Detmold Packaging Pty Ltd

Incident description:

On 1 May 2008 a machine operator sustained degloving and crush injuries to her left hand while trying to remove a jammed paper bag from the rollers of a bag manufacturing machine.

The worker had operated the machine for several hours, and had experienced continued problems with the machine not sewing bags properly. The problem was fixed temporarily but then reoccurred.

Seeing a bag jam, the worker removed the guard by undoing the wing nut while the machine was still running.

When she pulled the bag it did not dislodge, but drew her left hand into the rollers.

The investigation findings presented to the court revealed:

• The machine's guard was originally secured by an 'allen head' nut requiring a special tool to remove it. The defendant modified this fixing of the guard, replacing it with a wing nut. The wing nut did not require any special tool to undo it.
• The production supervisor participated in unsafe work practices in the company of other workers while demonstrating or problem-solving plant operation.
• Unsafe practices of workers, including bypassing safety switches on plant, was brought to the notice of the site manager.
• These unsafe work practices were addressed only through administrative controls such as verbal warnings or procedural notes.
• The design and type of guards to be fitted were not specified by the defendant and were the responsibility of the maintenance fitter.
• The guards were fabricated or altered without reference to relevant workplace health and safety legislation, or the relevant Australian Standard - AS4024.

Court result:

The defendant pleaded guilty in the Brisbane Industrial Magistrates Court on 22 May 2009 to breaching s.24(1) of the Workplace Health and Safety Act 1995, having failed to meet its workplace health and safety obligations.

Industrial Magistrate Mr Walter Ehrich fined the defendant $32 000 as well as ordering investigation and court costs totalling $4000.09.

In deciding the penalty imposed Industrial Magistrate Ehrich acknowledged the defendant had not been prosecuted previously for any workplace health and safety breaches, had cooperated with the investigation and entered an early plea of guilty when ordering no conviction be recorded.

Considerations for prevention:

When working in the manufacturing industry where there is exposure to risks from plant with moving parts, obligation holders should apply a risk management approach to ensure the selection of suitable control measures.

Risk management involves evaluating the consequences and likelihood of harm that may result from the hazard, deciding on and implementing control measures to prevent or minimise the level of the risk from the hazard and monitoring the effectiveness of the control measures to ensure they remain working correctly.

When deciding on and implementing appropriate control measures associated with the use of plant, obligation holders should ensure that such tasks are undertaken by suitably qualified and experienced workers.

Control measures that may be considered when working with or near plant with exposed moving parts include:

• installing guards that comply with the manufacturer's recommendations
• restricting access to the exposed area
• enforcing the use of personal protective equipment when operating plant
• scheduling periodic checks and maintenance of plant
• implementing a system of work to clearly identify plant that requires repairs
• installing safety stop/latches to restrict or stop the movement of plant in an emergency
• implementing an emergency action plan to ensure emergencies are dealt with efficiently and effectively.

Visit the Workplace Health and Safety Queensland website for more information on:

• health and safety information for manufacturing
• manufacturing 
• Guide to safeguarding common machinery and plant  (PDF, 737kB)
• training staff and using control measures to manage risks associated with workplace hazards
• Plant Code of Practice 2005
• Risk Management Code of Practice 2007
• Workplace Health and Safety Act 1995.