Ingot stacks fall crushing worker's legs, torso, chest and head

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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