Well, yes in evidence many of the witnesses talked UP about the safety culture at Diemould. There was an insistence that this was a company had a very high focus on workplace safety ...but in order to have determined how to make a machine safe, one has to actually look at how dangerous the job is and then make a determination on how it can be done more safely.
Did Diemould Tooling Services look at the Horizontal Borer and ask themselves whether it was being operated in the safest possible manner? After all, they have allocated the least experienced, youngest and unskilled workers to it...where I might add, mistakes were considered ‘not worth mentioning’ by the Director. That doesn’t suggest these mistakes are no big deal, quite the opposite - not worth mentioning means that they are just not an option.
PAUL BARBER was Diemould’s apprentice master. He was charged with supervision and training of 1st and 2nd year apprentices. One would assume he would also be there to look out for their safety and well being.
Mr Crocker had asked MR BARBER whether he had ever given any thought as to whether the Horizontal Borer was safe prior to June 5th 2004?
P670 L28 – “Honestly, no I probably didn’t”
One would wonder then why he felt the need to add:
P671 L9 – “I just emphasised the dangers of using it and standing clear on it”
These two statements are like chalk and cheese. If he had not given thought to the dangers of this machine, why would he need to emphasise those dangers?
ROBERT SHAW was an EEAGTS apprentice that started his apprenticeship a little after Daniel. He remained with Diemould until sometime in 2008. When he was asked whether he felt the Horizontal Borer was as safe as it could have been, he felt there could have been small improvements. He didn’t think there was much that could be done with it.
P375 L29 – “There could possibly have been small improvements here and there but I believe that it’s a reasonably dangerous machine and with a spindle like that I don’t think there’s much you can do with it”
When asked about things like pressure plates or telescopic arms, he was not familiar with those things nor what opportunities they offered in terms of safety improvements. This did leave me wondering just how many employees were actively involved in safety talks after the incident and at least into 2008.
Then we had FRED HULL – a senior staff member who had many good things to say about the company with a good many years of experience in the industry. His testimony was that prior to June 2004 he did not view the Horizontal Borer as a high risk machine...
P880 L37 – “Back then I didn’t view it as high risk...”
He did further that with he has now changed his mind but then in the same sentence he added:
P881 L1 “this may seem like a silly way to look at it but it seems like toolmakers have always just got on with the job”.
Silly? I found it an extraordinary blasé and dangerous attitude – and this is coming from the man that was jointly tasked (along with PAUL BARBER) to oversee the these young workers. “Oh bugger, that guy just lost his arm ... any chaps, on with it...”
P1191 L22 - “My opinion of the machine is that it’s a large machine and we know the spindle turns and I think if the machine is used as its intended to be used...”
This perhaps begins to echo the sentiment of the King of Diemould, the late NEVILLE GROSE.
“Adhering to general machining safety principles that are absolutely daily re-enforced into our people, the likelihood of getting tangled up in that machine is very low in my opinion.” Neville Grose Statement P30 L34
Right! So please let’s look at how these safety principles were reinforced by this company.
THE BORER – SAFEGUARDING
On that topic, this shouldn’t take long.
There was an emergency stop button under the swinging pendant. This effectively removed the power from the machine no different to the operations stop button. This emergency stop button did not perform as an emergency brake. Even once depressed, it took 8 seconds for this machine to come to a halt. That 8 seconds spinning 200 RPM is in itself long enough to cause catastrophic results.
ALAN McLEAN – a risk consultant gave evidence to this court. He viewed the Horizontal Borer whilst in storage and was given the DVD to view the machine in operation. He was asked what his opinion was as to what the associated risks were with regard to the Horizontal Borer Daniel was operating:
P501 L38 – “This machine needed to be guarded and that’s (death) the outcome” ... Because it’s too risky not to guard.”
When asked what he identified as specific hazards are:
P502 L5 – “Everything that you can imagine actually. There’s rotating, there’s swarf, there’s coolant, there’s slippery floors, there’s drawing and shearing – even just being hit by the traversing tables you could be crushed...”
MR McLEAN talked about some of the very basic or minimal improvements that might have reduced the risk ever so slightly – a coolant bottle with a long nozzle. Every step you can move the operator away from the danger zone ...
He also spoke of the availability of light curtains and pressure sensing devices as reasonably effective safety devices – especially when the triggering an emergency braking system that could stop a machine like this Horizontal Borer in a matter of ¼ of a turn. We heard from his testimony that a light curtain for this machine would have set Diemould back around $2,000. P511 L38
For me, that was a devastating detail to have pass my ears.
I’m not even going to attempt to draw a comparison to the risk assessments done at Diemould Tooling for the purpose of its quality assurance requirements. It would seem that if they were done properly, if they were done at all, we perhaps would not be here today.
What has been determined through some of DAVID McMINN’s testimony was that the purpose of the risk assessment done at Diemould was done during the process of it going through the motions to gain ISO 9001 accreditation.
DAVID McMINN was asked specifically whether during those months in meetings, whilst the quality assurance accreditation was the priority, whether there had been discussions on specific machines and the specific risks associated with those machines. His answer was No. P1188 L27
I am unsure that one can lay claim to having done risk assessment on machines unless those machines are each given some consideration.
When FRED HULL was asked whose job it might have been at Diemould Tooling to look after OHS, and specifically, hazard assessment / risk assessment:
P877 L14 – “I’m not sure”
Both of these gentlemen are in management roles and have been involved with the company a good many years. It would seem on the face of it that if RISK ASSESSMENT and safety were as high a priority as some of their testimony suggested. Neither of these men recognised the danger associated with the Horizontal Borer.
Had someone within that organisation taken a few minutes - perhaps switched on a computer, kicked into action one of the many search engines, typed in a few key words like horizontal boring machine and maybe, safety? Maybe they too would have come across a document like I did. A document that outlines the risks very quickly. A document that says,
“A review of accident history shows that the single largest cause of injury is entanglement at revolving tools. Entanglement also accounts for the majority of fatalities.”
FRED HULL recounted at least 2 instances where he talked about his own eye witness accounts of a dustcoat being pulled into a traditional lathe - not once, but twice. (P878 L24)
They simply didn’t bother to look. Everyone was too busy making sure money was coming in - that labour was being used in the most profitable and effective way.
SAFE OPERATING PROCEDURES
Throughout this inquest it has been quite a difficult task for someone like myself to make sense of the evidence relating to safety and more specifically, SOP’s. It seemed there were so many different versions and accounts that it left me wondering whether these people were even working at the same company.
In spite of the confusion in varying witnesses testimony, I think it has been finally been clarified based on the evidence of JIM GROSE.
On examination of JIM GROSE by Ms Cacas – in relation to the SOP’s that had never been produced but that were argued existed initially:
Q: “You must have turned your own mind at some time as to during that period of three years (after the death of his father) whether they existed or not?”
Q: “And what conclusion did you reach in your own mind....?”
A L: “They didn’t exist” (P1076, L14)
AMARNDO BAKER was asked several questions pertaining to written SOP’s and whether or not they existed - on each reply he answered “No” P451 from L19
DAVID WELLING gave evidence that stated he was not aware of any SOP’s . P232 L12
DANIEL GOLDFINCH when questioned about written SOP’s and his evidence was, “No, there definitely wasn’t anything like that.” P212 L32
So now having determined that there was no suitable risk assessment undertaken at Diemould and as a result of this, the dangerous consequence surrounding the use of the Horizontal Borer had not been identified nor addressed.
There were witnesses that were adamant that these written Safety Operating Procedures did exist! When pressed to locate them in the various photographs taken of the Horizontal Borer and surrounding areas, that evidence became shakier if not downright ridiculous given how things unfolded. I suppose this is how painfully obvious it became that people were lying - and not very well either I might add.
It just goes to show - the truth is always so much easier to remember.
The applying of coolant to the machining of the tool was a part of the process that created yet another safety hazard. It was not only due to the lubricant’s slippery nature but also the location of where the coolant was kept.
One of the glaring short comings I noted immediately was the location of the coolant bottles and the likelihood that an operator may need to use the step up or platform to hoist themselves up to reach it. Further to that, this area can become quite polluted with coolant that has been sprayed out from the tool. .
Coolant is a mix of water and oil ... the step is made of steel – there alone is a mind blowing example of an obvious safety hazard that not one person in this company identified.
MARK REMFREY commented on this by saying:
P120 L4 – “There would be times, if you’d spilt a lot of coolant around or whatever, could become slippery. “
DAVID WELLING on the same topic - when asked whether this work platform and surrounding step could become saturated with excess coolant:
P247 L21–“Yes, definitely...”
Just for a second I’d like to quickly refer back to FRED HULL as he was shown photographs illustrating where the coolant bottles were kept. His memory appeared to recall things very differently. He had said previously that there would be no reason for an operator to step off the mat. When asked by Ms Cacas about the height the coolant bottles were kept and the need to use the step / platform to hoist oneself up to reach them:
P921 L6 – “At that height there you’d never grab it (the coolant), you’d never be able to get it from the rubber mat...”
When Ms Cacas asked about the normal operation of running the Horizontal Borer and the order of things when applying coolant:
P927 L12 – “This is what the guys do – you get the machine going and a twist drill like that, it can drill the first little bit before it needs to have a spray on there because its building up temperature...”
Line 23 - “...and then you grab your bottle and – some operators may have the bottle in their other hand (from the one operating the feed?) while they’re doing that, but generally you’d get going and then just grab the bottle or whatever.”
In any event, there’s no evidence at all to suggest Daniel had placed himself on that machine beyond the work area.
DAVID WELLING was as close to an eye witness as we were going to get. Daniel wasn’t in full view of DAVID WELLING because the die block was large and it was obstructing his vision of Daniel immediately before the incident occurred:
When asked if he could describe where Daniel was standing:
P245 L17 – “...I remember seeing the back of his – sorry his body sticking out from behind the job (die block) which means if I saw him there, he would have had to have been on the normal work platform and then like I said, I turned away to see Jason, turned back, and then it was happening.”
I think perhaps it is possible that the management – the decision makers, those charged with the training of these apprentices had a very poor concept of not only the training, but also the operations in working on the Horizontal Borer and what that entailed.