$250,000 penalty after student’s fingers amputated
On 4 August 2014, a 17-year-old work experience student from a nearby high school was working at Thermal Electric Elements, a NSW-based company that designs and manufactures electric heating elements and systems. It employs 33 workers. The student was folding strips of sheet metal using a CNC brake press when he accidentally crushed two of his fingers, resulting in the partial amputation of them.
When the student began his work placement on 4 August 2014, he was given a general workplace induction lasting 20-30 minutes. It covered general administration and human resource topics, emergency procedures and factory layout. However, the student was not instructed on machinery operation during the induction.
Later that day, the student was given initial training on the operation of a CNC brake press. The training consisted of a demonstration on the use of the machine and the student then operated the machine for approximately 5 to 10 minutes under observation.
After the initial demonstration and observation, another worker continued the student’s training on the operation of the CNC brake press, which took approximately 10 minutes.
The CNC brake press creates a crush zone between the descending upper beam holding the knife and the die when folding metal strips.
As a safety measure, the CNC brake press is fitted with a light curtain that acts as a sensing device.
A ‘mute point’ is a point during the descent of the standard knife at which the light curtain is disabled and permits access to the brake press beyond the light curtain. It is required to be set at a position above the job piece where the danger of a person inserting his fingers between the job piece and the standard knife has passed. The gap should be too small to allow fingers to be inserted. The Court was told the machine’s operation manual provides that it should be set at 6mm. However, the Court heard that the mute point on this machine was manually set by the defendant at 15mm.
Also, in evidence presented to the Court, it was found that the machine was set to the ‘slow’ mode, which allowed the machine to continue its operation even if the light curtain was obstructed. The operation manual for the machine provided that the default setting for the machine should be ‘off’. This setting would have stopped the downward movement of the standard knife when the student’s hand was in the vicinity of the crush zone.
On his third day at the business, and after making 100s of pieces on the machine, at around 2pm, the student was finishing folding the metal strips to be completed by him that day. He was removing the die on several metal strips he had just folded when he inadvertently depressed the down pedal, causing the CNC brake press to commence a cycle with the standard knife lowering onto the die area on to his left hand, which was in the crush zone.
He crushed his index and middle fingers, which resulted in partial amputation of both fingers.
What the Court found
The Court determined there were three significant contributing factors to the incident:
- The company had the default setting on the machine to ‘slow’, which allowed it to operate.
- The ‘mute point’ on the light curtain was manually set at 15mm instead of 6mm.
- The operator’s pedestal for the brake press was not fixed to the floor and, being portable, had been accidentally contacted by the student while his hand was in the crush zone.
Judge Kearns found that the company’s instruction document for the machine had minimal information in relation to the safe operation of the press, especially as to the Obstructed Mode, Mute Point and Control Pedestal.
He also determined that the defendant did not undertake regular risk assessments, especially in relation to the press, which was contrary to the operation manual and the work placement agreement.
Judge Kearns was critical of the level of training and supervision the student received, in particular, the worker who continued the initial training did not even know how the Obstructed Mode was set when the student was using the machine.
The Work Placement agreement between the high school and company also warned the host employer of prohibited activities that “need special consideration” including:
- the student is given appropriate information, instruction and training and a checklist for the safe operation and handling of the equipment;
- the equipment is in safe working order, complete with required safety devices or guards;
- a suitably qualified or experienced person in the workplace who has good communication skills and the ability to give clear instructions provides on-going close supervision.
In sentencing, Judge Kearns said the risk of injury to the student “was foreseen”. He said machinery of this kind is notorious for injuries and the risk of the type of injury suffered by the student ranked extremely highly on any scale of foreseeability.
He said measures were readily available to eliminate the risk and referred to failures in training, information, instruction and supervision by the company.
Safety concerns addressed
The judge also noted that the company had addressed safety concerns since the incident and had expressed regret for the student’s injury, as well as entering an early guilty plea.
The company was convicted and penalised $250,000, reduced by 25% for a guilty plea (maximum was $1,500,000) and paid the prosecutor’s costs.
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