Adelaide Desalination Plant Death - Allen ONeil

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ADELAIDE DESAL PLANT

The death of Allen O’Neil

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Just a quick recap on some of the media

reports that have been made in relation to

the 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.

The Advertiser – August 30th 2010

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The Advertiser – September 1st 2010

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HANSARD 24th NOVEMBER 2010

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Gosh so this does really beg for a look at just how

thorough this investigation was…

…and just what steps had been taken by the company

(McConnell Dowel Built Environ Joint Venture MDBE-JV) to

prevent such an incident happening again?

Let’s have a look shall we?

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 steps to avoid such an incident happening and

had relevant procedures in place ?

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This is SafeWork SA’s Case File Report – an internal file that

tracks the progress of an investigation.

Please do make a mental note now to watch out for

Slide 13 … and when you have read that, please feel

free to go back and read the bottom section on Slide 4

again - or go back and read it again now because you

may not get another chance!

Dreary me, so in September 2010 did SafeWork SA know when the incident was reported?

Did anyone actually open the file and read any of the

documents?

Prey tell we do hope the investigation is a little less clumsy

than what we’ve seen so far …

GO BACK

TO

SLIDE 4

Case File ReportDocument # 59 – Page 8

17/12/2009NOTIFICATION RECEIVED

18/01/2010MORE THAN 1 MONTH LATER

A PHONE CALL IS MADE

12/02/2010ANOTHER MONTH LATER

SOMEONE GETS IN A CAR!

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Case File ReportDocument # 59 – Page 7

24/02/2010ALLEN O’NEIL HAS PASSED

AWAY A WEEK AGO

17/12/2009NOTIFICATION RECEIVED

18/01/2010MORE THAN 1 MONTH LATER

A PHONE CALL IS MADE

12/02/2010ANOTHER MONTH LATER

SOMEONE GETS IN A CAR!

03/03/2010NOW AN INVESTIGATION

FINALLY PROCEEDS

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SafeWork SA waited until Allen O’Neil was dead before it

decided to conduct a proper investigation?

Do we understand this correctly?

Allen O’Neil is placed in a medically induced coma from

the moment he is hospitalised and no one thought this matter was serious enough to launch something that

remotely looks like an investigation?

Oh there simply must be more to this …

Case File ReportDocument # 59 – Page 6

17/03/2010THE FIRST VISIT TO GATHER

EVIDENCE 3 MONTHS AFTER

NOTIFICATION!

24/02/2010ALLEN O’NEIL HAS PASSED

AWAY A WEEK AGO

17/12/2009NOTIFICATION RECEIVED

18/01/2010MORE THAN 1 MONTH LATER

A PHONE CALL IS MADE

12/02/2010ANOTHER MONTH LATER

SOMEONE GETS IN A CAR!

03/03/2010NOW AN INVESTIGATION

FINALLY PROCEEDS

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Statement of SafeWork SA InspectorDocument # 50 – Page 2

17/03/2010THE FIRST VISIT TO GATHER

EVIDENCE 3 MONTHS AFTER

NOTIFICATION!

24/02/2010ALLEN O’NEIL HAS PASSED

AWAY A WEEK AGO

18/01/2010MORE THAN 1 MONTH LATER

A PHONE CALL IS MADE

12/02/2010ANOTHER MONTH LATER

SOMEONE GETS IN A CAR!

03/03/2010NOW AN INVESTIGATION

FINALLY PROCEEDS

17/12/2009NOTIFICATION RECEIVED

12/12/2009NOTIFICATION OF INCIDENT

13/12/2009NOTIFICATION

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Immediately Notifiable Work Related Injury Form Document # 4

17/03/2010THE FIRST VISIT TO GATHER

EVIDENCE 3 MONTHS AFTER

NOTIFICATION!

24/02/2010ALLEN O’NEIL HAS PASSED

AWAY A WEEK AGO

18/01/2010MORE THAN 1 MONTH LATER

A PHONE CALL IS MADE

12/02/2010ANOTHER MONTH LATER

SOMEONE GETS IN A CAR!

03/03/2010NOW AN INVESTIGATION

FINALLY PROCEEDS

17/12/2009NOTIFICATION FORM ?

13/12/2009NOTIFICATION?

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So it was the Immediately Notifiable Work

Related Injury Form that was lodged 5 days late…even though it is supposed to be

lodged within 24 hours of an oral

notification.

Still…maybe this document is full of

information that may explain why things

made no sense?

Surely the administrative side to the

investigation has been conducted in a

manner that …

Well, let’s have a look shall we?

Immediately Notifiable Work Related Injury Form Document # 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 ….?

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Immediately Notifiable Work Related Injury Form Document # 4 – Page 2

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This is Page 2 of 2 of the

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?

Regulation 418 – (Extract from OHS&W Regulations (2010)

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; orb) 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?

Back to the Statement of SafeWork SA InspectorDocument # 50 – Page 2

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.

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Photographs taken by the company MDBE-JV of the site area as

it appeared ROUGHLY at the time of the incident were obtained by 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 back

the day after the incident was formerly notified (SLIDE 21) .

Allen O’Neil’s father and a friend attended Valve Pit 1 on the

Monday following the incident and after seeing these

photographs both say the area did NOT look like this.

But hey – it doesn’t matter…it’s only justice and a man’s

reputation that’s at stake here.

The evidence of photographs taken by MDBE-JVDocument #15 (2 of 4) Allen O’Neil’s work vehicle and a small section of the lunch room

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Most of the photo’s taken

by MDBE-JV seemed fairly

pointless but this one

deserves 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 …

Coates Hire Invoice Document # 42

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SafeWork SA Inspector McCallum’s Photo Log (Taken 17th March 2010) Document # 17 – Photograph 1

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Here’s a photo

taken for

evidence in

March 2010

when SafeWork

SA conducted

its investigation.

…??...

Lucky the company

conducted its own

investigation ey?

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Now moving from this to the

claim that the incident that

occurred outside of normal work

hours …

That’s interesting …

SafeWork SA Internal Memo – Executive SummaryDocument # 56

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Minutes Regarding Fatality ReviewDocument # 53

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2004 - 2005

What constitutes a Workplace Injury or fatality?

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So who keeps changing the rules?

Oh - it appears they actually haven’t ….

Next slide please…

Evidently – the rules have not changed!

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So based on SafeWork SA’s own media release in

December 2010, Allen O’Neil was no less acting out of work

hours than someone at an after hours work event.

Similarly, not convinced there would be any work-related

activities carried out at an after work Xmas bash either … so

wonder why they would bother with this media release.

Is anyone else scratching their head?

Confused?

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Now let’s look at what systems and procedures were in place when the

SafeWork SA inspectors arrived in March 2010 – 3 months after

the incident…

Field Notes taken by SafeWork SA Inspector (17/03/2010)Document # 18 - Page 18

Safety Systems and Procedures?

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Statement of SafeWork SA InspectorDocument # 50

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Photograph taken by SafeWork SA Inspector (17/03/2010)Document # 17 – Photo No. 7

Safety Systems and Procedures?

The lock and flap

designed to control

access to the

generator’s diesel

fuel supply.

NOTE

Fuel access remains

unrestricted in

March 2010.

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Come on!

The inspector even makes notes on the complete lack of access controls in the field notebook!

Look how easy it would have been to control the fuel access. Flap closed –key locked – problem solved.

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• 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.

The bundle of documents received from FOI showed zero references to any document

to any safety systems, procedures or controls relating to the removal of fuel from

machinery 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 that

the administrative process was rushed and incomplete.

Clearly SafeWork SA have relied heavily on the ‘statements’ provided by management and its employees. Every witness statement (without exception) provided in the bundle

obtained 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 the

witnesses and all the physical evidence were by this time completely contaminated by

rumour, hearsay and internal influences.

VOID is NOT comforted by the notion that the company was allowed to conduct an

internal investigation. It was allowed to grill, (sorry) interview people that it pays! It took

its own photographic evidence leaving out crucial pieces of evidence. It removed and

tampered with the only evidence that could determine the real circumstances

surrounding the death of Allen O’Neil.

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In 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 a

leading 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 for

personal use?

The only eye witness revealed to VOID that Allen O’Neil was siphoning the diesel for the

company 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 service

station? 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 he

would confidently make it to the service station to refuel? Perhaps deliver a portable

generator?

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Remember, MDBE-JV said it could not restrict access to the generator

fuel supply from Allen O’Neil because he was a supervisor and he had

a ‘key’.

Really?

There is a key that operates the generator and there is a key that locks

fuel access so to which key does MDBE-JV refer?

It does not matter because only one key controls the fuel access and it

hangs from a padlock NOT utilised … both before and after O’Neil is

admitted to hospital – and well after his death in March 2010.

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.

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We note that SafeWork SA has provided an updated submission to the

Select Committee Inquiry in August 2011 in response to our evidence.

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…and we do have

a little something to

say about that.

You got that right!

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SafeWork SA Submission Update – August 2011Page 8

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?

Well now there’s a surprise…

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SafeWork SA Submission March 2011 – August 2011Page 9

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!

So which is it – the 13th or the 17th? Remember SLIDE # 4 – how did the

department come up with the 5 day delay?

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SafeWork SA Submission March 2011 – August 2011Page 10

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?

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?

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SafeWork SA Submission March 2011 – August 2011Page 10

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.

…and this is supposed to instil us with confidence…how exactly?

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SafeWork SA Submission March 2011 – August 2011Page 10

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?

…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?

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SafeWork SA Submission March 2011 – August 2011Page 12

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 !

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.

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SafeWork SA Submission March 2011 – August 2011Page 14

YET ANOTHER OHS EPIC FAIL !