritten amendments were made to the SWMS by Ms Mugford in consultation with Operations Manager, Billie Dowds, Mr Anderson and Mr Notaras, removing the requirement for the gun operator to wear Kevlar jacket and pants during gun work.
The handwritten amendments to the SWMS were signed by Mr Anderson and Mr Notaras and stated, "No need for Kevlar Jacket/Pants as Gun is in Casing with 3.6m of Lance".
There was a revised version of the SWMS dated 24 August 2021 (revised SWMS) which incorporated the earlier handwritten amendments.
Ms Mugford and Mr Anderson stated to SafeWork NSW that the amendment was due to the risk of workers falling into the water whilst wearing the PPE suit. The revised SWMS did not contain other control measures to address the risk of working near water that would still require the use of Kevlar PPE to address the risk of working with high pressure water equipment.
There was no adequate hose restraint system in place at the time of the incident. The hose being used by Mr Notaras was fitted with a twin eye whip sock. The whip sock was not, however, secured to any shackle points or tied to any anchor points.
The Kevlar Sleeve/safety shroud used at the time of the incident to cover the joiner did not have cam buckle strap restraints to keep the shroud attached to the gun/lance assembly if the connector failed and a hose separator occurred. On the day of the incident, the shroud had been cable-tied onto the gun/lance assembly. Mr Notaras had not been trained or instructed in the use of cam buckle restraints for the shroud.
The offender had a Pre-Start Inspection and Maintenance Manual which included a pre start inspection/maintenance procedure which required: 1. check the hose connection fitting for damage; 2. hose connections to equipment or other hoses are restrained with braided stockings or are restricted in some other suitable way to stop their movement if the hose end fails; and 3. the Manual makes reference to AS4233.12013 5.5.1.2 Restraints.
The hose involved in the incident only had whip socks on one end which did not comply with the relevant Australian Standard or the requirement in the offender's documentation.
On the morning of the incident, the job pre-start risk assessment and prestart inspection checklist were conducted, with the checklist having identified the hoses and fittings used by the offender's workers were in good condition.
Mr Notaras said that prior to undertaking high pressure water jetting works every morning, that workers could generally check the hoses and make sure they had safety shrouds.
Prior to work commencing at 7:40am, Mr Anderson completed a High Pressure Water Blasting Equipment Prestart Equipment Checklist dated 1 September 2024. The checklist identified that in the event of non-compliances detected in the colour red "Do not operate, notify supervisor".
The pre-start inspection checklist used on the day of the incident did not record that the shroud was missing cam buckle restraints or reference a specific requirement that the connector/shroud to be restrained. The job pre-start form completed on 1 September 2021 identified the risk of "pump failure" but did not record a potential hazard of failure of the gun/lance.
A toolbox talk was completed by Mr Anderson and Mr Notaras on the day of the incident. The toolbox talk identified "HPW Injuries" as a risk.
Following each shift Mr Anderson would take the equipment apart, check it and re-grease them. Ms Mugford would visit the site twice a week.

[12]

About the offender

The offender commenced trading in 1998 providing mostly civil construction and demolition works. In or around 2008, the offender commenced high pressure water jetting services with Class B pumps.
The offender, at the date of Ms Eliades affidavit, employed 22 people in its business, including office-based management and administrative staff. The number of employees has halved since the incident on 1 September 2021.
Mr Flanagan is currently the Operations Manager. He has 26 years industry experience, holds a HPWJ Operator ticket and multiple other high-risk work licences. At the time of the incident, Billie Dowds was the operations manager. Ms Dowds held a Certificate IV in Project Management and other high-risk work licences.
Simon Namura Alves is the Hydro Manager. Mr Namura Alves is a civil engineer with 11 years' experience in the hydro industry. His responsibilities include ensuring the hydro plant and equipment is serviced and maintained and confirming appropriate equipment is assigned to hydro projects. At the time of the incident the Hydro Manager was Douglas Catt, who had 14 years' experience in the hydro industry. It is a requirement that the Hydro Manager hold a HPWJ Operator Ticket.
The offender employs eight Project Managers, who report directly to the Hydro Manager. All Project Managers are tertiary qualified civil or mechanical engineers. Those who supervise hydro work hold HPWJ Operator tickets. These managers are responsible for: 1. selecting the equipment for use for the project; 2. confirming the correct set up of equipment on site; 3. ensuring the SEWMS and pre-start processes are completed; 4. ensuring the crew understand their role; 5. ensuring PPE is worn; and 6. overseeing the operation of the equipment.
Since early November 2017, the offender has dedicated a resource to assist managing its health and safety responsibilities. Since this time the role has either been filled by a permanent employee or an external consultant. At the time of the incident, Ms Mugford filled the HSEQ Manager role. She held a Certificate IV in Work Health and Safety, HPJW User ticket and other high-risk work licences. The offender's health and safety management is now completed with the assistance of an external consultant.
The offender currently has 11 live projects at various stages of completion.

At a glance

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Decision date

Source

Judgment (32 paragraphs)

Parties

Legislation Cited (1)

Cases Cited (4)