Manufacturer fined $135,000 after bystander death.

The importance of following manufacturers’ instructions and carrying out inspections and maintenance on schedule was brought home after a business was recently fined $135,000 for its part in a fatal incident.

The Maroochydore Magistrates Court was told the roof product manufacturing company was well overdue to carry out its 10-year major inspection of a crane, as required by the Australian Standard and the manufacturer’s recommendations.

The inspection was 18 months overdue and the defendant did not have a maintenance plan or schedule in place to ensure periodic inspections and maintenance were done when required.

Part of the company’s business included manufacturing metal products such as flashing and roof sheeting and delivering them on two leased trucks with vehicle loading cranes.

The defendant was responsible for maintaining one truck – the ‘rack truck’ and two locking mechanisms were fitted to each outrigger of the crane to prevent it extending in transit.

A company worker was driving the truck when an outrigger on the crane extended, causing it to strike a parked van, pushing it backwards, dragging another man who’d been standing at the back underneath it. He suffered fatal injuries.

The court heard the company was aware of the need for a 10-year inspection and a mandatory major inspection and service would have included a check of the locking mechanisms.

Workplace Health and Safety Queensland investigators found the truck driver failed to engage the primary locking mechanism on the passenger side outrigger.

The secondary locking mechanism was damaged and would not have given adequate and reliable restraint.

In sentencing, Magistrate Haydn Stjernqvist noted the defendant company was responsible for the maintenance of the crane. He accepted the company had no system in place to ensure the trucks it used were properly maintained, and that the truck was being driven on public roads, exposing the public to risk.

Post-incident improvements made by the defendant, including the purchase of new cranes and the commencement of an ongoing service contract with a specialist company to inspect and maintain the cranes, were considered by the magistrate, and also the company’s lack of previous convictions, cooperation with the WHSQ investigation, and guilty plea.

The company was convicted under section 32 of the Work Health and Safety Act 2011 for failing to comply with health and safety duties.

It was fined $135,000 and ordered to pay professional and court costs of almost $1,600. No conviction was recorded.

Worker injured after fall from roof

Overview

In March 2021, a worker suffered serious injuries when he fell approximately six metres through a roof after walking on an old skylight panel that had previously been covered. It appears the void cover plate was held in place by pop rivets. These findings are not confirmed, investigations are still ongoing.

Safety issues

Falls, particularly falls through roofing, are a major cause of workplace deaths and serious injuries. The risk from a fall depends on whether fall control measures are implemented, the height involved and the surface directly below the work area. There may be additional risk when working on or near fragile roof surfaces. Roofs are likely to be fragile if they are made with:

• asbestos roofing sheets

• poly carbonate sheets (alsynite) or plastic commonly used in skylights

• fibre cement sheets

• liner panels on built-up sheeted roofs

• metal sheets and fasteners (especially when corroded).

Before commencing any work on a roof or at height, all surfaces must be inspected to identify any potentially fragile spots. All locations and tasks which could lead to a fall should also be identified. This includes access to areas where the work is to be done. Close attention is required for tasks:

• on any structure or plant being constructed or installed, demolished or dismantled, inspected, tested, repaired or cleaned

• on a fragile surface (for example, poly carbonate or cement sheeted roofs, rusty metal roofs, fibre glass sheeting roofs and skylights)

• on a sloping or slippery surface where it is difficult for people to maintain their balance (for example, on glazed tiles or a metal roof that is wet from morning dew or light rain)

• near an unprotected open edge or internal void area (for example, removed roof sheeting).

Possible control measures to prevent similar incidents

The WHS Regulation requires specific fall risk control measures to be implemented, where it is reasonably practicable to do so. For example:

• if the work is construction work, then Chapter 6 of the WHS Regulation applies

• if the work meets the definition for high risk construction work (e.g. if the work is over two metres and it is a complete roof replacement of a large shed) then a safe work method statement must be prepared as provided for in the Work Health and Safety Regulation 2011. Further regulations would also then apply (for e.g. Part 6.3 Sub-division 2 “Falls” which provides prescriptive control measures).

Effective controls for the risk of falling from a height are often made up of a combination of controls. Some common control measures can include but are not limited to the following examples:

• Constructing a roof with the roof structure on the ground and then lifting it into place – this can eliminate many falls from heights hazards but is only suitable for the construction of some roofs on new structures where the roof can be lifted into place. In addition, lifting the roof into place will create other hazards that need to be addressed.

• Using an elevating work platform (EWP) to do work on a roof so workers can remain within the EWP and avoid standing on the roof. This is primarily an example of substituting the hazard for a lesser hazard. However, an EWP design may also be considered an engineering control measure and the EWP must be assessed to determine whether it is the most suitable one for the task/s.

  • The safe operation of EWPs also relies on safe work procedures (i.e. administrative controls), which includes ensuring operators hold the relevant high risk work licence (where required) to operate the particular EWP.

• Ensuring safety mesh, complying with AS/NZS 4389:2015, has been installed under the roofing and skylights and perimeter edge protection (complying with the Work Health and Safety Regulation 2011). Both safety mesh and edge protection are primarily engineering control measures that address the risk of falling through the roof or off the roof edge. However, safe systems of work need to be implemented for the workers installing the safety mesh and edge protection.

• Travel restraint systems intended to prevent a fall from a roof edge by physically restricting how close a worker can get to a roof edge. These systems are generally unsuitable where a fall through a roof can occur (i.e. because the roof is fragile or there is no safety mesh under the roof sheeting). They also largely rely on worker training and the worker following a safe system of work. A travel restraint system is a combination of an engineering control (system design), administrative control and personal protective equipment (i.e. the tethering lines and harness).

• Fall arrest systems for work on roofs are the least preferred risk control measure because they do not prevent a fall occurring but arrest the fall once it has occurred. The worker can still be injured, even if the fall arrest system is set up correctly and the worker's fall is arrested before the worker hits the ground or another obstruction. After the fall, the worker must be rescued both promptly and safely. Fall arrest systems are primarily a form of personal protective equipment but also rely on engineering controls (i.e. anchorage point strength, harness and lanyard design) and administrative controls (e.g. making sure the lanyard is connected and not too long).

In addition to the hierarchy of controls, the manufacturer’s instructions, should be followed, for the safe operation and use of plant, machinery and/or systems engaged by the PCBU.

Person falls from tank.

In November 2020, a man sustained serious head injuries after falling from a water tank that had just been put in place by a vehicle loading crane. It appears he was standing on the tank close to the crane.

Prevention:

Falls are a major cause of death and serious injury. The risk of falling is common in construction, but may also occur during many other work activities.

The risk of serious injury from a fall is largely dependent on the height, but also the surface below (e.g. working on a roof near an unprotected edge or performing installation work from a ladder). A risk management approach must be used to manage the risks of falls from heights.

Managing work health and safety risks is an ongoing process.

Risk management involves four steps:

1. Identify the hazard – find out what could cause harm

2. Assess the risk – understand the nature of the harm that could be caused by the hazard, how serious the harm could be and the likelihood of it happening

3. Control the risk – implement the most effective control measure reasonably practicable in the circumstances

4. Review risk controls – asses control measures to ensure they are working as planned.

Other controls that can be looked at and analysed:

• Substitution Controls: Replacing with something of lesser risk.

• Engineering Controls: Changing physical characteristics of the plant/system of work.

• Administrative Controls: Information, training, instruction or supervision necessary to control the risks associated with plant.

• Personal Protective Equipment (PPE): Use of PPE to reduce injuries.

Worker falls from forklift

In December 2020, a worker suffered serious injuries when he fell from a forklift. Early investigations indicate he was attempting to repair a jammed roller door. The man was working from a stillage container being used as a makeshift work box and had been lifted on the tines of a forklift. It appears that as the worker moved to one side of the create it overbalanced causing him (and the crate) to fall almost 5 metres.

The following safety issues were factors in influencing this incident:

• Instability: tipping over is the biggest danger for an employee using a forklift. If an employee jumps from an unstable forklift, the chances of serious harm are high.

• Speed & Stopping distances: applying a forklift’s brakes inappropriately can cause the forklift to tip forward or lose its load. The workplace environment always needs to be considered.

• Attachments: when an attachment is fitted to a forklift, the dynamic and operating characteristics may change, making it necessary to adjust the forklift capacity and restrict some operating controls.

Possible control measures/strategies to prevent similar incidents:

Forklifts:

• Work boxes should only be attached to a compliant forklift, with a load capacity data plate stating the attachments that may be used.

• Ensure your traffic management plan deals with tasks involving work boxes.

• Before starting work, ensure the parking brake is set, the controls are in neutral, the mast is vertical, and all controls are immobilised except lift and lower.

• Employees should be trained in the safe use of work boxes including emergency procedures to ensure occupants can be rescued if an incident or breakdown occurs.

• Employees must stand on the floor of the work box not on a ladder or other object.

• Never use work boxes to transport people.

• The employee operating the forklift must remain at the controls at all times. The forklift operator should perform an initial trial lift without a person inside to make sure the cage has a clear path.

Work boxes:

• Work boxes must only be used to raise people if performing short-term tasks (see AS2359.2—2013 clause 3.10.1(b)).

• A work box fitted to a forklift must be securely attached to the forklift carriage and engineer-designed and constructed in accordance with AS 2359 Powered Industrial Trucks series (see Code of Practice (2018) for Managing the Risks of Falls at Workplaces).

• Work boxes must be securely attached to the forklift with a minimum of two independent securing devices. The devices must be visible to the person in the work box.

• People using a work box must be protected from the mast of the forklift and associated moving parts by a barrier at the back of the work box.

• Tines lifting a work box must be spaced widely apart to avoid the cage overbalancing.

• The tines must be in tunnels or clamps under the work cage. They may not be in an open arrangement like in a pallet as they may be accidently placed too far from the edge and tip over. Fork tunnels or clamps must be located within 150mm to 250mm of the outside edge of a work box, with further tolerances as specified in AS 2359 Powered Industrial Trucks series.

• Refer to AS 2359 Powered Industrial Trucks series for other requirements, such as handrails, gates, and anchorage points for safety harnesses.