Lessons Learned and Ramifications from the Prosecution of Visy Board Pty Ltd

In a recent case with significant implications for workplace safety, Visy Board Pty Ltd was fined $275,000 for failing to ensure a safe work environment at its cardboard box manufacturing facility in O’Connor, Western Australia. This case highlights the critical importance of rigorous safety protocols and employee training, particularly when operating complex machinery like the Titan 1 rotary die cutter. The incident that led to this prosecution involved a worker who suffered partial amputation of two fingers, exposing serious gaps in Visy's safety measures. Here are the key lessons and ramifications from this case for businesses in high-risk industries.

Overview of the Incident

The incident occurred on January 7, 2020, when an employee was attempting to make adjustments to the Titan 1 machine. The machine was still running at the time, and due to inadequate controls and procedures, the worker’s hand was pulled into the feed rolls, resulting in severe injuries and partial amputation. Investigations revealed several lapses in safety measures, including inadequate training, a lack of proper competency assessments, and the absence of critical machine safety features.

This case underscores the legal and ethical responsibility of employers to protect their workers from foreseeable hazards. The lessons learned provide valuable insights into how businesses can avoid similar safety breaches.

Key Lessons Learned from the Prosecution

1. Importance of Machine Safeguarding and Engineering Controls:

   - The Titan 1 machine lacked sufficient engineering controls to prevent hands from entering hazardous areas. Following the incident, Visy implemented a "two-hand feed system" and a jam detection system that automatically stops the machine when a jam is detected.

   - Engineering controls, such as physical guards, two-hand controls, and automatic shutdowns, are essential for protecting workers from hazardous machinery. This case highlights that, where reasonably practicable, employers must implement physical controls over relying solely on procedural safeguards.

2. Adequate Training and Competency Assessments:

   - A critical finding was that the operator involved in clearing the jam had not received proper competency assessments or formal training on the Titan 1. Additionally, an audit conducted after the incident revealed that around 200 competency assessments were either incomplete or undocumented across the site.

   - This demonstrates the importance of not only providing initial training but also conducting ongoing competency assessments. Businesses must ensure that employees understand and adhere to safe work practices, especially when operating complex machinery. Competency checks should be practical, timely, and documented.

3. Clear, Enforced Safety Procedures:

   - Visy’s Standard Work Practice (SWP) document required that machines be fully stopped before clearing jams, but this procedure was not followed, leading to the accident. The prosecution found that employees were not adequately trained or supervised to ensure compliance with this crucial safety measure.

   - Employers must ensure that safety protocols are clear, enforceable, and integrated into daily operations. Regular reminders, reinforcement of procedures, and supervision are essential to create a culture where employees understand and follow safe practices consistently.

4. The Value of a Proactive Approach to Hazard Identification:

   - Prior to the incident, Visy had been issued an Improvement Notice related to machinery guarding, but further proactive steps to prevent this specific hazard were not implemented until after the accident.

   - Businesses should be proactive in identifying hazards and implementing necessary safety improvements, even before incidents occur. Regular audits, risk assessments, and adjustments to safety protocols should be standard practices, especially in high-risk environments.

Ramifications for Employers in High-Risk Industries

This case has broader implications for employers in manufacturing and other high-risk industries where machinery and automation are common:

- Legal and Financial Consequences: Visy was fined $275,000 and ordered to pay additional legal costs, demonstrating that safety lapses can lead to significant financial penalties. Employers are legally bound to ensure safe work environments, and breaches can result in severe penalties, both financially and reputationally.

- Increased Focus on Machine Safety: Employers should expect greater scrutiny on machinery safeguarding and employee training in industries where equipment presents serious risks. Compliance with codes of practice, such as those for safeguarding machinery, is essential to avoid incidents and penalties.

- Stronger Emphasis on Competency Assessments: This case underscores that informal, on-the-job training is insufficient for high-risk tasks. Formal competency assessments, documented thoroughly, are necessary to verify that workers have the skills and understanding needed to perform tasks safely.

Steps to Improve Workplace Safety and Compliance

For businesses aiming to avoid similar incidents, here are practical steps to improve workplace safety:

1. Implement Engineering Controls: Ensure all machinery is equipped with appropriate safety features, such as guards, two-hand controls, and automatic shutdowns for jam detection. Regularly review and update machinery to align with safety standards and best practices.

2. Formalise Training and Competency Checks: Conduct formal, documented training and competency assessments for all machinery operators. Periodically reassess employees to ensure they retain necessary skills and follow safe work procedures.

3. Reinforce Safety Protocols and Supervision: Establish clear safety protocols, regularly remind employees of these practices, and ensure supervisors enforce compliance. Supervisors should actively monitor safety practices and provide immediate feedback.

4. Conduct Regular Safety Audits: Perform routine safety audits and risk assessments to identify and mitigate potential hazards before they lead to incidents. Continuous improvement of safety protocols is essential to maintaining a safe workplace.

The prosecution of Visy Board Pty Ltd highlights the severe consequences of failing to prioritise worker safety in high-risk environments. This case emphasises that businesses must adopt a proactive approach to hazard identification, provide thorough training and competency assessments, and implement robust engineering controls. For employers, investing in a comprehensive safety management system is essential not only to meet regulatory obligations but also to protect the health and well-being of employees. This case serves as a cautionary tale, underscoring that cutting corners on safety can lead to serious harm, legal repercussions, and costly fines.