Isis Central Sugar Mill Company Pty Ltd

Incident description:

A worker was inspecting the grates of a boiler at a sugar manufacturing company in order to determine how to re-light the furnace of the boiler. The boiler was in a hot 'banked' state, meaning the rate of combustion had been purposely reduced to a very low rate. As the worker was looking into the furnace of the boiler through an open furnace door, a fireball rolled out and engulfed him. The worker suffered burns to his face and hands.

Investigation findings:

Although the company provided safe systems of work and work procedures for preparing to light the boiler from a cold state, it did not provide this for preparing to light the boiler from a hot banked state. The company had not documented any specific requirement for personal protective equipment to be worn when opening furnace doors. The company could produce no evidence of having performed any risk management for boilers.

Considerations for prevention:

After the incident, the company developed and implemented a permit to work system for opening the furnace doors and provided additional training to all grounds staff.

Obligation holders should consider the requirements the Sugar Industry Code of Practice 2005, in particular part 3.1 Risk Management and part 3.6 Training. They should also consider the requirements of the Plant Code of Practice 2005, particularly part 1.8 Design to Facilitate Safe Use, part 5.4 Operation, part 5.2 Design and manufacture and 5.22 Instructing, Training and Supervising Workers.

Court result:

The company was found guilty and fined $20,000 with no conviction recorded

• Safe working in confined spaces
• Plant Code of Practice 2005