Porta Tas Pty Ltd
December 2021
The incident
A worker was trying to remove a piece of timber that had become jammed in the docking section of the dry line at timber wholesalers Porta Tas Pty Ltd. The machine was switched off however the saw blade continued to run for 3 to 4 minutes after being shut down due to 'rundown'.
As the worker was reaching in to free the jammed timber, his hand touched the unguarded, rotating saw blade. His right thumb was partially amputated; he needed surgery to re-attach his thumb.
Findings
Inspectors from WorkSafe Tasmania investigating the incident found:
- there had been a risk assessment conducted when the equipment was first installed, but despite cutting being identified as a hazard, no adequate control measures were installed
- there was inadequate guarding around the docking saw’s rotating saw blade
- there were no safe systems of work, and no documentation of how to clear a timber jam
- there was only ‘on the job’ training and verbal instructions to workers not to put their hands near the blade until it stopped
- the worker, who had only been working at Porta for a month, was not supervised to ensure that work was performed in a safe manner, nor was their competency to operate the equipment assessed
- there was no formal induction process for new workers, workers were just shown around the worksite.
Since the incident, the company has:
- installed padlocked guarding around the saw blade
- developed site inductions
- documented risk assessments for the equipment and an action place for installing controls
- developed and documented safe work procedures for the equipment, which are discussed with workers at tool box
- employed a full-time safety officer, and worked with an external WHS consultant to review its operations.
The penalties
Porta Tas Pty Ltd was charged with one count of failing to comply with a health and safety duty: Category 2 contrary to Section 32 of the Work Health and Safety Act 2012.
It pleaded guilty and was convicted and fined $50,000 plus court fees.
Forager Foods Pty Ltd
October 2021
The incident
As part of its operations, dried fruit company Forager Foods Pty Ltd uses an automatic apple slicer machine.
The machine’s operating manual stated that:
- servicing/maintenance was not to be done while the machine is operating
- the safety features should not be turned off during operation
- workers should keep away from moving parts.
However, the machine could be put into ‘jog mode’. This bypassed the machine’s safety features and kept the machine running while workers did servicing/maintenance. To do this, a worker would activate and hold a ‘jog key’. This was only to be used by workers trained in its use.
A worker employed by Forager Foods put the machine into jog mode to clean it. He was trying to remove a stubborn piece of apple from a moving part, when his hand became trapped in the moving components. He sustained a deep cut, severed tendons and nerves, ligament damage and fractures to his hand.
Findings
Inspectors from WorkSafe Tasmania investigating the incident found:
- the jog mode switch had failed previously, and was at first replaced correctly. But soon after it was altered, contrary to the operator manual, so it could be locked into jog mode
- a risk assessment was not done at the time the changes were made
- workers were instructed to operate the machine using the unsafe jog mode.
It was found that workers had previously expressed their concerns to management about the jog mode being used for servicing/maintenance.
The investigation also found that Forager Foods had a standard operating procedure for the machine, but it covered food safety and quality assurance only, not work health and safety. Despite this shortcoming, the procedure did direct workers to turn power off using the emergency stop before clearing the machine by hand.
Finally, the investigation also found that Forager Foods:
- knew about the safety precautions contained in the machine’s operator manual, and knew of the risks associated with the machine (through an informal risk assessment), but still failed to do what was reasonably practicable to control the risks and ensure the safety of its workers
- had no formal system or documented procedures for training workers, and relied on only verbal training by other colleagues
- provided the injured worker with minimal supervision, by an unqualified person who was not competent in the use/maintenance of the machine
- did not routinely inspect the machine
- encouraged speed over safety.
Rectification actions required were:
- the jog mode be eliminated from the tasks of operational workers, and limited to maintenance workers only
- the jog mode be redesigned by an electrical specialist to be safe
- isolation procedures be implemented for the machine
- risk assessments be conducted for tasks and control measures implemented based on these risk assessments.
The penalties
Forager Foods Pty Ltd was charged with one count of failing to comply with a health and safety duty: Category 2 contrary to Section 32 of the Work Health and Safety Act 2012.
It pleaded guilty and was convicted and fined $120,000 plus court fees.
Forager Foods Pty Ltd
March 2021
The incident
A casual worker employed by dried fruit company Forager Foods Pty Ltd was directed to slice bananas using a vegetable cutter machine, along with two other workers.
The casual worker had not used the machine before, nor had she received any training in safe operating procedures or how to use the machine. One of the other workers was experienced using the machine, but had not formally received any instruction in the safe operating procedures or been signed off as competent to use the machine.
The casual worker observed the experienced worker operate the machine before she had a go and began feeding bananas into the machine’s conveyor belt. The machine’s chute began to get sticky from the banana, so the casual worker put her hands into the chute to clean the fruit.
The casual worker severely lacerated one of her fingers. She needed surgery to repair tendon and ligament damage. She has not regained full use of her finger, and suffers anxiety, depression and complex regional pain as a result of the injuries she sustained.
Findings
Inspectors from WorkSafe Tasmania investigating the incident found:
- there was a lack of information and instruction provided about the hazards and risks associated with the machine. For example, the machine’s standard operating procedures stated ‘keep hands out of machine’, but the workers did not know about this requirement
- there was a lack of training and supervision provided to ensure the worker knew how to operate the machine safely
- there were no warning signs displayed on the machine
- the chute was not adequately guarded.
The investigation also found that Forager Foods had notable deficiencies in its safety management systems, especially in risk management and training/supervision/information.
The penalties
Forager Foods Pty Ltd was charged with one count of failing to comply with a health and safety duty: Category 2 contrary to Section 32 of the Work Health and Safety Act 2012.
It pleaded guilty and was convicted and fined $40,000 plus court fees.
Artec Synergy
February 2021
The incident
Artec Synergy was engaged to complete electrical work as part of a renovation at a Launceston café.
On 20 November 2018, a worker of Artec Synergy went to the café to complete the installation of an alarm keypad.
The worker set up a ladder to gain access to the work area. He subsequently fell off the ladder from a height of 3 metres. He sustained a serious head injury requiring long-term rehabilitation. The fall also caused traumatic impact to café staff and members of the public who witnessed the fall.
Contributing factors
WorkSafe Tasmania’s investigation found the ladder used:
- was made for domestic purposes, not industrial/work uses
- was placed with the feet — which were not slip resistant — on a sloping polish cement floor
- was placed excessively away from the wall (twice the recommended distance), causing it to be in a precarious and unsafe set up
- was not tied off or secured
- had a damaged rung which could result in serious injury.
The investigation also found the worker did not consider the work to be high risk, so did not create a safe work method statement, which is required for working at heights that involves the risk of someone falling more than two metres.
The investigation recommended that:
- staff be re-trained in the safe use of ladders and the risks of working at height
- safe work method statements be written and used
- the damaged ladder be removed from service and an industrial ladder be used, and used correctly
- an overall safe system of work to manage the risk of falls be implemented.
The penalties
Artec Synergy Pty Ltd (as the Trustee for Artec Synergy Unit Trust) was charged with:
- one count of failing to ensure the preparation of a safe work method statement (contrary to reg 299 of the Work Health and Safety Regulations 2012)
- one count of failing to reduce the risk of a fall by providing adequate fall protection (contrary to reg 79(2) of the Work Health and Safety Regulations 2012).
It pleaded guilty to both charges, and was fined $3,500 for each charge, totalling $7,000.