Adelaide Desalination Plant Death - Allen ONeil

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 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.

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 the company(McConnell Dowel Built Environ Joint Venture MDBE-JV) toprevent such an incident happening again?Let’s have a look shall we?

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 ?

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 …

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!

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

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 …

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!

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!

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!

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?

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 ….?

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?

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.

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 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 …

21Coates Hire InvoiceDocument # 42

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?

23Now moving from this to theclaim that the incident thatoccurred outside of normal workhours … That’s interesting …

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 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?

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 Safety Systems and Procedures?Field Notes taken by SafeWork SA Inspector (17/03/2010)Document # 18 - Page 18

32Statement of SafeWork SA InspectorDocument # 50

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.

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• 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.

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.

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?

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.

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.

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?

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!

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?

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.

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?

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 !

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 !

Adelaide Desalination Plant Death - Allen ONeil

by Andrea_AUST on Nov 14, 2011

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Adelaide Desalination Plant Death - Allen ONeil — Presentation Transcript