1ADELAIDE DESAL PLANTThe death of Allen O’Neil
2Just a quick recap on some of the mediareports that have been made in relation tothe death of Allen O’Neil.   They said ...
3The Advertiser – August 30th 2010
4The Advertiser – September 1st 2010
5HANSARD 24th NOVEMBER 2010
6Gosh so this does really beg for a look at just howthorough this investigation was……and just what steps had been taken by...
7  SafeWork SA conducted a thorough            investigation ?The accident happened outside normal           working hours...
8This is SafeWork SA’s Case File Report – an internal file thattracks the progress of an investigation.Please do make a me...
9Case File ReportDocument # 59 – Page 8                             17/12/2009                          NOTIFICATION RECEI...
10Case File ReportDocument # 59 – Page 7                             17/12/2009                          NOTIFICATION RECE...
11SafeWork SA waited until Allen O’Neil was dead before itdecided to conduct a proper investigation?Do we understand this ...
12Case File ReportDocument # 59 – Page 6                              17/12/2009                          NOTIFICATION REC...
13Statement of SafeWork SA InspectorDocument # 50 – Page 2                                         12/12/2009             ...
14Immediately Notifiable Work Related Injury FormDocument # 4                                                      13/12/2...
15So it was the Immediately Notifiable WorkRelated Injury Form that was lodged 5 dayslate…even though it is supposed to be...
16Immediately Notifiable Work Related Injury FormDocument # 4 – Page 1                                                  Th...
17Immediately Notifiable Work Related Injury Form   This is Page 2 of 2 of theDocument # 4 – Page 2                       ...
18Regulation 418 – (Extract from OHS&W Regulations (2010)              Back to the Statement of SafeWork SA Inspector     ...
19Photographs taken by the company MDBE-JV of the site area asit appeared ROUGHLY at the time of the incident were obtaine...
20     The evidence of photographs taken by MDBE-JV     Document #15 (2 of 4) Allen O’Neil’s work vehicle and a small sect...
21Coates Hire InvoiceDocument # 42
22SafeWork SA Inspector McCallum’s Photo Log (Taken 17th March 2010)Document # 17 – Photograph 1Here’s a phototaken forevi...
23Now moving from this to theclaim that the incident thatoccurred outside of normal workhours …             That’s interes...
24SafeWork SA Internal Memo – Executive SummaryDocument # 56
25Minutes Regarding Fatality ReviewDocument # 53
26What constitutes a Workplace Injury or fatality?             2004 - 2005
27So who keeps changing the rules?      Oh - it appears they actually      haven’t ….      Next slide please…
28Evidently – the rules have not changed!
29So based on SafeWork SA’s own media release inDecember 2010, Allen O’Neil was no less acting out of workhours than someo...
30Now let’s look at what systems andprocedures were in place when the SafeWork SA inspectors arrived in   March 2010 – 3 m...
31                    Safety Systems and Procedures?Field Notes taken by SafeWork SA Inspector (17/03/2010)Document # 18 -...
32Statement of SafeWork SA InspectorDocument # 50
33                     Safety Systems and Procedures?Photograph taken by SafeWork SA Inspector (17/03/2010)Document # 17 –...
34Come on!The inspector even makesnotes on the completelack of access controls inthe field notebook!Look how easy it would...
35•   An eye witness and former employee confirmed that diesel was occasionally    siphoned from on site generators and th...
36The bundle of documents received from FOI showed zero references to any documentto any safety systems, procedures or con...
37In spite of SafeWork SA media comments in August and September 2010, there wasevidence in the documents to support that ...
38Remember, MDBE-JV said it could not restrict access to the generatorfuel supply from Allen O’Neil because he was a super...
39We note that SafeWork SA has provided an updated submission to theSelect Committee Inquiry in August 2011 in response to...
40SafeWork SA Submission Update – August 2011Page 8     You got that right!     What? No matters to raise about the incide...
41SafeWork SA Submission March 2011 – August 2011Page 9  Well now there’s a surprise…  VOID had communication with this em...
42SafeWork SA Submission March 2011 – August 2011Page 10 So which is it – the 13th or the 17th? Remember SLIDE # 4 – how d...
43SafeWork SA Submission March 2011 – August 2011Page 10 Go back and read your own comments to The Advertiser Sept 1st 201...
44SafeWork SA Submission March 2011 – August 2011Page 10 …and this is supposed to instil us with confidence…how exactly? P...
45SafeWork SA Submission March 2011 – August 2011Page 12 …and was your investigation also told that the small amount of fu...
46SafeWork SA Submission March 2011 – August 2011Page 14  Would these be the reliable witness statements given by workers ...
Upcoming SlideShare
Loading in …5
×

Adelaide Desalination Plant Death - Allen ONeil

1,538 views

Published on

Adelaide Desalination Plant Safety - death of Allen O'Neil - poor investigation by SafeWork SA - poor justice system. By VOID voice of industrial death.

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,538
On SlideShare
0
From Embeds
0
Number of Embeds
277
Actions
Shares
0
Downloads
8
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • The aim of this presentation is to step through some of the reported claims made by Government safety regulator SafeWork SA and inconsistencies that have arisen from the investigation into the death of Adelaide Desalination Pipeline Project worker Allen O’Neil on February 15th 2010.
  • I just want to quickly recap on some of the media reports that have been made in relation to the death of Allen O’Neil.You will note here Bryan Russell starts the run with these departmental comments – He said this incident happened out of normal work hours and was not related to work activity.He said that the department conducted a thorough investigation…And that the employer had relevant procedures and systems in place.
  • I just want to quickly recap on some of the media reports that have been made in relation to the death of Allen O’Neil.You will note here Bryan Russell starts the run with these departmental comments – He said this incident happened out of normal work hours and was not related to work activity.He said that the department conducted a thorough investigation…And that the employer had relevant procedures and systems in place.
  • The following day THE ADEVERTISER :Once again – more verbatim type dialogue – this time from a department spokeswoman.Hmmm…that’s interesting. Here SafeWork SA advised the public that the incident was reported 5 days later - on the 17th December 2010. Allen O’Neil was hospitalised on the 12th December 2010 – incidentally, he was placed into an induced coma.
  • Even the Legislative Council carried the same comment almost word for word .. Gosh that really is interesting. I wonder what steps had been taken to avoid such an incident happening again?
  • I just want to quickly recap on some of the media reports that have been made in relation to the death of Allen O’Neil.You will note here Bryan Russell starts the run with these departmental comments – He said this incident happened out of normal work hours and was not related to work activity.He said that the department conducted a thorough investigation…And that the employer had relevant procedures and systems in place.
  • Our primary focus during this presentation will be:How thorough the investigation actually was…was it conducted in a timely manner? What evidence was collected?Whether or not this happened outside of normal work hours – and what constitutes normal? Was Allen O’Neil still working or was he not?How did SafeWork SA manage to determine whether this was work-related activity or not?And just whatrelevant systems and procedures did the McConnell Dowel Built Environs joint venture have in place both before and after the incident?
  • Document 59 – this is the Department’s Case File Report …Page 8 shows us that the notification was recorded as being the 17/12/2009 which was indeed 5 days after the incident.Note on the 17th December the matter is referred to the Response Team.1 month later there is another entry – all the while there is a man that has been on life support now for 4 weeks. On the 12th February 2010 – 3 days before life support is terminated someone gets in a car and heads to the site!
  • On page 7 of the Case File ReportOn the 24th February 2010 it would appear SafeWork SA are now realising that they have a fatality on their hands.On the 3rd March 2010 finally there is a little ‘action’. Why on earth there are sections of the case file hidden in secrecy provisions is beyond us but there you have it, 81 days after the incident, SafeWork SA are now thinking about proceeding to an investigation.
  • Now to Page 6 …17th March 2010 – now SafeWork SA moves to collecting evidence. More than 3 months and 5 days go by – in all that time the said worker has been in a deep coma. Hmmm…3 months – really, now I ask you, how thorough can that investigation be?
  • BUT WAIT! What’s this? Just a minute – let’s just flash back to slide 3 for a moment …Okay, so in September 2010 when the media began questioning the death of Allen O’Neil, SafeWork SA came out publically defending their decision not to charge MDBE for their failure to notify because – well, lucky for everyone (except Allen O’Neil of course) that the injury (and consequent death) was deemed not to be work related anyway … phew. Question? Do the people at SafeWork SA actually even talk to each other? Here we have a matter in the hot hands of the media and one has to question whether anyone even bothered to read the file on Allen O’Neil’s death. I mean, it was never a very big case file was it? Oh … surely this document existed in the file prior to September 2010 didn’t it? Hmmm?
  • So the Case File Report (D 59) takes us to yet another file (document 4)The ‘Immediately Notifiable Work Related Injury Form’ Right! Maybe this document might tell us something?
  • Page 1Well now that’s fascinating. Admin forgets to include any relevant details that pertain to dates…
  • This is Page 2 of 2 of the form…It says *IMPORTANT NOTICE* - this should be read to the client? Nothing at the site is to be altered….There’s a check box there to ensure the statement is read and understood – and of course this remained unchecked.So are we to assume this was why MDBE-jv proceeded to remove evidence on site?
  • Regulation 418 outlines fairly clearly what an employer’s legal responsibilities are in relation to OHS Regulations in altering the work site where an employee has been hospitalised or killed.So what happened here?Back to the inspector’s statement – read the highlight text again …From the 13th December, the company gave clear indications as to why Allen O’Neil was in hospital.Before anyone had even had time to start any form of questioning, it was deemed non-work related and deemed unauthorised.And if the company that might have been investigated said this from Day 1 – then it must be true, right?Even more unbelievable was the fact that MDBE then conducted its own investigation – tampering with the only evidence that might have been of any assistance in a properly conducted investigation.MDBE took the photographic evidence on site.MDBE – the employer, consented itself to question employeesMDBE had the most crucial pieces of evidence removed from site within days.The one that should have been investigated is allowed to conduct the only real investigation.ALL witness statements relating to this incident have been suppressed (secrecy provisions) but the photographs are here … so … let’s have a look at those (which incidentally are not dated)
  • The only photographic evidence of any use was actually taken by the company. The photographs were not dated. Most of them seemed quite pointless (unless a macro view of Allen O’Neil’s vehicle number plate is vital…given it was in all the other photo’s of his car) but this one was perhaps worth showing.I draw your attention to what looks like a fuel cell next to Allen’s work vehicle. The only problem here is that Eric O’Neil and Mr AlisterMcNickle attended this area very soon after Allen was hospitalised. There was no sign of a fuel cell. The trench was also exposed and not neatly covered over.The amenities room is far right with the temporary fencing surrounding it … the generator was located within that area. ……But it would seem MDBE-jv didn’t consider the genset worth photographing. We’re busting to know why not? Is it because it had already been removed from site?
  • The Coates Hire Invoice – Document 42As you can see, this crucial piece of evidence was sent back to Coates Hire on the 18th December 2009….the morning afterthe Notification Form was lodged at SafeWork SA !What a remarkable coincidence!
  • To draw a comparison with what SafeWork SA inspectors saw when they arrived at Valve Pit #1 to gather evidence … 3 months later…Not that it would have made much difference – the area was being wiped clean before the ink had time to dry on the Immediately Notifiable Workplace Injury Notification Form!
  • Now to the question: Was Allen O’Neil was working at the time? SafeWork SA Internal Memo – Executive Summary (Document 56)On page 1 we note that as per VOID’s submission in January 2010, the information from Chris Tillbrook is correct and confirmed here. The executive summary includes reference to the portable generator and that Allen O’Neil needed help to lift this into his vehicle. On Page 2 – the executive summary also acknowledges the information VOID had obtained that Allen O’Neil returned to the area to lock up – as was part of his duties as a leading hand.VOID’s Submission in January (Page 7) outlined conversations with a Senior Supervisor of the area at the time – obviously employed by MDBE-jv. That staff returned VOID’s call to clarify some questions. He gave clear direction that suggested Allen O’Neil and Chris Tillbrook had no reason to be on site that afternoon. Based on this content of this executive summary, his information appears less than accurate.
  • Once again in the minutes regarding the Fatality Review, Page 1 – there is more reference made to Allen O’Neil needing to attend to a few matters … although it is conveniently ambiguous but based on the Executive Summary, there appears to be some acceptance that Allen O’Neil was still at work in his capacity as a leading hand employee …
  • So what does constitute a workplace injury?Please look at one example of a workplace tragedy which occurred out side of normal work hours – from the DAIS Annual Report – that being before being renamed to the Department of Premier & Cabinets.This report outlines a fatality that occurred in December 2004…Outside of normal work hoursThe employee no longer even worked there…This man’s death is not a result of work related duties…And yet SafeWork SA concluded that this man’s death does constitute a workplace fatality.It is perhaps worth noting that the death of the young boy a few months later would likely not have been associated with normal work duties either and yet also has been included on the stats.
  • And just in case SafeWork SA decided to change the criteria, we note quite recently this Media Release from the Department.So in the face of this, we would argue that the incident that ultimately claimed the life of Allen O’Neil should have fallen within the realm of a workplace injury and fatality. It happened on site. It happened whilst he was still performing work duties.But … of course this is a Government Funded project – perhaps the same rules don’t apply here?
  • Now we move to the 17th March 2010 – 3 months after the incident occurred and we’re looking at the hand written FIELD NOTES of a SafeWork SA Inspector (Document 18 – Page 18)…Page 18 in the absence of the generator in question, the Inspector has asked to view a similar generator …Of interest is this paragraph in her notes…Inspector McCallum feels compelledto make notes relating to the lack of provisions of access control to the fuel supply - padlock was unlocked …and hanging from a chain when we arrived.There was no site access control and the gate was open.So the lock that is designed to control access to the fuel is right there – but not being used.For 3 monthsMcConnell Dowell Built Environs management were aware of the hazard associated with poor security control over a generator’s fuel supply and yet, based on the observations of this inspector, they saw no need to change a thing?
  • On December 13th 2009 MDBE-jv were advised to ensure that fuel supplies in generators were secured to prevent unauthorised access by employees or the public! The response was that it was already done…but O’Neil had a key.What an absolute travesty to suggest that MDBE-JV could have done nothing more. The key – whether it be for the amenities area or the genset, it does not matter. The simplest form of access control was to use the fuel access lock that comes with the genset.
  • Here is the generator Inspector McCallum has photographed:On arriving – the flap is open and the padlock is hanging from a chain…which might suggest not much has changed since December 12th 2009.
  • Back to our focus … and the determination by SafeWork SA that the accident happened as a result of non work-related activity…Doesn’t it seem reasonable that Allen had a key because there may have been times when he needed to access the fuel supply of the generator?Is it conceivable that in the spirit of keeping the project moving along, McConnell Dowell were indifferent to measures like this being taken – to keep the work moving along – no delays – no dramas … well fingers crossed anyway…Chris Tillbrook commented to VOID that Allen had siphoned diesel from the generator to get a tractor on site going again…Eddie Kingston commented that McConnell Dowell was aware that diesel was being removed from generators – even prior to this incident according to him when we spoke in October 2010 - and yet McConnell Dowell Built Environs failed to action this – failed to secure the generator’s fuel supply…the question has to be … why?And Eddie Kingston … of course his statement to SafeWork SA has been suppressed from us – but…
  • Now let’s speculate a little on these so-called safety systems and procedures that were reported by our safety regulator to be in place and adequate…and in this bundle of documents released by FOI – of those not buried in secrecy provisions…Not one reference in any of the documents to any safety systems, procedures or controls relating to the removal of fuel from machinery or equipment- There wasn’t even any sign of a circulated memo to employees or contractors after the fact.There was no measure in place to ensure if it needed to happen, that it could be done safely – for example a siphon hose that does not require suction from a human.There were no signs on or around the generator that made it clear that the activity of siphoning diesel was dangerous or was prohibited.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk of death if inhaled or ingested – but this appeared not to hit the radar of the management - either before … or after the incident on 12/12/09.
  • Now let’s speculate a little on these so-called safety systems and procedures that were reported by our safety regulator to be in place and adequate…and in this bundle of documents released by FOI – of those not buried in secrecy provisions…Not one reference in any of the documents to any safety systems, procedures or controls relating to the removal of fuel from machinery or equipment- There wasn’t even any sign of a circulated memo to employees or contractors after the fact.There was no measure in place to ensure if it needed to happen, that it could be done safely – for example a siphon hose that does not require suction from a human.There were no signs on or around the generator that made it clear that the activity of siphoning diesel was dangerous or was prohibited.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk of death if inhaled or ingested – but this appeared not to hit the radar of the management - either before … or after the incident on 12/12/09.
  • Now let’s speculate a little on these so-called safety systems and procedures that were reported by our safety regulator to be in place and adequate…and in this bundle of documents released by FOI – of those not buried in secrecy provisions…Not one reference in any of the documents to any safety systems, procedures or controls relating to the removal of fuel from machinery or equipment- There wasn’t even any sign of a circulated memo to employees or contractors after the fact.There was no measure in place to ensure if it needed to happen, that it could be done safely – for example a siphon hose that does not require suction from a human.There were no signs on or around the generator that made it clear that the activity of siphoning diesel was dangerous or was prohibited.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk of death if inhaled or ingested – but this appeared not to hit the radar of the management - either before … or after the incident on 12/12/09.
  • Now let’s speculate a little on these so-called safety systems and procedures that were reported by our safety regulator to be in place and adequate…and in this bundle of documents released by FOI – of those not buried in secrecy provisions…Not one reference in any of the documents to any safety systems, procedures or controls relating to the removal of fuel from machinery or equipment- There wasn’t even any sign of a circulated memo to employees or contractors after the fact.There was no measure in place to ensure if it needed to happen, that it could be done safely – for example a siphon hose that does not require suction from a human.There were no signs on or around the generator that made it clear that the activity of siphoning diesel was dangerous or was prohibited.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk of death if inhaled or ingested – but this appeared not to hit the radar of the management - either before … or after the incident on 12/12/09.
  • Now let’s speculate a little on these so-called safety systems and procedures that were reported by our safety regulator to be in place and adequate…and in this bundle of documents released by FOI – of those not buried in secrecy provisions…Not one reference in any of the documents to any safety systems, procedures or controls relating to the removal of fuel from machinery or equipment- There wasn’t even any sign of a circulated memo to employees or contractors after the fact.There was no measure in place to ensure if it needed to happen, that it could be done safely – for example a siphon hose that does not require suction from a human.There were no signs on or around the generator that made it clear that the activity of siphoning diesel was dangerous or was prohibited.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk of death if inhaled or ingested – but this appeared not to hit the radar of the management - either before … or after the incident on 12/12/09.
  • Now let’s speculate a little on these so-called safety systems and procedures that were reported by our safety regulator to be in place and adequate…and in this bundle of documents released by FOI – of those not buried in secrecy provisions…Not one reference in any of the documents to any safety systems, procedures or controls relating to the removal of fuel from machinery or equipment- There wasn’t even any sign of a circulated memo to employees or contractors after the fact.There was no measure in place to ensure if it needed to happen, that it could be done safely – for example a siphon hose that does not require suction from a human.There were no signs on or around the generator that made it clear that the activity of siphoning diesel was dangerous or was prohibited.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk of death if inhaled or ingested – but this appeared not to hit the radar of the management - either before … or after the incident on 12/12/09.
  • Now let’s speculate a little on these so-called safety systems and procedures that were reported by our safety regulator to be in place and adequate…and in this bundle of documents released by FOI – of those not buried in secrecy provisions…Not one reference in any of the documents to any safety systems, procedures or controls relating to the removal of fuel from machinery or equipment- There wasn’t even any sign of a circulated memo to employees or contractors after the fact.There was no measure in place to ensure if it needed to happen, that it could be done safely – for example a siphon hose that does not require suction from a human.There were no signs on or around the generator that made it clear that the activity of siphoning diesel was dangerous or was prohibited.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk of death if inhaled or ingested – but this appeared not to hit the radar of the management - either before … or after the incident on 12/12/09.
  • Now let’s speculate a little on these so-called safety systems and procedures that were reported by our safety regulator to be in place and adequate…and in this bundle of documents released by FOI – of those not buried in secrecy provisions…Not one reference in any of the documents to any safety systems, procedures or controls relating to the removal of fuel from machinery or equipment- There wasn’t even any sign of a circulated memo to employees or contractors after the fact.There was no measure in place to ensure if it needed to happen, that it could be done safely – for example a siphon hose that does not require suction from a human.There were no signs on or around the generator that made it clear that the activity of siphoning diesel was dangerous or was prohibited.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk of death if inhaled or ingested – but this appeared not to hit the radar of the management - either before … or after the incident on 12/12/09.
  • Now let’s speculate a little on these so-called safety systems and procedures that were reported by our safety regulator to be in place and adequate…and in this bundle of documents released by FOI – of those not buried in secrecy provisions…Not one reference in any of the documents to any safety systems, procedures or controls relating to the removal of fuel from machinery or equipment- There wasn’t even any sign of a circulated memo to employees or contractors after the fact.There was no measure in place to ensure if it needed to happen, that it could be done safely – for example a siphon hose that does not require suction from a human.There were no signs on or around the generator that made it clear that the activity of siphoning diesel was dangerous or was prohibited.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk of death if inhaled or ingested – but this appeared not to hit the radar of the management - either before … or after the incident on 12/12/09.
  • Now let’s speculate a little on these so-called safety systems and procedures that were reported by our safety regulator to be in place and adequate…and in this bundle of documents released by FOI – of those not buried in secrecy provisions…Not one reference in any of the documents to any safety systems, procedures or controls relating to the removal of fuel from machinery or equipment- There wasn’t even any sign of a circulated memo to employees or contractors after the fact.There was no measure in place to ensure if it needed to happen, that it could be done safely – for example a siphon hose that does not require suction from a human.There were no signs on or around the generator that made it clear that the activity of siphoning diesel was dangerous or was prohibited.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk of death if inhaled or ingested – but this appeared not to hit the radar of the management - either before … or after the incident on 12/12/09.
  • Now let’s speculate a little on these so-called safety systems and procedures that were reported by our safety regulator to be in place and adequate…and in this bundle of documents released by FOI – of those not buried in secrecy provisions…Not one reference in any of the documents to any safety systems, procedures or controls relating to the removal of fuel from machinery or equipment- There wasn’t even any sign of a circulated memo to employees or contractors after the fact.There was no measure in place to ensure if it needed to happen, that it could be done safely – for example a siphon hose that does not require suction from a human.There were no signs on or around the generator that made it clear that the activity of siphoning diesel was dangerous or was prohibited.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk of death if inhaled or ingested – but this appeared not to hit the radar of the management - either before … or after the incident on 12/12/09.
  • Adelaide Desalination Plant Death - Allen ONeil

    1. 1. 1ADELAIDE DESAL PLANTThe death of Allen O’Neil
    2. 2. 2Just a quick recap on some of the mediareports that have been made in relation tothe death of Allen O’Neil.  They said the incident happened out of normal work hours and was not related to work activity.  He said that the department conducted a thorough investigation…  And that the employer had relevant procedures and systems in place.
    3. 3. 3The Advertiser – August 30th 2010
    4. 4. 4The Advertiser – September 1st 2010
    5. 5. 5HANSARD 24th NOVEMBER 2010
    6. 6. 6Gosh so this does really beg for a look at just howthorough this investigation was……and just what steps had been taken by the company(McConnell Dowel Built Environ Joint Venture MDBE-JV) toprevent such an incident happening again?Let’s have a look shall we?
    7. 7. 7 SafeWork SA conducted a thorough investigation ?The accident happened outside normal working hours ?The accident happened as a result of non work-related activity ?The employer had taken reasonable stepsto avoid such an incident happening and had relevant procedures in place ?
    8. 8. 8This is SafeWork SA’s Case File Report – an internal file thattracks the progress of an investigation.Please do make a mental note now to watch out for GO BACK TOSlide 13 … and when you have read that, please feel SLIDE 4free to go back and read the bottom section on Slide 4again - or go back and read it again now because youmay not get another chance!Dreary me, so in September 2010 did SafeWork SA knowwhen the incident was reported?Did anyone actually open the file and read any of thedocuments?Prey tell we do hope the investigation is a little less clumsythan what we’ve seen so far …
    9. 9. 9Case File ReportDocument # 59 – Page 8 17/12/2009 NOTIFICATION RECEIVED 18/01/2010 MORE THAN 1 MONTH LATER A PHONE CALL IS MADE 12/02/2010 ANOTHER MONTH LATER SOMEONE GETS IN A CAR!
    10. 10. 10Case File ReportDocument # 59 – Page 7 17/12/2009 NOTIFICATION RECEIVED 18/01/2010 MORE THAN 1 MONTH LATER A PHONE CALL IS MADE 12/02/2010 ANOTHER MONTH LATER SOMEONE GETS IN A CAR! 24/02/2010 ALLEN O’NEIL HAS PASSED AWAY A WEEK AGO 03/03/2010 NOW AN INVESTIGATION FINALLY PROCEEDS
    11. 11. 11SafeWork SA waited until Allen O’Neil was dead before itdecided to conduct a proper investigation?Do we understand this correctly?Allen O’Neil is placed in a medically induced coma fromthe moment he is hospitalised and no one thought thismatter was serious enough to launch something thatremotely looks like an investigation?Oh there simply must be more to this …
    12. 12. 12Case File ReportDocument # 59 – Page 6 17/12/2009 NOTIFICATION RECEIVED 18/01/2010 MORE THAN 1 MONTH LATER A PHONE CALL IS MADE 12/02/2010 ANOTHER MONTH LATER SOMEONE GETS IN A CAR! 24/02/2010 ALLEN O’NEIL HAS PASSED AWAY A WEEK AGO 03/03/2010 NOW AN INVESTIGATION FINALLY PROCEEDS 17/03/2010 THE FIRST VISIT TO GATHER EVIDENCE 3 MONTHS AFTER NOTIFICATION!
    13. 13. 13Statement of SafeWork SA InspectorDocument # 50 – Page 2 12/12/2009 13/12/2009 NOTIFICATION OF INCIDENT NOTIFICATION 17/12/2009 NOTIFICATION RECEIVED 18/01/2010 MORE THAN 1 MONTH LATER A PHONE CALL IS MADE 12/02/2010 ANOTHER MONTH LATER SOMEONE GETS IN A CAR! 24/02/2010 ALLEN O’NEIL HAS PASSED AWAY A WEEK AGO 03/03/2010 NOW AN INVESTIGATION FINALLY PROCEEDS 17/03/2010 THE FIRST VISIT TO GATHER EVIDENCE 3 MONTHS AFTER NOTIFICATION!
    14. 14. 14Immediately Notifiable Work Related Injury FormDocument # 4 13/12/2009 NOTIFICATION? 17/12/2009 NOTIFICATION FORM ? 18/01/2010 MORE THAN 1 MONTH LATER A PHONE CALL IS MADE 12/02/2010 ANOTHER MONTH LATER SOMEONE GETS IN A CAR! 24/02/2010 ALLEN O’NEIL HAS PASSED AWAY A WEEK AGO 03/03/2010 NOW AN INVESTIGATION FINALLY PROCEEDS 17/03/2010 THE FIRST VISIT TO GATHER EVIDENCE 3 MONTHS AFTER NOTIFICATION!
    15. 15. 15So it was the Immediately Notifiable WorkRelated Injury Form that was lodged 5 dayslate…even though it is supposed to belodged within 24 hours of an oralnotification.Still…maybe this document is full ofinformation that may explain why thingsmade no sense?Surely the administrative side to theinvestigation has been conducted in amanner that …Well, let’s have a look shall we?
    16. 16. 16Immediately Notifiable Work Related Injury FormDocument # 4 – Page 1 There are no entries to identify who created this file or when it was created Nothing here either – OOPS – did someone forget or ….?
    17. 17. 17Immediately Notifiable Work Related Injury Form This is Page 2 of 2 of theDocument # 4 – Page 2 form… • Note: under IMPORTANT NOTICE • There’s a check box there – and of course this remained unchecked. So are we to assume this was why MDBE-JV proceeded to remove evidence on site?
    18. 18. 18Regulation 418 – (Extract from OHS&W Regulations (2010) Back to the Statement of SafeWork SA Inspector Document # 50 – Page 2 If an employee suffers an immediate notifiable work related injury, the employer must not,without the permission of an inspector – a) alter the site where the injury occurred; or b) reuse, repair or remove plant, or reuse, repair or remove any substance, that caused or was connected with the occurrence of the death or injury. So what happened here? On 13th December 2009 McConnell Dowell alleged that the activities of this injured employee were unauthorised…that what he was doing was not authorised. SafeWork SA didn’t question these claims. MDBE-JV then conducted its own internal investigation; interviewed its own employee witnesses and took statements; took its own photographic evidence … while SafeWork SA stayed home.
    19. 19. 19Photographs taken by the company MDBE-JV of the site area asit appeared ROUGHLY at the time of the incident were obtainedby SafeWork SA in March 2010 (3 months after the incident).That’s okay …who needs independent evidence anyway?It doesn’t matter that the generator in question was sent backthe day after the incident was formerly notified (SLIDE 21) .Allen O’Neil’s father and a friend attended Valve Pit 1 on theMonday following the incident and after seeing thesephotographs both say the area did NOT look like this.But hey – it doesn’t matter…it’s only justice and a man’sreputation that’s at stake here.
    20. 20. 20 The evidence of photographs taken by MDBE-JV Document #15 (2 of 4) Allen O’Neil’s work vehicle and a small section of the lunch roomMost of the photo’s takenby MDBE-JV seemed fairlypointless but this onedeserves a mention:1. We draw your attention to what looks like a fuel cell next to Allen’s work vehicle.2. Problem here is that Mr O’Neil and Mr McNickle attended the area very soon after Allen was hospitalised. There was no sign of a fuel cell. The trench was also exposed and not neatly covered over.2. The amenities room is far right - the generator was located within that area but it would seem either the genset was long gone or – they forgot to take a picture of it? Ooops again …
    21. 21. 21Coates Hire InvoiceDocument # 42
    22. 22. 22SafeWork SA Inspector McCallum’s Photo Log (Taken 17th March 2010)Document # 17 – Photograph 1Here’s a phototaken forevidence inMarch 2010when SafeWorkSA conductedits investigation. …??... Lucky the companyconducted its own investigation ey?
    23. 23. 23Now moving from this to theclaim that the incident thatoccurred outside of normal workhours … That’s interesting …
    24. 24. 24SafeWork SA Internal Memo – Executive SummaryDocument # 56
    25. 25. 25Minutes Regarding Fatality ReviewDocument # 53
    26. 26. 26What constitutes a Workplace Injury or fatality? 2004 - 2005
    27. 27. 27So who keeps changing the rules? Oh - it appears they actually haven’t …. Next slide please…
    28. 28. 28Evidently – the rules have not changed!
    29. 29. 29So based on SafeWork SA’s own media release inDecember 2010, Allen O’Neil was no less acting out of workhours than someone at an after hours work event.Similarly, not convinced there would be any work-relatedactivities carried out at an after work Xmas bash either … sowonder why they would bother with this media release.Is anyone else scratching their head?Confused?
    30. 30. 30Now let’s look at what systems andprocedures were in place when the SafeWork SA inspectors arrived in March 2010 – 3 months after the incident…
    31. 31. 31 Safety Systems and Procedures?Field Notes taken by SafeWork SA Inspector (17/03/2010)Document # 18 - Page 18
    32. 32. 32Statement of SafeWork SA InspectorDocument # 50
    33. 33. 33 Safety Systems and Procedures?Photograph taken by SafeWork SA Inspector (17/03/2010)Document # 17 – Photo No. 7 The lock and flap designed to control access to the generator’s diesel fuel supply. NOTE Fuel access remains unrestricted in March 2010.
    34. 34. 34Come on!The inspector even makesnotes on the completelack of access controls inthe field notebook!Look how easy it wouldhave been to control thefuel access. Flap closed –key locked – problemsolved.
    35. 35. 35• An eye witness and former employee confirmed that diesel was occasionally siphoned from on site generators and this was ‘common knowledge’ and the company should have provided a safer means of siphoning. • Comments made to VOID by the supervisor suggested that siphoning diesel from gensets was something senior staff were aware of.• Regardless of whether the practise was considered authorised or not, what measures were taken to curtail it? Any warning signs? Any memo’s, emails or faxes to issue cautions that the habit of siphoning diesel was not allowed / authorised? • There was nothing in the bundle of documents that gave any indication that MDBE-JV or the contractor had raised the matter nor is there a document that contains any such information that was refused under secrecy provisions.• MDBE-JV had prior knowledge of diesel fuel being siphoned from these gensets leading up to the incident. Why did the company not simply ensure fuel access was restricted? • Fuel access control was as easy as using the flap and padlock provided. Look at the photographs of the genset taken in March 2010. The inspector makes direct comment in the field notes that there was no fuel access restrictions.
    36. 36. 36The bundle of documents received from FOI showed zero references to any documentto any safety systems, procedures or controls relating to the removal of fuel frommachinery or equipment.If such a document exists, we would love to see it.The company documents that related to Allen O’Neil and his induction showed only thatthe administrative process was rushed and incomplete.Clearly SafeWork SA have relied heavily on the ‘statements’ provided by managementand its employees. Every witness statement (without exception) provided in the bundleobtained by FOI was hidden from O’Neil’s family under secrecy provisions.SafeWork SA took these witness statements 3 months after the incident.That is an unacceptable lapse of time to make any reasonable determination given thewitnesses and all the physical evidence were by this time completely contaminated byrumour, hearsay and internal influences.VOID is NOT comforted by the notion that the company was allowed to conduct aninternal investigation. It was allowed to grill, (sorry) interview people that it pays! It tookits own photographic evidence leaving out crucial pieces of evidence. It removed andtampered with the only evidence that could determine the real circumstancessurrounding the death of Allen O’Neil.
    37. 37. 37In spite of SafeWork SA media comments in August and September 2010, there wasevidence in the documents to support that Allen O’Neil was still at work in his capacity as aleading hand to lock up Valve Pit 1 area.What happened to the portable generator in the back of Allen O’Neil’s work vehicle?What happened to the siphon hose that Allen O’Neil was allegedly using?Where is the evidence to support the allegation that Allen O’Neil was taking the diesel forpersonal use?The only eye witness revealed to VOID that Allen O’Neil was siphoning the diesel for thecompany work vehicle. A vehicle that O’Neil had a fuel card for…If O’Neil really wanted diesel fuel for personal use, why not just fill a jerry can at the servicestation? Pay for it with the company fuel card? That sounds a lot easier and far less messy.Is it possible that O’Neil’s work vehicle was low on fuel?Is it possible that his vehicle was so low on fuel that he needed to siphon diesel so that hewould confidently make it to the service station to refuel? Perhaps deliver a portablegenerator?
    38. 38. 38Remember, MDBE-JV said it could not restrict access to the generatorfuel supply from Allen O’Neil because he was a supervisor and he hada ‘key’.Really?There is a key that operates the generator and there is a key that locksfuel access so to which key does MDBE-JV refer?It does not matter because only one key controls the fuel access and ithangs from a padlock NOT utilised … both before and after O’Neil isadmitted to hospital – and well after his death in March 2010.The MSDS on Diesel Fuel supplied by MDBE did summarise the risk ofdeath if inhaled or ingested – but this appeared not to hit the radar ofthe management - either before … or after the incident on 12/12/09.
    39. 39. 39We note that SafeWork SA has provided an updated submission to theSelect Committee Inquiry in August 2011 in response to our evidence. …and we do have a little something to say about that.
    40. 40. 40SafeWork SA Submission Update – August 2011Page 8 You got that right! What? No matters to raise about the incident taking place out of work hours anymore? Did the department have a sudden change of heart on that front or did you actually read your own files?
    41. 41. 41SafeWork SA Submission March 2011 – August 2011Page 9 Well now there’s a surprise… VOID had communication with this employee too. This witnesses comments were precisely why VOID became concerned that SafeWork SA was not protecting employees from company management inquisition and speculation relating to on site safety issues. MDBE-JV had no business investigating itself when there is a perfectly capable safety regulator available to do the job!
    42. 42. 42SafeWork SA Submission March 2011 – August 2011Page 10 So which is it – the 13th or the 17th? Remember SLIDE # 4 – how did the department come up with the 5 day delay? If not for the incompetence of your own public comment, VOID would have had no reason to question the timeline. However now that you mention that Case File Report document – surely you’re not suggesting that this document is untrustworthy – unreliable – isn’t it part of the Coroner’s file of evidence?
    43. 43. 43SafeWork SA Submission March 2011 – August 2011Page 10 Go back and read your own comments to The Advertiser Sept 1st 2010 and reassure us please you’re not making this up as you go? Oh…am finding statements like this hard to stomach from a department that is charged with workplace safety. Allen O’Neil did not break a toe or strain his wrist, he was placed in a medically induced coma! That is a serious matter – yes – no? SafeWork SA should have taken this matter far more seriously than it did - period.
    44. 44. 44SafeWork SA Submission March 2011 – August 2011Page 10 …and this is supposed to instil us with confidence…how exactly? Perhaps SafeWork SA needs to become more acquainted with Safety Data on diesel fuel. It outlines pretty clearly the risk of death when ingested. At any rate, do you think after a week or so in that coma that the outcome was looking less favourable and perhaps someone should initiate some further inquiries?
    45. 45. 45SafeWork SA Submission March 2011 – August 2011Page 12 …and was your investigation also told that the small amount of fuel that was in that vehicle had been put in it AFTER Allen O’Neil had been rushed to hospital? Your department made this determination in December 2009 based solely on the word of MDBE-JV management. SafeWork SA allowed a self invested business to determine the circumstances surrounding a serious incident on their work site with no attempt made by your department to gain reliable timely evidence !
    46. 46. 46SafeWork SA Submission March 2011 – August 2011Page 14 Would these be the reliable witness statements given by workers who had been under the influence of MDBE-JV and its management for 3 months before SafeWork SA took those statements? Please, you are going to have to do be smarter than that. YET ANOTHER OHS EPIC FAIL !

    ×