Many times the Aluminium
Plant Safety Blog hear about a past incident because of a recent court case.
Many times these incidents are several years old. But, we feel not posting them
would be a disservice to the injured and dead. As we have repeatedly stated it
is our sincere hope that by bringing awareness to these incidents we can
prevent recurrence. Here is the story:
In October 2016, a
stevedoring company, was convicted and fined $150,000 by a court in the South
Pacific in relation to an incident in the Fall of 2012 when a team leader was
fatally injured after 20-tonne stacks of aluminium ingot fell and crushed him
while in the process of being loaded onto a ship.
The stevedoring company pleaded
guilty for failing to comply with its primary duty of care to ensure, so far as
is reasonably practicable, the health and safety of its workers under the
pertinent government regulations.
The incident
The deceased worker led a
team of five other stevedores in loading aluminium ingot stacks into the cargo
holds of a tanker in port. Midway through the loading process, some timber
planks which the team had laid to prevent cargo from shifting during sea
passage moved out of position. The deceased directed his crane operator to move
the suspended load to allow him to readjust the timber planks. To do so, the
deceased climbed down the open face of previously loaded aluminium ingot stacks
in the cargo hold, rather than using the portable ladders provided by stevedoring
company. While climbing down, some ingot stacks started toppling causing some
adjacent ingot stacks to fall directly onto him, crushing his legs, torso,
chest and head.
The company's safety
systems
The stevedoring company operated
in a high risk work environment, providing stevedoring services for the loading
and unloading of bulk cargo onto ships and had extensive safety systems in place
developed by persons experienced in safety matters. Among other things, the
stevedoring company:
- regularly reviewed the written safety procedures it had developed for six different vessel types and 16 different cargo types
- provided ongoing training for workers in these procedures as well as additional specialised training in relation to specific work tasks
- had a process for identifying and addressing risks and hazards in place, relevantly identified the risk of a crushing injury while loading aluminium ingot stacks and implemented controls
- monitored and updated its safety systems on an ongoing basis
- had a work health and safety committee (which met approximately every two months) and a consultative committee.
The Court's findings
The Court acknowledged the
stevedoring company’s extensive safety
systems, noting that its approach to safety both before and after the incident
was 'conscientious and diligent'. There was evidence before the Court
that this was the first incident involving an injury in approximately 50,000
loads.
However, the Court was
critical of two deficiencies in respect of the stevedoring company’s system for
loading aluminium ingots. In particular:
- the safety system did not require
the use of the portable ladders the stevedoring company made available for
climbing down aluminium ingot stacks, it was not mandatory to use the
ladders
- exclusion zones were not implemented or enforced with a prerequisite for zone entry being to secure ingot lifts with sling straps and ratchets to prevent ingots toppling over (despite the company's argument that this did not reflect industry practice).
The Court held that
measures were readily available to eliminate or minimise risk of injury caused
by aluminium ingot stacks falling. In fact, stevedoring company acknowledged
these deficiencies by rectifying them through updated safety procedures
following the incident.
In all of the
circumstances, the judge assessed the stevedoring company’s breach as being
towards the upper end of the low range (without giving any guidance about what
low range means). In making this finding, the judge considered the fact that the
stevedoring company:
- had no prior convictions
- had shown contrition and remorse
- was a good corporate citizen
- was unlikely to reoffend
- cooperated with authorities.
What does this mean for
your organisation?
Even if your organisation
takes safety seriously, has extensive safety systems in place and continually
monitors and updates those systems, and has had no major incidents, there is
still a risk that deficiencies exist which could lead to non-compliance with
work health and safety law. The Court's decision highlights the importance of
focusing on continuous WHS improvement, including:
- not only taking steps to identify
and address a risk, but to ensure that the measures implemented
effectively eliminate or minimise the risk, even if they are not industry
practice. The stevedoring company had measures in place but they were not
effective enough
- enforcing the controls and safety
systems in place. The stevedoring company implemented the ladder control
but did not mandate its use. In this regard, the Court stated:'There is
little point putting in place safety systems unless there is a process to
ensure that the systems are enforced'.
We offer our sincere condolences
to the deceased worker’s family, friends and coworkers. We hope by bringing
awareness to this incident we can prevent another worker from being injured or
killed when a situation like this occurs.
What grabbed our attention in
this incident was that the deceased worker was a supervisor. He was leading a
team of five workers in loading a ship. On occasion we have been asked to speak
to supervisors about safety related topics. Supervisors have a responsibility to
ensure that their workers are safe and are performing their job functions in a
safe manner. This responsibility is huge. One could argue that the responsibility
that a supervisor in their worker’s well being comes a close second to a parent’s
responsibility to the children. Sadly some supervisors do not acknowledge their
responsibility. That is where department and plant managers can have a valuable
impact.
When talking with a group of
supervisors we first talk about the the importance of “practicing what you
preach” in regarding to managing their workers. Supervisors must wear all of
the personnel protection equipment (PPE) that their company requires. Any
deviation or failure to follow the company’s safety requirements will be seen
by their workers. Who will quickly disregard the safety message that is being
put forth. We have heard many times “Why should I do this or that when I’ve
seen my supervisor not do it?” It is amazing how many supervisors we see that
are not following the safety guidelines. On occasion we have pulled a worker
aside and asked a question. “Do you have a family?” Why they ask. We explain
that their family loves them. The supervisor will say “yeah I know”. We then
will say, “then show their love by following the safety rules”.
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