Endeavour Foundation

Incident description:

On 28 June 2010, a 21 year old worker sustained injuries when his hand was crushed in a metal power press. The Endeavour Foundation employed the worker to use a metal power press in its manufacture of sheet metal rainwater goods.

The court found the defendant held obligations under sections 24(1) and 28(1) of the Workplace Health and Safety Act 1995 being a person conducting a business or undertaking.

The defendant was a non-government disability service provider employing persons with both physical and intellectual disabilities. The injured worker had left hemiplegia and a mild intellectual disability which rendered him unable to use his left hand and affected the left side of his body and associated analytical and perceptual tasks.

The investigation found that the worker's right hand became trapped between the dies of the press while he was processing metal pieces. He sustained fracture and laceration injuries to the fingers on his right hand, including tendon and artery damage.

The investigation findings presented to the court revealed:

• a documented risk assessment was carried out by a foreman of the Endeavour Foundation in May 2009
• the control measures required all guards to be in place, all operators trained, a safe work system used to control processes and start-up logs in place to ensure machinery was in good condition
• the procedure used to operate the press required the operator to manually lift the guard, place a metal work piece onto the die, pull and hold the guard down and depress the foot activation pedal to commence the die movement
• each day before work commenced the supervisor completed a Machine Operating Log (MOL) comprising a daily start-up check list. The MOL for the press only required that the guard appeared complete and was fitted to the machine
• the supervisor who checked the operation of the guard system on the day said that she only raised the guard less than a finger thickness
• the defendant's only inspection and maintenance program for the press or its guarding system was a monthly grease and oil service and the daily start-up check
• the mechanical linkage between the operator manipulated guard door and the clutch/fly wheel was defective due to wear. It was possible to raise the guard up approximately 70mm from the fully closed down position while the press was operating
• activating the emergency stop button on the press only isolated the electrical power to the press and did not immediately cause the press to cease motion. It may have taken up to one minute for the flywheel to come to a stop
• the injured worker was not told the press would not come to an immediate stop if the emergency stop button was pressed
• the exact sequence of events that caused the incident were not able to be confirmed by Workplace Health and Safety Queensland or the defendant
• an investigation report prepared by the defendant's OHS Manager showed that guarding of the press could be improved to ensure hand intrusion was not possible within the pressing area. It also found that the start-up log checklist did not recognise that the guard on the front of the machine could be raised sufficiently to allow hand intrusion

The injured worker was deemed 'not yet competent' on the press and was undergoing training for the machine, however was deemed competent on a similar machine.

Court result:

The defendant pleaded guilty in the Redcliffe Industrial Magistrates Court on 28 November 2011 to breaching s.24(1) of the Workplace Health and Safety Act 1995, having failed to meet its workplace health and safety obligations and was sentenced with no conviction recorded.

Industrial Magistrate Mr Alec Chilcott fined the defendant $40 000 as well as ordering investigation and court costs totaling $3309.90.

In reaching a decision, the Industrial Magistrate acknowledged the defendant failed to manage the hazards associated with the moving parts on the press and the system of work for the use of the press.

In deciding on the penalty imposed, Industrial Magistrate Chilcott took into account the defendant had previous workplace health and safety breaches for other unrelated matters in 1998 and 2001 but no previous recorded convictions, cooperated with the investigation and entered an early plea of guilty.

Considerations for prevention:

(Commentary under this heading is not part of the Court's decision.)

When working in the manufacturing industry where there is exposure to risks from plant, 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. This could include:

• tasks supervised or undertaken by qualified and experienced workers
• guarding controls that do not involve the operator e.g. fixed guards (consideration should be given to the physical and intellectual capacity of the operator)
• rigorous supervision, inspection, auditing, maintenance, monitoring and review of control measures to ensure the control is achieving the intended outcome
• application of Australian Standard AS 4024 – fixed guarding and the Plant code of Practice 2005 - guarding.

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

• managing risk
• employer training options
• training staff
• Guide to safeguarding common machinery and plant 
• How to Manage Work Health and Safety Risks Code of Practice 2011
• Work Health and Safety Act 2011.