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Court Summary - at a glance
End fine: $340,000 to be split 50/50 between ANZCO and REL.
Riverlands Eltham failed to:
- Ensure, in consultation with Kia Ma Limited, that an effective hazard identification and risk assessment has been undertaken in relation to the cleaning processes of the Carsoe HKV300 Bin Lifter and La Par’ refiner in the mountain chain room.
- Develop, implement and monitor a safe operating procedure for cleaning the Carsoe HKV300 bin lifter and the La Parmentiere tripe refiner in the mountain chain room, or ensured that Kia Ma Limited did so.
- Install an adequate cleaning platform on the La Parmentiere tripe refiner to allow sufficient working space for cleaning of the top of the tripe refiner.
- Consult, co-operate with and co-ordinate with Kia Ma Limited in relation to the provision and maintenance of safe plant and of safe systems of work regarding the Bin Lifter and La Par.
The site is a meat processing site.
Kia Ma was contracted by ANZCO to clean the site and machinery.
ANZCO is the 100% shareholder of REL.
REL owns all plant and machinery at the site.
One of Mr Killeen’s tasks was to clean the Mountain Chain Room (MCR) and Tripe Room.
Once tripe has been washed, it is ejected down a chute into a 300 kg capacity plastic bin (the Bin) in the MCR.
The Bin is attached to a Bin Lifter.
There is a chain lifting device housed within a fabricated steel column that raises and lowers the Bin.
The Bin is encased in a metal structure and cannot be removed from the Bin Lifter. The Bin Lifter operates as follows:
- When the Bin is raised and reaches the top of the column, it enters a steel track which tips the Bin over, the contents of the Bin to be tipped into the La Parmentiere tripe refiner (La Par) below.
- Immediately prior to the Bin tipping a “trip switch” causes the access hatch to the La Par to open.
- The Bin continues through its cycle to the point where it meets a “limit switch” that stops the drive mechanism and the Bin stops until the “Down” button is pressed.
- This takes approximately 22 seconds from its lowest position to its highest position including the tipping process. The La Par washes and polishes the tripe. Once the tripe is processed in the La Par, it is emptied onto a table in the Tripe Room for packaging.
- The Bin Lifter is operated by a three-button control panel situated on the Bin Lifter column to the left of the Bin approximately one metre from ground level. The buttons are stacked vertically with the top button labelled “UP”, the middle button is a red unlabelled button and the bottom button is labelled “DOWN”.
- At the time of the incident, the UP button was configured as “push-to-run”, meaning that, if a user pushed this button momentarily, the lifting mechanism would be activated and would raise the Bin up the elevator column. The user did not need to continue holding the UP button; the lifting mechanism would not stop until it reached the limit switch. While in UP mode, the system can be stopped by pushing the stop button, which is the red middle button. The DOWN button was configured as “hold-to-run”. This means that, as the user holds the button, the Bin is lowered down the lifter system. If the user releases the button, the Bin stops lowering automatically.
The platform for the cleaners to stand on to clean the La Par was not effective (too small) so workers would get into the Bin use the controls to move the Bin high enough to clean the machine. This is what Mr Killeen was doing.
Although Bin is not designed for people to stand in it, the control panel is at a level that can be accessed by a worker standing in the bin and is halfway up the lifter column.
Mr Killeen was trapped between the pillar that holds the mechanics for the Bin lifter, the Bin and the La Par hood which is above the La Par bowl.
End fine: $340,000 to be split 50/50 between ANZCO and REL.
Consequential loss: $15,000 over 3 years to be paid to the widow.
Costs: $10,000
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