Polite or ignorant?
Coroners can be a polite lot, preferring what they would call ‘substance’ to emotion, accuracy to grand standing. They also hope that their Findings make a difference and help to protect people against a range of lethal circumstances. Ex-coroner Graeme Johnstone (Victoria) was an outstanding example in OHS. So any comments in their Findings ought to be considered against this background.
However, the comments by the South Australian State Coroner Mark Frederick Johns in his Findings (9/2/2011) in the death of Daniel Nicholas Madeley who died (6/6/2004) as a result of an occupational incident are puzzling. Either the man is being very polite or seriously ignorant of what really goes on in industry. And it does matter because coroners carry a lot of authority. Work by Johnstone, Olle and Tasmanian coroners (mining disasters) has been very helpful.
To paraphrase: Daniel was 18 years old when he died of ‘horrific injuries sustained when he was caught in a horizontal boring machine’. He became entangled in the machine and was spun violently around so that his feet were amputated by the force when they came into contact with parts of the machine.
This imported machine was old, probably built between 1960 and 1970 in the then U.S.S.R.
“The machine had no guarding or other safety devices that might have prevented the occurrence of an event such as that which took Mr Madeley’s life.”
Preventable and ‘unbelievable’
He wrote that this
“…tragic death was entirely preventable” and that the company was operating a machine which was clearly unsafe.”
So far so good. But then he goes on to write:
“It is inexplicable in an age in which occupational health, welfare and safety is so much a part of the modern workplace, [where has this man been?!] that a workplace could have existed so recently as 2004 with a machine that was so obviously unsafe….. The system of work employed in its operation, namely the need to lean in towards the work with the plastic bottle of lubricant and squirt it on the work, was a major accident waiting to happen. The horizontal boring machine and the method of its operation might have been something one could have expected to see in a workplace in the 1950s, but certainly not in 2004.”
“I simply cannot understand how such a workplace existed in South Australia in 2004 bearing in mind the existence of SafeWork SA and its various predecessors, and the Workcover Corporation which, I understand, also takes an interest in occupational health, welfare and safety.”
“I would have thought that an intelligent ‘strategic intervention’ by SafeWork SA might have decided to target small manufacturing businesses in possession of heavy machinery such as the horizontal borer. I certainly would have thought that such a ‘strategic intervention’ would have been taken very soon after Mr Madeley’s death.”
“However, it was not until more than 6 years after Mr Madeley’s death that the ‘strategic interventions’ section of SafeWork SA finally commenced compliance project to identify the number of horizontal and vertical borers at South Australian workplaces and ensure that they are appropriately guarded, amongst other things. In my view this is completely unacceptable.”
So what’s the problem?
So what’s my problem with what he writes? I’ll group the bits that worry me. He writes:
- It is inexplicable;
- The horizontal boring machine and the method of its operation might have been something one could have expected to see in a workplace in the 1950s, but certainly not in 2004;
- I simply cannot understand how such a workplace existed in South Australia in 2004;
- I would have thought;
- I certainly would have thought that such a ‘strategic intervention’ would have been taken very soon after Mr Madeley’s death;
- However, it was not until more than 6 years after Mr Madeley’s death that the ‘strategic interventions’ section of SafeWork SA finally commenced a compliance project.
What does this astonishment represent? I reckon it expresses a studied coronial politeness – no irony intended – to invoke sympathy for his recommendations so they can actually achieve some improvements. And that’s a good thing.
It just cannot be the case that someone in such an important position would not know that such disgustingly dangerous machines, such poor work practices, pressure to get on with the job and not complain about H&S standards, intimidation and fear of job loss if a worker mentions unease with an H&S matter are all around us. I have found life-threatening conditions in some 80% of workplaces I’ve inspected. Workers have been killed because of missing machine guards or poor guarding methods during the very period the coroner talks of, 3 in NSW alone in recent times. Workers have lost arms in circumstances where machine guards were missing or there were no adequate guarding methods. Read about the most recent one in Hobart and the horrendous injuries that worker suffered.
So far as the speed of response by regulators. What can I say? I agree. I’ve been on the back of some state regulators, including in Victoria, for months now about the hazards of riding quad bikes without crush protection devices and their “proneness to rollover” (as coroner Olle wrote a couple of years back). I’ve been suggesting to them in writing that they need to move quickly, that we need to meet and do something, and that there are some things that could be done. No practical interest. And, tragically, in the last two weeks there have been 4 deaths and a very serious injury (Victoria and Tasmania) as a result of riding quad bikes.
So why is coroner Johns surprised? Nah! I don’t believe it, he is surely being diplomatic and polite.