UNDUE PRESSURE - COMPLEX WORK

With such a great responsibility of very expensive tooling, there was an awful lot to take in.  An awful lot to remember for those least skilled in the factory.  

Daniel was awarded ‘Apprentice of the Month’ for the month of May 2004. He was a kid that tried his heart out to please – to do the right thing.  Of course I could see he was as proud as punch and as his mother, those moments are like gold.  I loved to see him stand tall and feel proud of his achievements.

There were signs in September 2003 and again in early 2004 that suggested Daniel was struggling somewhat. This has been confirmed by evidence presented in court.

ROBERT DRYSDALE (EEAGTS) confirmed that on 2 occasions at least, he was called in to Diemould to speak to Daniel directly about him constantly seeking reassurance as well as some issues with him forgetting to pull his safety glasses from being cradled on his head rather than over his eyes.  P592 L30

DRYSDALE on this occasion in the 1st quarter of 2004 spoke to Daniel regarding concentration concerns.  

P598 L18 – “I think the company was questioning at that particular point in time why Daniel wasn’t actually retaining information that he previously questioned.”

DRYSDALE mentions neither EEAGTS nor Diemould took any course of action:

P598 L28 – “...because what that pointed to was the fact that we needed to consolidate his training.”

 When I asked DRYSDALE whether this issue occurring soon after starting his work on the Horizontal Borer – whether this should have raised a red flag?  His reply

P599 L35 – “At that particular point, Daniel did make me aware, look, his discomfort was nothing more than a desire to learn more about the job as such.”

PAUL BARBER (Apprentice Master Trainer) in his statement C34A (Page 7) 1st paragraph

 “(Daniel) was very paranoid about whether he was doing something right or wrong – took him longer than others to gain self confidence – he asked trivial questions.”

Then in court when I questioned him a little further on that he replied:

P682 L23 – “Worried about making a mistake, no different to anyone else

Which is it?  Did he take longer than others to gain confidence or was he no different?  I have become so tired of these contradictions.

In relation to a whether he met with ROB DRYSDALE regarding Daniel’s issues in holding or grasping information, he replied:

P684 L21 – “I can’t say I did, I can’t say I didn’t...”

When I asked FRED HULL about his assessment on Daniel when it appeared that there were concerns raised with EEAGTS regarding Daniel’s lack of confidence  – asking lots of repeated questions in the early part of 2004 he replied:

P895 L30 – “No, I don’t think so because the statement that he repeatedly asked questions was probably seen in a lot of respects as a good thing in the sense that he didn’t want to make a mistake and he was being cautious and careful with things.  It probably fell in line with the way we wanted him to go anyway, you know, like, the way we wanted him to proceed. ”

Then one would have to wonder why go to the effort of calling in his employer to have a bit of a chat with him?  Why add to the pressure and make the kid feel bad when he was already trying so hard?

So I think your Honour will still be wondering how does this relate to what happened when he was showing to be doing so well in May 2004?

On the morning of his death he was doing something brand new – a far more complex operation than he had ever done before.  He may well have become very efficient at operating the HB on the tasks that he had learned but this was not what he knew and understood.

We know he was having problems that morning.  

AMARNDO BAKER gave evidence in his statement to WPS C31 that Daniel had approached him on several occasions on the morning of the 5th June 2004 in respect to difficulties he was having with the set up on this particular die-block.  He commented in that statement that “things weren’t working out for him”.

When I asked him MR BAKER what those ‘problems’ were:

P477 L36 – “Because I think – normally you’d have the job square on a machine but his process required that it be set off on an angle, what’s called clocking up, so it’s exactly on that angle. I think he might have been having troubles where sometimes you’re clocking up and it’s just, you know, you clock it up and measure it again and it would be out at the other way so you adjust it and then you know, you’d have to keep creeping up on it to get it exactly dead right.”

This was a complex job – it was something brand new.  There is no room for mistakes -  this die block is very large and very expensive.  There is SANDEEP CHALIL that is helping him but I can’t help but wonder why he feels the need to go to Armando Baker for help?  He said that things were not working out for him.  Maybe SANDEEP CHALIL wasn’t explaining things in a way Daniel was able to understand.  I don’t know whether that was the problem or not but it seems to me there is a reason why things are not working out for him and he needs to go to another tradesman.

I keep thinking – knowing Daniel as I did ... it breaks my heart-  to think he may have been struggling with getting something right and that distraction and concern may have been enough to have him hoist up onto that step – the step that can get slippery with oil and water – to check – just to be sure.

It’s true, we don’t know that this is what happened, but there is a feeling in my gut that tells me that this is Daniel – he’s someone who will be quite meticulous and careful not to make a mistake.  He may have been worried ... he would have been worried ... if he’s asking for help he’s not sure.

I think the people at Diemould may have considered that possibility too.

I found it the answers given in court here when questioned about the complexity of the work – the critical nature of the work – I was quite perplexed.

PAUL BARBER said in relation to the work Daniel was doing the morning of the 5th June, the answer was,

P685 L14 – “ I think it was the set up of the job that was different to what he was used to because there were angles involved. The process of drilling was very much the same...”

P685 L22 –  “the job that he was doing was more complex, a lot of calculations, he would have spent hours setting the job up before he drilled the hole.”

MARK REMFREY gave the same response:

P113 L9 – “It was one of the more complex operations.  The complexity lies in the setting the job up, not the actual machining.” ... “The complexity is actually being able to read the drawing and figure out what way the block has to go and at what angle and get your angle set properly and also your position because you are drilling from the back of the die block through the cavity site and if you come out in the wrong spot, then it’s a throw away.”

FRED HULL when asked by Mr Crocker whether the tradesmen would ordinarily assist an apprentice in the set up more so than supervising them once the machine had started;

P840 L10 – “That’s right, the boring process was a very basic process”

SANDEED CHALIL – Daniel’s supervisor that morning.  This was the first time he had done work for this tradesman -  when asked whether there had been other jobs or projects where Daniel had done work for him, SANDEEP CHALIL responded:

P140 L37 – “No, I think”

When asked whether Daniel had been working on that job prior to that Saturday morning:

P150 L3 – “I think we only started working on that job from that Saturday”

When asked whether CHALIL thought the job Daniel was doing for him that morning was quite a complex operation – something he had never done before that day – angled lifters:

P202 L18 – “It was a complex operation to do the set up but to do the machining it wasn’t a complex operation at all.  It was only mainly drilling a couple of holes.”

Is it a coincidence that they all said that the set up was the hard bit – the drilling is easy?

Finally the man that called the shots – NEVILLE GROSE – what does he have to say?

When asked by WPS investigators  whether he believed that it was quite a complicated task for a 1st year apprentice:

“Yes, great training for him. However you do know, really speaking, Daniel wouldn’t have set that job up.  It was Sandeep.  Sandeep nursed him all the way through it and made sure it was right before he drilled it.” C18aaaaar P18 L26

SANDEEP CHALIL gave evidence in court as to how much time he spent with Daniel that morning if he rolled it all in together.  His reply was about an hour.  That really does not equal much in a working shift that was already into it’s 6th or 7th hour.

Aside from that – I do believe the drilling process may still have initiated a great deal of anxiety in its own right.  He was manually feeding the tool– he wasn’t allowed to drill through this die.  No I’m, afraid that I think the drilling is cloaked in as much apprehension for a young worker who has just that morning learned something quite complex on a die that is big and expensive to ruin.

I’ve done a little woodwork over the years – it’s always nice to think that we get it right when we measure properly and do all those things ... but alas I don’t know about other folk but I do have these pangs of doubt just as I’m about to start cutting.  A piece of wood isn’t worth a quarter million dollars ... I think it is quite possible he was very apprehensive when that tool started to cut.

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