he gruesome workplace death of an apprentice could have been averted had a host employer spent as little as $15,000 on retrofitting a "deplorably" unsafe machine, the South Australian Coroner has found.
Coroner Mark Johns also slammed SafeWork SA's sluggish response to the incident, and described it as a "matter of public concern" that the cost of acquiring new safe equipment often far outweighed the likely penalty in an OHS prosecution.
In June 2004 the 18-year-old apprentice toolmaker was operating a horizontal borer when his clothing became entangled in the machine's rotating spindle, causing him to be spun around so violently that his feet were amputated when they struck non-moving parts.
He also suffered multiple bilateral fractures of the ribs, as well as significant bruising to the lungs, liver, spleen and heart, and died from respiratory failure.
The worker was employed by the Engineering Employers Association Group Training Scheme (EEAGTS), now known as the Australian Industry Group Training Scheme, and had been placed at Diemould Tooling Services Pty Ltd for nearly a year when the incident occurred.
Both companies were charged with and pleaded guilty to breaches of the State OHS Act, and in 2006 EEAGTS was fined $60,000.
But Diemould argued that the charges laid against it were duplicitous, and unsuccessfully fought the issue all the way to the High Court. It was eventually fined $72,000 in June 2009.
Machine inexplicably unsafe
The Coroner, who was unable to hold an inquest until the prosecution of Diemould was completed, found that at the time of the incident the horizontal boring machine had been in a "deplorably unsafe" condition for years.
He found the machine - which was manufactured in the USSR in the 1960s and was poorly maintained - had no guarding or other devices to prevent contact with moving parts, and that operators were required to stand within about 30cm of the machine to spray its rotating cutting device with coolant. (Modern borers have an automatic lubrication system.)
The only safety device on the machine was an emergency stop button, but this was inaccessible to anyone caught by the spindle, and there were no emergency brakes, the Coroner found.
"It is inexplicable in an age in which occupational health, welfare and safety is so much a part of the modern workplace, that a workplace could have existed so recently as 2004 with a machine that was so obviously unsafe," he said, adding that the borer could have been fitted with guarding and emergency brakes for about $15,000.
"[The worker's] tragic death was entirely preventable."
Coroner questions penalty regime
The Coroner noted that shortly after the incident Diemould replaced the old borer with a modern machine, equipped with interlock devices, at a cost of $230,000.
This not only provided further evidence that the death was preventable, he said, but raised concerns about the penalty regime.
"I do not suggest that an economic decision was ever made by Diemould that it would be cheaper to pay a fine in a prosecution... than invest in a new horizontal boring machine, the cost of which would be 230 per cent higher than the maximum penalty available," he said.
"However, it might be considered a matter of public concern that in an operation such as Diemould's, the cost of acquiring safe plant and equipment far outweighs the likely penalty in a criminal prosecution."
SafeWork slammed for tardy response
The Coroner was particularly critical of SafeWork SA's response to the incident.
The regulator, he said, did not commence a compliance project to identify the number of horizontal and vertical borers at other South Australian workplaces until May 2010.
"I certainly would have thought that such a 'strategic intervention' would have been taken very soon after [the] death."
The Coroner said that SafeWork had implied in a letter to the inquest that the primary responsibility for ensuring the safety of borers rested with the owners of the machines or the employers that used them, rather than the regulator.
"This may be technically true, but it seems to me that it does not absolve SafeWork SA from an obligation to fully utilise the powers available to it," he said.
"In my opinion, the system of leaving industrial safety compliance to employers and then simply prosecuting them once an employee is fatally injured, is inadequate and insufficient.
"A rigorous system of inspection and a full use of the range of improvement notices and prohibition notices would be a far more effective way of preventing accidents such as [the apprentice's]."
The Coroner noted that within four months of commencing the 2010 compliance project, SafeWork SA had issued three prohibition notices and five improvement notices in seven workplace visits.
"This is an indication that the process of inspection was bearing fruit, and the preventative aspect of SafeWork SA's function was being deployed," he said.