We have previously written about the benefits of the Positive Investigation Methodology and the need to shift the safety investigation focus from a traditional accident causation analysis to the proactive consideration of near misses in the workplace.

The importance of considering and acting on near miss incidents was recently highlighted in the decision of Russell v Leonhard Kurz (Aust) Pty Ltd [2015] SAIRC 13.

This case involved a factory assistant who had operated an automatic core cutter (which cuts paper roll cores to length) for a number of years. The factory assistant was considered to be an “experienced operator” of the core cutter, and had received training in relation to its operation.

In the years prior to the incident, the factory assistant had regularly worn a glove while operating the core cutter in an attempt to avoid blisters developing. On the day of the incident in 2012, the factory assistant was wearing a glove on her left hand while operating the core cutter, when her left hand became caught under the spinning rod of the core cutter and her lower arm was dragged under the rod. The factory worker’s lower left arm was amputated as a result of the incident.

At the time of the incident, the employer had given its employees verbal and visual on the job training in relation to the operation of the core cutter. However, the employer did not have a safe operating procedure in place.

In 2008, the same factory operator had been involved in a near miss incident while operating the core cutter. Her hand had become caught by the shaft of the core cutter, but she was able to pull away in time. She did not suffer injuries as a result of this near miss incident.

In considering the incident and the prior incident, Industrial Magistrate Ardile commented that “it is of significance that the defendant failed to prohibit the use of a glove even after the earlier incident which highlighted the serious risks associated with operating the plant whilst wearing a glove.”

Despite the near miss in 2008, it does not appear that the employer took proactive steps to consider the learnings from this near miss incident. Had the employer adopted the Positive Investigation Methodology it would have been highly likely that:

  • a safe work procedure would have been prepared in relation to the safe operation of the core cutter;
  • the use of gloves during the operation of the core cutter would have been strictly prohibited and this prohibition would have been expressly noted in the safe work procedure; and
  • the incident that took place in 2012 could have been completely avoided.

In addition to spending $200,000 on making work health and safety improvements, the employer was fined $42,000 for its failure to provide and maintain a safe system of work and a safe operating procedure.

Proactively analysing all near miss incidents, rather than waiting until after serious incidents occur is an invaluable way of minimising work health and safety incidents. The Positive Investigation Methodology is a tool that Norton Rose Fulbright has developed which focuses on this proactive approach.



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