Coronial Investigation Case Number: 0758-02

Incident Circumstances
Mr L was a 47 year old man employed as an Electrical Leading Hand (Instrument Technician) by a paper manufacturing company. He had worked for this company for over 30 years.

On the day of the incident, the machine that Mr L normally operated was undergoing a fault-finding maintenance operation. The machine was a guillotine with a large bucket used to scoop up paper rolls and feed them into the machine.

As the machine was not operating normally, a number of large rolls of paper (up to 3m in diameter and 1.5m tall) had banked up on the factory floor near the machine. During the maintenance operation, Mr L walked between the paper rolls and the machine.

Mr L was caught between the lowering bucket of the machine and a nearby large roll of paper. He received severe neck injuries and was airlifted by ambulance to hospital where he subsequently died later that day.

Coronial investigation and Findings
The Coroner’s investigation found that Mr L had died from gross neck trauma. The Coroner found that;

“(Mr L’s) death was preventable. Simple safety controls or systems common to many items of plant could have avoided the outcome. There was a failure to adequately supervise for safety and thereby to manage obvious safety hazards.”

The Coroner listed various indicators of failure in overall safety supervision in this incident which are summarised as follows:

• The hazard surrounding moving machinery and the loading (or production line) operation (rolling the rolls onto the bucket) was not identified.
• Apparently it was common for pedestrians to move between the paper rolls and the moving bucket on the Reel Splitter line.
• The bucket area was not isolated from the pedestrians by appropriate guarding. The then operating guarding system did not comply with Australian Standard (AS. 4024.1).
• The paper rolls were permitted to bank up creating a congested area around the Reel Splitter line.
• The controls for the machine (bucket operation) were in a position where the bucket area could not be properly seen (a safety design issue). The position of the operator controls did not comply with Australian Standard (AS. 4024.1).
• Staff were unclear on the company’s hazard identification and risk management procedures. As a result Job Safety Analyses were not undertaken routinely.
• The machine was operated by an individual (maintenance contractor) who had not been trained in its operation or the Company’s hazard identification procedures. He was not adequately supervised by a staff member with sufficient training and knowledge of risk management procedures and hazard identification.

The Coroner also commented that:

“Failure to identify trapping points or to exclude pedestrians from hazardous areas of plant are also factors. Hydraulics are a common mechanism for moving parts of machinery and are regularly seen being involved in deaths at work.”

Recommendations
The Coroner made several recommendations in this finding which are summarised as follows:

• Hazard identification systems need to include an audit of compliance with Australian Standards and relevant plant regulations
• The manufacturing industry should regularly audit its workplace design and layout to ensure compliance with Australian Standards and relevant plant regulations with a view to ensuring:
• Exclusion of pedestrian traffic around plant or production lines
• that trapping points are guarded, and
• the operator’s panel is positioned to eliminate blind spots.
• Employers in the manufacturing industry should take a holistic approach to overall factory safety and risk management. It is essential that supervisors are appropriately qualified, trained and understand both production and OH&S management issues.
• It is vital that all personnel working with machinery in a factory or manufacturing environment be trained (and re-trained) in the relevant company’s risk management and hazard identification procedures.