22 In the context of the above well established sentencing principles it will also be necessary to have regard to those general matters going to aggravation, mitigation and other factors identified in s 21A (1) of the CSPA relevant to the defendant. As was said in R v Way at [56]:
... it is not to be overlooked that there is a well established body of principles that have been developed by the courts over a long period of time. By providing guidance in the form of a list of aggravating and mitigating factors in s 21A, the Parliament did not intend to overrule or disturb those principles or restrict their application. In so far as those principles refer to factors, whether objective or subjective, that affect the 'relative seriousness' of the offence, they are expressly preserved by s 21A(1)(c).
23 In addition to the above general principles, given that the defendant has been charged with two offences arising from the same incident, the principal of totality is relevant to any penalty that I impose. I will consider the principle of totality in the sentencing process in due course.
General considerations
24 It is agreed between the parties that as the defendant has no prior convictions, the maximum penalty is $550,000 for each offence.
25 A preliminary issue that was raised in the hearing of this matter was whether I could be satisfied that there was a causal nexus between the failures of the defendant, and the ultimate injury sustained by Mr Thatcher. It was submitted by counsel for the defendant that there was inadequate evidence to establish the manner in which Mr Thatcher sustained his injury. According to counsel for the defendant, it was not sufficiently established whether Mr Thatcher sustained his injury by dint of a part of the crane striking him, or if he sustained his injuries in the course of attempting to avoid the crane as it broke at the adaptor link.
26 It is correct that there were no eye-witnesses to the incident, and that Mr Thatcher was simply found lying on the ground after suffering a traumatic subarachnoid haemorrhage. The fact that Mr Thatcher was found lying on the ground in the immediate vicinity of the hydraulic brick grab when it snapped off at the adaptor link and fell to the ground raises a strong inference that, in falling, it struck Mr Thatcher. Alternatively of course, Mr Thatcher may have tripped and fell when he sought to take evasive action from the falling brick grab. In any event it is not necessary for me to determine beyond reasonable doubt a causal relationship between the risks to safety pleaded and any specific death or injury that arises They are matters which arise to be considered as part of the objective seriousness of the offence. By entering a plea of guilty to both offences the defendant has embraced without demur its failures as pleaded and, in doing so, has accepted the causal link between them and risks to the health and safety of its employees that arise as a result of the failures particularised. In WorkCover Authority of NSW (Inspector Farrell) v Ross Collin Morrison [2001] NSWIRComm 325, Walton J stated at [43]:
It is not necessary to arrive at a precise conclusion as to how the accident occurred. It is now axiomatic that the general duties created by the Act are directed at obviating risks to the health and safety of persons in the workplace rather than to the circumstances or causes of a particular accident.
27 The work performed by Mr Thatcher, which resulted in the injuries sustained, involved the operation of a potentially hazardous piece of machinery with inherent risks to health and safety. Accordingly, there was a clear obligation on the part of the defendant to ensure that the system of work in respect of that machinery was not such as to present a risk to the health and safety of its employees.
28 The issue of foreseeability is a central consideration when assessing the culpability of a defendant. As was stated in Capral, the presence of foreseeability 'will necessarily result in the offence being more serious in nature'. As such, the starting point for the determination of foreseeability within the context of the objective seriousness of an offence is whether there was 'an obvious or foreseeable risk to safety against which appropriate measures were not taken'. ( Lawrenson Diecasting at 476).
29 The agreed statement of facts discloses that prior to the accident of 12 September 2002, the defendant was aware of at least two other incidents involving failure in the adaptor link of the crane. The first of those failures occurred on 23 May 2001 when one of the cranes, which was being operated by Mr Bruce Byron (the Byron incident), broke at the adaptor link. The evidence before me does not clearly indicate the circumstances in which this break occurred. Discussions ensued following this incident between the Defendant, Transpec, as distributor of the crane, and Heavy Duty Hydraulics (HDH), as designer and manufacturer of the crane, to ascertain the cause of the breakage. Mr Hank Jager, an employee of HDH, inspected the adaptor link and concluded that the source of the problem was most likely operational abuse or error. According to the agreed facts:
... no analytical testing of the weld was undertaken or recommended by the Defendant or HDH.
30 As a result of this incident, HDH and the defendant agreed that all trucks in the defendant's fleet fitted with the relevant crane would 'call past' HDH and get the linkages, including the adaptor link, checked. The defendant, however, only contacted some and not all of the drivers whose trucks were fitted with the crane. According to the Inspections Spreadsheet prepared by Mr Fullerton and tendered by the prosecutor, of the thirteen cranes in operation within the defendant's fleet at the time, excluding the crane involved in the Byron incident, five were not inspected, including Mr Thatcher's crane.
31 The other incident of which the defendant was aware prior to the incident of 12 September 2002, occurred on 4 September 2001. On that occasion, a truck in the defendant's Clay and Concrete Fleet, fitted with the crane, was being driven by Mr Gary Bennett (the Bennett incident) when the adaptor to the grab broke whilst the crane was stationary on the truck. This occurred, notwithstanding that Mr Bennett had taken his truck to HDH for inspection of the adaptor following the Byron incident. As with the Byron incident, no analytical testing of the adaptor was conducted, nor did the defendant carry out a formal investigation into the incident or implement a recall to alert drivers within the defendant's fleet of the potential for breakage in the adaptor.
32 In short, there was no immediate or systematic process put in place to ensure that all drivers were contacted and all of the cranes recalled for rigorous inspection, as would have been expected in the circumstances.
33 In addition to these two incidents, and after 12 September 2002, the defendant became aware of two other problems that arose with respect to the adaptor link, that had occurred prior to the accident involving Mr Thatcher. On 17 June 2002, Mr Andrew Graham, a driver in the defendant's Fleet, identified cracks in the adaptor and arranged for them to be repaired by HDH. Likewise, on either 18 or 19 August 2002, Mr Ray Willis identified cracks in the adaptor of the crane fitted to his truck and arranged for HDH to repair the problem. The defendant only became aware of these two incidents after the accident of 12 September 2002 involving Mr Thatcher.
34 Irrespective of whether the defendant identified a common problem in the adaptor link before the incident of 12 September 2002, including that attached to Mr Thatcher's truck, the potential for risk to the safety of employees if the adaptor link was faulty meant that it was incumbent upon the defendant to be satisfied as to its operational integrity. Subsequent analysis testing revealed, inter alia, the use of high carbon steel in one component of the three-part adaptor. The consequences of using that material were set out by Mr Fullerton in his affidavit at [35]:
... The use of 'high carbon steel', would normally require highly specialised welding techniques to ensure a proper weld. The failure to use these techniques could result in internal 'non-visible' cracking that could be a cause of the failure.
35 As a result, in December 2003, after previously having re-welded the adaptors following the 12 September 2002 incident, new one-piece adaptors were fitted to all the relevant cranes in the fleet.
36 As the defendant has conceded, the training that was provided to Mr Thatcher in the operation of the crane was inadequate. As the agreed facts disclose no formal training or instruction was provided with respect to the safe operation of the crane, including the safest position in which Mr Thatcher should be positioned when operating the equipment. Any knowledge Mr Thatcher had acquired about operating the crane was largely informal, on the job experience.
37 Following Mr Thatcher's accident, the defendant engaged the Driver Education Centre of Australia (DECA) to undertake an investigation into the cause of the accident. According to the affidavit of Mr Fullerton, the ensuing report made the following recommendations, which were subsequently adopted by the defendant:
(a) 12-month inspection of equipment to be carried out by qualified technicians;
(b) That the remote control unit be used at more sites;
(c) Equipment faults should be reported and repaired;
(d) Operators (sic) should be instructed on the correct method for inspecting equipment during daily operations; and
(e) Guidelines for unloading on unsuitable sites should be put in place.
38 With respect to point (b) above, Mr Fullerton annexed to his affidavit a Safe Work Method Statement, which sets out the procedures that operators of the crane should undertake prior to, and during, the crane's operation.
39 Dealing firstly with the offence pursuant to s 8(2) which identifies a failure of the defendant to 'instruct' Mr Thatcher in the safe use of the crane. As already stated, Mr Thatcher was not adequately trained by the defendant in the operation of the crane. As was said by the Full Bench in Genner Constructions Pty Limited v WorkCover Authority of New South Wales (Inspector Guillarte) [2001] NSWIRComm 267 at [58]:
... in all cases, adequate training will necessarily involve the provision of such information and instruction as will fully equip employees to safely perform work which they are expected to undertake, including the provision of training as to all contingencies arising out of or relating to the performance of such work. In short, the employer must educate the employee to deal with the full range of circumstances which may arise in the performance of work, including eventualities which are more unusual in character. Such education should involve processes designed to ensure that employees have fully understood the training afforded them (and re-training of employees, where necessary, to ensure the continued sufficiency of such education).
40 It is unclear whether, in the circumstances, more extensive training would have allayed the risk to safety that arose because of the failure pleaded in the offence arising pursuant to s 10(2). Proper adequate training and instruction may have involved Mr Thatcher operating the crane from the same position that he did on the day of the incident. If that had been the case he may still have fallen foul of the risk to safety the faulty adaptor link represented. It was not suggested that with adequate training Mr Thatcher would have been able to readily identify the problem in the adaptor link prior to the breakage. It may be that in being taught the correct method for inspecting equipment on a daily basis, Mr Thatcher may have noted cracking of the adaptor link. It is not possible to be conclusive on that point. In any event the offences of the defendant and the failure particularised with respect to each offence stand independently of each other.
41 Nevertheless given the factual circumstances of the offences I believe that of the two offences arising pursuant to the incident of 12 September 2002, the most objectively serious is that arising pursuant to s 10(2) with respect to the defendant's failure to ensure the crane was safe and without risk to safety. That will be relevant when I come to apportion penalty between the two offences consistent with the principle of totality.
42 Immediately following the accident involving Mr Thatcher, the defendant organised for all trucks operating the cranes to be withdrawn from work. The initial modifications undertaken by the defendant were set out by Mr Fullerton in his affidavit at [17]:
... Our workshop supervised the removal of the linkages (adaptors). The intention of this modification was to make the crane safe to operate until the failure of the linkages (adaptors) could be properly evaluated. The removal of the linkages (adaptor) reduced the level of articulation but was not considered a permanent solution. The modification was undertaken on advice from Transpec as an interim measure only.
43 Following from that, the existing welds on all adaptors were removed and the adaptors were re-welded on the inside and externally with more substantial welds.
44 As indicated above, ultimately a metallurgist found high carbon steel in one component of the adaptor which, with inadequate welding, was prone to cracks and subsequent breakage. As a result, a new adaptor was constructed and fitted comprising only one piece.
45 Counsel for the defendant submitted that the steps which ultimately led to identifying the fault in the adaptor link, were not immediately obvious prior to the incident of 12 September 2002. Certainly the steps take by the defendant to resolve the fault in the adaptor link were extensive. They included:
· Initially removing the adaptor links after the incident of 12 September 2002 involving Mr Thatcher, and subsequently examining each crane to ensure the modification had been effected and identify any other faults;
· Performing an x-ray on the adaptor links to identify any cracking in the existing welds;
· Undertaking the removal of existing welds on all linkages, and re-welding each adaptor on the inside and externally with a more substantial weld;
· Obtaining a report from a metallurgist to analyse both the original and modified adaptor links;
· Subsequently redesigning the adaptor link so that it comprised only one piece, as opposed to three pieces welded together which was the manner in which the adaptor link was constructed as at 12 September 2002.