Investigation report

Report into the death of Mark Daniel Galton at

Boggabri Coal Mine on 21 May 2014

Report prepared by the NSW Mine Safety

Investigation Unit

www.resources.nsw.gov.au/safety
 Investigation report – death of Mark Galton

Published by NSW Department of Industry, Skills and Regional Development

Investigation report to the Secretary of NSW Department of Industry, Skills and Regional Development

Investigation into the death of Mark Daniel Galton at Boggabri Coal Mine on 21 May 2014

Published report date: August 2015

More information
NSW Mine Safety Investigation Unit

www.resourcesandenergy.nsw.gov.au/safety

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independent advisor.
 Investigation report – death of Mark Galton

Executive summary
Incident overview
At 8.48 am on Wednesday, 21 May 2014, Mark Daniel Galton, a rigger employed by Thiess
Sedgman Joint Venture (Theiss Sedgman) died when his head and neck were crushed between
a mobile elevated work platform (MEWP) 1 and the underside of a large, horizontal steel beam.
The incident occurred inside a partly constructed multi-level steel frame referred to as ST202 at
the coal handling and preparation plant construction site at Boggabri Coal Mine. The underside
of the steel beam was 12.5 m above the concrete floor.

Figure 1. Position of the MEWP after the recovery of Mr Galton inside the ST202 structure.

Mr Galton, 51, was relocating the platform to ground level after tightening bolts on the structure.
During the movement of the platform over walkway handrails, a crush point was created
between the platform frame above the control console rising towards the steel beam. Mr Galton
was alone in the platform.
He had a designated spotter on the ground and asked a leading hand rigger on a nearby level to
observe him during movement of the platform over a walkway. 2 The leading hand rigger called
out a warning to Mr Galton when he saw there was a gap about 5cm between Mr Galton’s head
and the steel beam above. Mr Galton stopped the platform and verbally acknowledged the
warning.
Neither Mr Galton’s designated spotter nor the leading hand rigger saw the actual incident.

1
Definition of AS 2550.10-2006 1.3.7 ‘A mobile machine that is intended to move persons, tools and material to working positions
and consists of at least a work platform with controls, an extending structure and a chassis, but does not include mast climbing work
platforms’.
2
The LHR was assisting Mr Galton but was not the designated ‘spotter’ for the task. The designated ‘spotter’ for Mr Galton was
located at ground level at the time of the incident.

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 Investigation report – death of Mark Galton

The leading hand rigger next observation was that Mr Galton was trapped between the frame
above the platform control console and the overhead beam. He initiated an emergency response
over the two-way radio.
The first attempts to free Mr Galton were unsuccessful. The platform was then tilted using its
ground controls. Mr Galton was released and he fell to the floor of the platform. Workers
accessed the platform and transferred Mr Galton to the second floor landing and began first aid.
Emergency services attended the scene at 9.16 am. NSW Ambulance paramedics ceased CPR
about 9.30 am.
The platform involved in the incident was a JLG 600 AJ 18.3 m rough terrain diesel knuckle
boom. 3 It was owned and maintained by Coates Hire Operations Pty Ltd and was on a hire
agreement to Theiss Sedgman at Boggabri Coal Mine since 22 March 2014.
Theiss Sedgman was contracted by the mine operator to build the coal processing plant at
Boggabri Coal Mine about 17 km northeast of Boggabri in the Gunnedah coalfields of NSW.
Cause of death
The direct cause of Mr Galton’s death was cervical spine trauma.
The autopsy report summarised the following:
• Transected upper cervical column and spinal cord (C2-C3 level).
• Fractured larynx with extensive soft tissue haemorrhage.
• There was no evidence Mr Galton had suffered a heart attack leading up to the incident.
• Toxicology negative for drugs and alcohol.
• Normal blood carbon monoxide saturation (1%).
Investigation observations
The specific cause of the platform rise cannot be established.
The platform was over a walkway handrail and rotated to the right (relative to the operator’s
control console) and nearly parallel to the alignment of the raised jib and boom.
The incident happened during a day shift. Mr Galton arrived at the mine site at 5.55 am and was
onsite for 2 hours and 53 minutes when the incident occurred.
Mr Galton was working his ninth consecutive 11-hour shift of a 10-day roster.
The investigation is unable to establish if Mr Galton’s fatigue level contributed to the incident.
The investigation has considered five potential cause theories and ranked them in the order of
most likely to least likely.
These are:
1. An unintended platform rise caused by Mr Galton coming in contact with one or more
control switches on the platform console, which activated the platform rise functions. In this
scenario the main rise control device (the lift swing joystick) was not activated by Mr Galton
however the covered footswitch was activated enabling a seven-second window for potential
machine movement.
The reason for the movement of Mr Galton forward over the console could either be considered
as:

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 Investigation report – death of Mark Galton

Voluntary – he made a decision to look over the console to obtain a better view of the position of
the platform jib and boom relative to steel structures below or:
Involuntarily – his head came into contact with the steel beam, which moved his body forward
over the console.

Figure 2. Simulation of an operator in a forward leaning position with his body in contact with control
switches that can activate platform to rise. In this position the left hand can apply forward motion to the lift
swing joy stick and activate platform to rise. The right hand can be placed on the base drive/steer joystick.
The operator’s right foot was able to activate the footswitch to permit platform control function.

2. An unintended platform rise as a result of Mr Galton either incorrectly selecting a platform

control switch or applying the wrong direction of movement to one or more platform control
devices. Or Mr Galton selected the base drive/steer joystick to move the platform base to
move the platform sideways over the walkway handrail. As the rear wheels moved down the
ramp it caused the platform to rise (platform pendulum effect). Or excessive platform
movement caused by incorrect control function ramp time settings.
3. An intended platform rise activated by Mr Galton as he accepted the risk of moving the
platform in proximity to the beam. In review of the circumstance of the incident there was no
evidence of intentional self-harm by Mr Galton.
4. Inadvertent movement of the platform caused by a defect.
5. External force applied by the environment to the plant caused the platform to rise.

Observations concerning systems to control the risk of crush injury:

Apart from the steel frame above the platform control console, which was directly involved in the
crush injury there were no secondary protection devices to prevent Mr Galton from being
crushed while operating the MEWP.
The risk of a person being trapped between the platform and a fixed overhead structure was
foreseeable. The risk was clearly identified in risk assessments and equipment manuals
published before the incident. The risk was also identified in a range of risk management
documents found at the mine site.

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 Investigation report – death of Mark Galton

The controls put in place to manage the known risk were lower order hierarchy of risk control
measures.
The documented controls included:
• MEWP training qualifications awarded by a registered training organisation.
• High risk licence awarded to the platform operator by a government regulatory agency.
• Verification of competency to operate the specific model of platform at the site.
• Risk assessment of the specific model of platform introduced to the work site.
• Work area plans, Work Area Plan Risk Assessment, Critical Safety Controls.
• Safe Work Method Statements (SWMS) and Job Safety Environment Analysis (JSEA)
included use of platform.
• Shift tool box talks.
• ‘Start Card’ created by operators at the start of the work task.
• Working at height permit (WAH permit) (Noting that Mr Galton had not signed onto a permit
for the platform task on the day of the incident).
• Operator pre-start inspection and defect report for the MEWP (signed by Mr Galton on 21
May 2014).
• Spotter being present during MEWP tasks.
• While there were examples of documented generic risk assessments for use of MEWP at the
site there was no specific risk assessment considering the task of using a MEWP under a
fixed structure within ST202. These risk control measures did not prevent the incident from
occurring.
Observation concerning the use of secondary guarding devices on MEWPs
1. In July 2010, overseas regulatory authorities and platform end user groups published best
practice guidance for MEWPs and information on secondary guarding. 4 The Australian hire
and rental industry was informed of the guideline in February 2011. 5
2. In October 2011, a secondary guarding device registered as SkyGuard® was designed and
manufactured by JLG (America). By late 2012, the device was made available to European
MEWP user groups.
3. In May 2012, JLG informed the Australian hire and rental industry that SkyGuard® could be
previewed at the 2012 hire and rental industry convention. 6
4. In February 2013, JLG informed the Australian hire and rental industry that SkyGuard® was
available as an aftermarket kit on all JLG booms manufactured from 2004. 7 Australian
Design Registration had not been obtained for SkyGuard® at that time.
5. In May 2013, a United Kingdom equipment hire registry web page published information to
MEWP user groups related to SkyGuard®. An extract of the publication stated:
‘JLG SkyGuard® provides operators with enhanced control panel protection. When
activated by approximately 23 kg of force, SkyGuard® stops all functions in use at the
time. The reverse functionality momentarily “undoes” most functions that were in use at
the time of activation for less than a second’s worth of time.’

4
UK HSE and IPAFF
5
Hire and Rental News published February 2011 page 22
6
Hire and Rental News published May 2012 front cover and page 3
7
Hire and Rental News published February 2013 page 34

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 Investigation report – death of Mark Galton

Figure 3: JLG SkyGuard® secondary protection device fitted above a JLG platform control console. ADR
8
received for SkyGuard® by JLG on 31 May 2014.

6. In July 2013, European Standard EN280:2013 Mobile Elevating Work Platforms was updated
(with a transition period of 18 months to January 2015) to require secondary guarding
options to be fitted to all MEWPs. The current Australian MEWP Standards for safe use is
dated 2006. 9
7. On 14 May 2014, Australian Design Registration (ADR) for SkyGuard® was submitted by
JLG.
8. Before 14 May 2014, JLG had not received any purchase orders from Australian JLG MEWP
users to fit the SkyGuard® secondary guarding device.
9. On 30 May 2014, ADR for SkyGuard® was awarded by Worksafe Western Australia and
received by JLG for the 600 AJ model on 10 June 2014.
10. ADR for SkyGuard® was received after Mr Galton’s incident and approximately 17 months
after the device was made available in Europe.
11. Australian regulatory authorities had published information relating to fatal incidents and
risks associated with use of MEWP before Mr Galton’s incident. 10
12. In November 2014, Safe Work Australia (SWA) identified that there were seven fatal
incidents involving users of elevating work platforms being crushed against roofing beams
during the period 2006 to 2011. 11
Remedial safety measures
Following Mr Galton’s incident, Thiess Sedgman undertook a range of continuous improvement
programs:

8
http://rermag.com/aerial-work-platforms/skyguard-aftermarket-accessory-jlg-boomlifts publication date 1 May 2013
9
AS2550.10-2006 Cranes, Hoists and Winches Part 10 MEWP
10
NSW Workcover Safety Alerts WC03042 WC 03987, NSW Trade and Investment Mine Safety Alert SA06-15, WA Department of
Mine s and Petroleum Resources safety Alert No 151 and No 162
11
Safe Work Australia – Work related fatalities associated with unsafe design of machinery, plant & powered tools 2006-2011 –
Published November 2014

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 Investigation report – death of Mark Galton

• After the incident, Thiess Sedgman reviewed available secondary guarding device options
that could be fitted to the various brands and models of MEWP at the site.
• In July 2014, Thiess Sedgman revised the MEWP spotter training package and completed
the training.
• In or about July 2014, Thiess Sedgman updated the generic site induction assessment and
the Boggabri Coal CHPP induction PowerPoint presentation to incorporate information from
the MEWP skills review (VOC) package.
• From 20 August 2014, Thiess Sedgman required secondary control devices to be fitted to
MEWPs operating in and under structures or where an overhead crush risk exists at BCM.
• In August 2014, Thiess Sedgman developed and implemented a supervisors MEWP
presentation and supervisors MEWP scenarios assessment program to help supervisors and
leading hands to better understand the specific controls which should be used in various
circumstances.
• In August 2014, Thiess Sedgman developed and implemented a VOC authorisation
assessment for MEWP authority levels for operators.
• In August 2014, Thiess Sedgman developed other initiatives as part of Work Area Pack Risk
Assessment (WAPRA) for working in MEWPs. This included toolbox talks on MEWP
selection, revising and processing work packs to incorporate information identified in the
WAPRA, and revising the WHS Area Inspection Form to incorporate a MEWP section based
on the Thiess Critical Safety Control (CSC) Prevention of Falls.
Recommendations
The incident highlights the importance of having an effective risk management program in
relation to specific complex three dimensional movements of mobile elevated work platforms in
proximity to fixed structures.
When a MEWP is required to move in proximity to fixed structures, higher order risk
management controls to prevent crush injury should be identified and implemented. This is in
addition to the existing industry emphasis on lower order risk controls such as operator high risk
work licence, specific MEWP operator certification, verification of competency, work at heights
permit and a spotter being present.
When considering the recommendations below, mine operators are reminded of their obligation
to take a combination of measures to minimise risk, if no single measure is sufficient for that
purpose.

Recommended practice for industry

MEWP access in proximity of fixed structures:
• Assess if the risk of crush injury can be removed by using an alternative access method.
• If the risk of crush injury cannot be removed, reduce the risk by selecting a fit-for-purpose
MEWP with secondary guarding devices fitted.
• Assess and control crush injury risk from an inadvertent activation of platform controls due to
body contact with controls or the incorrect selection of controls.
• Assess and control crush injury risk due to control function ramp times creating greater
movements of the platform than intended.
• Assess and control crush injury risk due to the platform pendulum effects when working at
height in close proximity to fixed structures.

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Work permit system –

Pathway of a MEWP moving in proximity to fixed structures
• Undertake a specific task risk assessment when a MEWP pathway requires complex three
dimensional positioning of the platform, jib, boom and base when in close proximity to fixed
structures.
• When undertaking complex three-dimensional movements of a platform in close proximity to
fixed structures, the task risk assessment should consider the proposed sequence of
platform movement using a combination of either:
o platform alignment and rotation angle relative to the jib
o jib angle and telescope length
o upper boom angle and telescope length
o lower boom angle and telescope length
o base position, base rotation angle and direction of base movement
o function speed selection.
• When operating a MEWP in proximity to fixed structures apply ‘No Go Zone’ separation
distances similar to risk reduction strategies implemented when operating MEWP in proximity
to aerial conductors (overhead power lines).
• Reduce the risk of crush injury by assessing and planning the specific access pathway the
MEWP is proposed to take in and out of the work area and ensure that sufficient clearance is
maintained between fixed structures and the platform at all times.
• If the sufficient clearance between fixed structures and the MEWP platform cannot be
maintained at all times, make alternative access arrangements.
• Ensure the MEWP operator and spotter are clearly aware of fixed structures in proximity to
the path of the MEWP.
• Supervisor required to sign off and consult with people associated with the activity as part of
the work permit system.
• If appropriate in the circumstance of the task, consider placing hard barrier warning systems
to delineate the ‘No Go Zone’ (e.g. flag and rope marker lines) to give visual warning to the
operator and spotter of the proximity of the platform approaching a fixed structure.
• Consider using electronic warning systems (e.g. electronic detection devices attached either
to the fixed structure or the platform) that can audibly and visibly warn the operator and
spotter of the proximity of the platform to a fixed structure. The application of electronic
warning systems are being developed to resolve reliability and user interface challenges
identified by MEWP manufacturers.

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Training and competency assessment

• Ensure during verification of competency (VOC) for a specific type of MEWP that a
competent assessor verifies that the operator is competent and able to accurately and
consistently select the correct range of control functions to move the platform and the base.
• The verification of competency assessment should include operating the MEWP over a pre-
planned pathway (without any risk of crush injury) to verify that the operator can accurately
and consistently operate the MEWP over the full range of movement of platform and base.
• If the MEWP operator cannot demonstrate consistent and accurate MEWP control then the
operator should be provided with further training with the specific MEWP and undertake
competency reassessment.
Inspection of MEWP control devices
• Operators and maintainers of MEWPs should ensure close inspection of the rubber
protective covers of platform controls to identify deterioration such as cracking and splitting,
which can allow dust and water ingress and cause corrosion on electrical control circuit
boards.
Manufacturers, importers and suppliers of MEWPs
• Manufacturers, importers and suppliers of MEWPs so far as is reasonably practicable,
should ensure that the MEWP is without risk to the health and safety of operators who use
the MEWP at a workplace for the purpose for which it was designed or manufactured, or who
carry out any reasonably foreseeable activity at a workplace.
• Manufacturers, importers and suppliers of MEWPs should ensure that sufficient testing or
examination is undertaken that may be necessary for the performance of the duty.
• Manufacturers, importers and suppliers of MEWPs should ensure that adequate information
is made available concerning any conditions necessary to ensure that MEWPs are without
risk to health and safety when used for a purpose designed or manufactured.
Access industry associations and industry regulators
• Further develop and provide information and training programs for use by MEWP-registered
training organisations and assessors undertaking training and verification of competency of
MEWP operators.
Australian Standards Committee ME005
• Consider review of AS 1418.10:2011 Cranes, Hoists and Winches Part 10 Mobile Elevating
Work Platforms for consistency with European MEWP standards.

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Contents
Executive summary ................................................................................................................. iii
Incident overview ..................................................................................................................... iii
Cause of death ........................................................................................................................iv
Investigation observations .......................................................................................................iv
Observations concerning systems to control the risk of crush injury: ....................................... v
Observation concerning the use of secondary guarding devices on MEWPs ....................... vi
Remedial safety measures .................................................................................................. vii
Recommendations................................................................................................................. viii
Recommended practice for industry ...................................................................................... viii
MEWP access in proximity of fixed structures: ................................................................... viii
Work permit system – ..............................................................................................................ix
Pathway of a MEWP moving in proximity to fixed structures ................................................ ix
Training and competency assessment ................................................................................. x
Inspection of MEWP control devices .................................................................................... x
Manufacturers, importers and suppliers of MEWPs .............................................................. x
Access industry associations and industry regulators........................................................... x
Australian Standards Committee ME005.............................................................................. x
1. Purpose of the report......................................................................................................... 1
2. Background of the investigation....................................................................................... 1
The department’s Investigation Unit......................................................................................... 1
Legislative authority to investigate ........................................................................................... 1
The department’s response to the incident .............................................................................. 1
NSW Police ............................................................................................................................. 1
Investigation activities .............................................................................................................. 2
3. Mark Galton ........................................................................................................................ 2
Autopsy report for the Coroner ................................................................................................ 2
Mr Galton’s training qualifications and competency ................................................................. 2
Mr Galton’s hours of work ........................................................................................................ 3
Occasions Mr Galton operated similar plant ............................................................................ 3
4. Boggabri Coal Mine ........................................................................................................... 4
Boggabri Coal Mine lease details ............................................................................................ 4
Second phase design and construct contract .......................................................................... 5
Statutory control of the incident site ......................................................................................... 5
5. Thiess Pty Ltd .................................................................................................................... 7
6. Sedgman Limited ............................................................................................................... 7
7. Thiess Sedgman Joint Venture ......................................................................................... 7

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 Investigation report – death of Mark Galton

The agreements between the companies ................................................................................ 7

8. JLG Industries Inc. (Australia branch) the importer of the plant .................................... 8
JLG had identified the risk of crush injuries.............................................................................. 8
JLG published crushing hazard safety information................................................................... 9
JLG recommends minimum training and competency to operate MEWP ............................... 10
JLG recommended minimum operating distance measurements........................................... 10
9. Coates Hire Operations Pty Ltd the owner of the plant ................................................. 11
Coates Hire modifications to the JLG 600 AJ MEWP............................................................. 11
Coates Hire inspection and maintenance of the MEWP involved in the incident .................... 14
Coates Hire published crush injury safety information ........................................................... 14
10. The plant ....................................................................................................................... 16
MEWP specifications ............................................................................................................. 16
Platform control console ........................................................................................................ 17
Platform rise controls ............................................................................................................. 19
OEM Controls Inc. lift swing joystick ...................................................................................... 20
Control speed range .............................................................................................................. 20
Available upward force applied to the platform ...................................................................... 20
11. The incident site ........................................................................................................... 21
12. The incident chronology .............................................................................................. 25
The working at height permit dated 20 May 2014 .................................................................. 25
6.30 am - The prestart meeting on 21 May 2014 ................................................................... 25
7 am - The ‘Start Card’ created on 21 May 2014 ................................................................... 26
7.10 am - Prestart inspection by Mr Galton ............................................................................ 27
The work task allocated to Mr Galton..................................................................................... 27
8 am - Supervisor observes and speaks to Mr Galton ........................................................... 27
8.45 am - Verbal warning given to Mr Galton ......................................................................... 27
8.48 am - The emergency radio call....................................................................................... 28
8.50 am - Supervisor attends the scene ................................................................................ 28
The rescue attempts and recovery of Mr Galton .................................................................... 28
13. Examination of circumstances of the incident ........................................................... 29
Electronic recording devices at the site.................................................................................. 29
Background circumstances to the incident ............................................................................. 29
The position of the wheels on the MEWP base ...................................................................... 30
The load contained in the platform......................................................................................... 30
The platform control console speed setting............................................................................ 34
The position of the platform, jib, fly boom, base boom and MEWP base................................ 35
Lowering the platform after the incident ................................................................................. 36
Deflection of the platform control console bar ........................................................................ 39

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The work task at the structure................................................................................................ 40

The spotter allocated for the task ........................................................................................... 40
The working at heights permit was not applicable for ST202 ................................................. 41
Plant defect investigation ....................................................................................................... 41
Wenn Wilkinson Associates report on MEWP........................................................................ 42
Bureau Veritas report on the lift swing joystick ....................................................................... 42
Austest Laboratories report into the lift swing joystick ............................................................ 45
Electromagnetic effects on the operation of the JLG MEWP joystick unit .............................. 46
14. Incident causation review ............................................................................................ 47
Incident causation ranking diagram ....................................................................................... 51
15. Health and Safety Management Systems ........................................................................ 52
Machine risk assessments introduction of JLG 600 AJ to site ................................................ 52
Thiess critical safety controls ................................................................................................. 53
Work packs............................................................................................................................ 53
Job Safety Environment Assessment .................................................................................... 53
Working at Heights Permit ..................................................................................................... 54
Operators pre-start inspection and defect report .................................................................... 54
Safety observations at site..................................................................................................... 54
SAI Global external audit ....................................................................................................... 54
Controls to prevent the risk from occurring ............................................................................ 54
Secondary guarding on MEWP.............................................................................................. 55
16. Australian Standards and State regulatory guidelines................................................... 57
Australian Work Safety Regulators ........................................................................................ 57
NSW WorkCover ................................................................................................................... 57
Victorian WorkCover Authority ............................................................................................... 58
NSW Department of Industry, Resources & Energy Mine Safety ........................................... 58
Worksafe Queensland ........................................................................................................... 58
Western Australia Government .............................................................................................. 58
Elevating Work Platforms Association of Australia ................................................................. 59
United Kingdom Health & Safety Executive Safety Regulator ................................................ 59
International Powered Access Federation and European MEWP Standards ......................... 59
18. Post incident response ..................................................................................................... 60
Post-incident actions by the department ................................................................................ 60
Post-incident actions by Theiss Sedgman ............................................................................. 60
Appendix A - Applicable reference extracts to Australian Standards ...................................... 62
Appendix B - International Powered Access Federation information ...................................... 64

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 Investigation report – death of Mark Galton

1. Purpose of the report

This report concerns the investigation into the fatal crush injury of Mark Daniel Galton. This
report was prepared for the Secretary of NSW Department of Industry, Skills and Regional
Development. It presents information from the investigation conducted by the department’s
Investigation Unit into the cause and circumstances of the incident and makes recommendations
to enhance industry safety.
The purpose of this report is to assist the Secretary, as regulator of the work health and safety
legislation at mines, to learn about the incident and to share information with the industry and the
community so that steps can be taken to improve industry safety and to prevent incidents of a
similar nature from reoccurring.

2. Background of the investigation

The department’s Investigation Unit
The unit investigates the nature, cause and circumstances of major incidents in the NSW mining
and extractives industry.
Its role is to carry out a detailed analysis of incidents to ensure that lessons can be applied for
the safety of workers at mines, and to give effect to the department’s Enforcement Policy.
The unit is autonomous within the department and reports to the Secretary. It is separate from
the department’s Mine Safety inspectorate and is not involved in the activities of the inspectors
or the day-to-day inspection of mines.
Legislative authority to investigate
The investigation was conducted under the Work Health and Safety Act 2011 (WHSA).
Investigators had authority to conduct an investigation into this matter because the incident
occurred at a coal workplace regulated by the department.

The department’s response to the incident

The department received notification of the incident from the mine. Department officers attended
the mine on 21 May 2014 and issued a WHSA section 198 Non-Disturbance Notice requiring
preservation and non-disturbance of the scene.
A WHSA section 195 Prohibition Notice was issued on 22 May 2014 to the mine operator
prohibiting the use of any boom-type MEWP at the site until a detailed risk assessment was
completed regarding the risk of MEWPs colliding with fixed objects.
In accordance with departmental policy, the incident was automatically referred to the
Investigation Unit. Investigators attended the incident scene and conducted investigation
activities using WHSA powers to obtain information and documents from individuals and
companies.
Department officers have observed demonstrations of secondary protective devices fitted to
MEWPs at the site during June 2014 and issued Coal Mine Health and Safety Act 2002
(CMHSA) section 150 Government Official advice notices to the site operators.
NSW Police
NSW Police officers attended the incident scene about 9.30 am on 21 May 2014, collected
witness statements and took photographs. NSW Police have prepared a report for the NSW
Coroner’s Court, Narrabri.

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 Investigation report – death of Mark Galton

Investigation activities
The Investigation Unit’s activities included:
• incident scene photography and taking of exhibits
• interviewing witnesses
• collecting information and documents from individuals and companies
• observing testing of the MEWP involved in the incident
• organising specialist inspection and testing of the MEWP’s lift swing joy stick control unit
• conducting an industry review of secondary guarding on MEWPs to prevent crush injury
The Investigation Unit published an information release on the department’s web site on 4 June
2014. The document contained preliminary information about the incident.

3. Mark Galton
Mr Galton accepted employment as a rigger classification level ‘B’ with Theiss Sedgman on 28
February 2014. Mr Galton attended the mine site on 4 March 2014 and undertook a site
induction of Thiess Sedgman management systems. He had 11 weeks of employment at the
mine site.

Autopsy report for the Coroner

The direct cause leading to Mr Galton’s death was cervical spine trauma.
Autopsy report summary:
1. Transected upper cervical column and spinal cord (C2-C3 level).
2. Fractured larynx with extensive soft tissue haemorrhage.
3. There was no evidence Mr Galton had suffered a ‘heart attack’ leading up to the incident.
4. Toxicology negative for drugs and alcohol.
5. Normal blood carbon monoxide saturation (1%).

Mr Galton’s training qualifications and competency

Mr Galton held a valid national licence to perform high risk work (application dated 21 December
2012). He had held this licence for 1 year and 5 months.
Mr Galton held registered training organisation certificates of competency dated 25 June 2013
and 14 November 2013 to operate MEWPs.
Mr Galton had undertaken a Thiess Pty Ltd verification of competency on the first day of
induction to Boggabri Coal Mine site to operate the specific model of MEWP involved in the
incident. The verification of competency was conducted and signed by Mr Galton’s supervisor
(Supervisor 1) on 4 March 2014.
The designated ‘spotter’ (Spotter 2) for the other platform at ST202 told investigators that he had
performed the same work of tightening bolts at ST202 using the incident MEWP the day before
the incident. On the morning of the incident, Spotter 2 did not continue with the work task
because of a discussion between Spotter 2 and Mark Galton during which Spotter 2 said Mr
Galton ‘put up his hand’ to undertake the bolt tightening task at ST202.
Spotter 2 told investigators that in his opinion he had observed competency issues with Mr
Galton operating a MEWP before the day of the incident. Spotter 2 also said that Mr Galton had

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 Investigation report – death of Mark Galton

required extra time to complete his VOC in Queensland. Spotter 2 said he had given Mr Galton
instructions on how to get the platform into a position where he needed to get to at the site.
The issue of Mr Galton’s training and competency was reviewed during the investigation
including the registered training organisations, MEWP assessors and other workers at the site
who had observed Mr Galton operating MEWP. There was no other information identifying any
issue with the competency of Mr Galton to operate MEWP.
Mr Galton’s hours of work
Mr Galton arrived at the mine site at 5.55 am on 21 May 2014 and was at work for 2 hours and
53 minutes when the incident occurred.
Mr Galton was working the ninth consecutive day shift of his 10-day roster. He worked a total of
88 hours and 15 minutes by the time of the incident. Generally, Mr Galton worked an 11-hour
day shift roster between 6 am and 5 pm.
In his previous roster, Mr Galton had taken four rostered leave days from 9 May 2014 to 12 May
2014.
Before this leave Mr Galton had worked 84 hours and 3 minutes on the previous 10-day roster
between 29 April 2014 and 8 May 2014.
Occasions Mr Galton operated similar plant
Records indicate Mr Galton had operated a JLG 600 AJ MEWP on at least two occasions at the
mine before the day of the incident.
Mr Galton signed the ‘Operator Safety Check’ records for the incident JLG 600 AJ No 1058702
on two occasions: 8.30 am on 7 April 2014 and 7.10 am on 21 May 2014.
On 21 May 2014 Mr Galton also completed the Thiess Sedgman operator’s pre-start inspection
and defect report number 75239 for incident MEWP No 1058702 on which he ticked ‘yes OK’ to
all the machine function checks.
Mr Galton signed onto a WAH permit at ST801 on 20 May 2014 with the leading hand rigger. It
is not known if Mr Galton operated a JLG 600 AJ on that date.
Spotter 2 told investigators that he had operated the incident MEWP on 20 May 2014 and had
no functional issues with it. On that occasion another operator had completed the pre-start
Operator Safety Check records for the incident MEWP on 19 and 20 May 2014.
Mr Galton signed onto two WAH permits on 22 April 2014 and 23 April 2014 for MEWP activity
at ST801. However it is not known if he personally operated a JLG 600 AJ on either of those
dates.
Mr Galton undertook VOC on a JLG 600 AJ MEWP on 4 March 2014 it is likely that he operated
a JLG 600 AJ MEWP on that occasion to obtain VOC.

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4. Boggabri Coal Mine

Idemitsu Australia Resources Pty Ltd (IAR) through its wholly owned subsidiary Boggabri Coal
Pty Ltd owns the Boggabri Coal Mine and significant land holdings in the Gunnedah Basin of
NSW. Boggabri Coal Mine is within Coal Lease No 368. An adjacent authorisation area, A355 is
also held by Boggabri Coal Pty Ltd. The resources within CL368 and A355 are mostly located in
the NSW-owned Leard State Forest.
Boggabri Coal Mine was established in 2006 with a nominal production capacity of 1.5 million
tonnes per annum (Mtpa). At the time of writing, the operation requires coal to pass through a
crushing system at the ROM pad before being loaded into oversize B-double trucks. These
trucks haul the coal approximately 17 km via private road haul road to the Boggabri Coal Pty Ltd
owned train-loading facility where coal was loaded onto trains and transported to the Port of
Newcastle.
The Boggabri Coal Expansion Project (Boggabri Coal Pty Ltd) will increase the capacity of the
mine to 6.9Mtpa by mid-2015.
Boggabri Coal Mine lease details
The incident site was within Coal Lease No 368 (CL 368 -Coal Mining Act 1973) which was held
by Boggabri Coal Pty Ltd.
CL 368 was originally granted on 15 November 1990. In accordance with the provisions of
Section 114(1)(a) of the Mining Act 1992 the Minister signed an instrument of renewal of the
lease on 9 May 2013 and the lease was renewed until 14 November 2032.

Figure 4. Boggabri Coal Mine CL368 and the location of incident.

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Figure 5. Boggabri Coal Expansion Project in relation to the incident site.

Second phase design and construct contract

Thiess Sedgman won a competitive tender in November 2010 to deliver a tender for the
Boggabri Coal Mine Coal Handling Processing Plant as part of the early contractor involvement
phase. Sedgman Limited also delivered a feasibility study in November 2010 focusing on the
product stockpiling, reclaim and train load out.
A second phase design and construct contact agreement was signed on 12 September 2013
between Boggabri Coal Pty Ltd (the principal) and Thiess Sedgman (the contractor).
Thiess Sedgman is an unincorporated joint venture between Thiess Pty Ltd (Thiess) and
Sedgman Ltd.
Statutory control of the incident site
The incident involving Mr Galton was within the statutory area allocated by Boggabri Coal Pty
Ltd to Boggabri Coal Expansion Project.

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Figure 6. Boggabri Coal Expansion Project statutory area of control in red hatch and the incident site.

Boggabri Coal Expansion Project had further allocated statutory control to Thiess Sedgman at
the specific location where Mr Galton’s death occurred.

Figure 7. Thiess Sedgman statutory area of control in yellow and the incident site.

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5. Thiess Pty Ltd

Thiess is an Australian proprietary company limited by shares with a registered office in South
Brisbane, Queensland. The single shareholder is Leighton Holdings Limited listed at St
Leonards, NSW.

6. Sedgman Limited
Sedgman Limited is a listed Australian public company limited by shares with a registered office
in Milton, Queensland. SL was established in 1979 and listed on the ASX in 2006.
Sedgman Limited has more than 800 employees globally with offices in China, Mongolia, Africa,
South America and Canada. SL is a provider of mineral processing and infrastructure solutions
to the resource industry with operations across coal, iron ore, copper, gold, lead and other base
metals.
Sedgman Limited is involved in the design, construction and operation of coal handling and
preparation plants in Australia. The projects and engineering division provides integrated
services across the complete life cycle from initial feasibility, to construction, operation and
completion. 12

7. Thiess Sedgman Joint Venture

Thiess Sedgman Joint Venture is an unincorporated joint venture agreement between Thiess
and Sedgman Limited. On 18 February 2005, Theiss Sedgman was registered with ASIC as a
Business Name in Queensland.
Thiess Sedgman Joint Venture is the ‘Principal Contractor’ for all construction work under the
Second Phase Design and Construction Contract at Boggabri Coal Mine.
Thiess Sedgman Joint Venture was Mr Galton’s employer. On 25 February 2014, Mr Galton was
offered an employment letter. On 28 February 2014, Mr Galton signed an employment
acceptance and began work at Boggabri Coal Mine on 4 March 2014 where he declared in
writing he had read and understood 13 mandatory site operating procedures for site induction.
The agreements between the companies
On 12 September 2013, Boggabri Coal Pty Ltd (the principal) signed a ‘formal instrument of
agreement’ with Thiess Sedgman (the contractor) for the Second Phase Design and Construct
Contract for the coal handling preparation plant at the mine.
In February 2014, Thiess and Sedgman Limited entered into the unincorporated joint venture
agreement for the Second Phase Design and Construct Contract for the processing plant, which
retrospectively operated from 16 September 2013.
The joint venture agreement required a ‘Management Committee’ consisting of two senior
employees of Thiess and two senior employees of Sedgman Limited to receive and review
reports from the Theiss “Project Manager’ which included health and safety and incident reports
for activities at Boggabri Coal Expansion Project.
The joint venture provided supervisory responsibilities at the expansion project and included
daily site coordination meetings between supervisors and the daily pre-start meeting with work
crews. Work crews would then attend the location where supervisors employed by Thiess

12
http//www.sedgman/about us

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monitor and maintain site standards as required under the Theiss Sedgman Health and Safety
Management Plan.
The joint venture produced monthly reports that included safety management reporting
concerning the joint venture health and safety management plan.

8. JLG Industries Inc. (Australia branch) the importer of the plant

JLG Industries Inc. was founded in Pennsylvania, USA in 1969. The first JLG aerial platform was
sold in 1970. JLG is an Oshkosh Corporation Company listed on the New York stock
exchange. 13.
JLG Industries Inc. (Australian branch) imports the 600 AJ boom lift device into Australia.
On 28 February 2007, JLG provided a statement of importers design adherence ‘Certificate of
Assurance’ for the 600 series elevated work platform.
On 25 June 2007, design registration in the Northern Territory of Australia was obtained for a
600A type articulated boom lift.
On 29 March 2010, JLG provided a ‘Certificate of Assurance’ for the 600AJ EWP.
In October 2011, JLG Industries Inc reviewed secondary platform guarding applications for
MEWPs in America. The outcome of the review was a device that became to be known as
SkyGuard® a platform switch. The review by JLG opted for SkyGuard® over provision of hard
barrier guards surrounding the platform console.
SkyGuard® for the 600 AJ MEWP was not available in Australia at the date of incident involving
Mr Galton.
SkyGuard® was commercially available in the United Kingdom prior to January 2013.
On 14 May 2014, design registration for 600 AJ SkyGuard® was submitted to WorkSafe
Western Australia. On 30 May 2014, Worksafe WA design registered SkyGuard®. The design
registration was received by JLG on 10 June 2014.
JLG had identified the risk of crush injuries
On 17 February 2011, JLG produced design risk assessment and control measures for the 600A
series MEWP. The risk assessment identified the hazard of crushing, striking as a result of
sudden or unintended movements.
Identified risk assessment control measures to reduce the risk were:
1. Function ramping time may be adjusted to suit the owner.
2. Braking and a foot switch that needs to be depressed for any function to operate, is provided
to prevent inadvertent movement.
3. Emergency stop buttons are in place to halt movement in the case of an emergency.
4. Controls return to neutral when released.
5. Brakes are spring applied (electric over hydraulic release).
6. Only one set of controls may be used at a time.
7. Ground controls are recessed.
8. Optional padding for platform rails is also available.

13
http//www.jlg.com/about

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The control measures above when ranked reduced the likelihood of occurrence from very low to
rare and consequence of occurrence was not altered and remained at numerous fatalities.
An earlier JLG risk hazard assessment dated 29 September 2009 identified when ‘operating
boom functions’ and in ‘proximity to overhead structures’ there existed a ‘crushing hazard due to
operator striking obstruction and being forced on to machine controls and unable to stop
movement’.
JLG documented controls included a seven second timer applied to the footswitch operation and
platform control console designed with features to physically guard the toggle switches against
damage and inadvertent operation.
On 2 December 2014 investigators identified that a platform rise could be achieved by bodily
contact with a control panel toggle switch. The platform rise could only be achieved when the
documented controls of covered footswitch was intentionally activated by the operator and then
only within the seven second timer window.
If there was more than seven seconds between the selection of functions, the footswitch must be
released and depressed again to restore power to the controls. Releasing the footswitch
removes power from all platform controls, halting all functions immediately.
The emergency stop button serves as the primary power supply switch for all platform controls.
In the event of an emergency, this switch is deactivated to cease operation of the platform
control inputs regardless of footswitch activation. Deactivation of the functions is immediate,
without any ramping action. All function controls are designed to return to neutral position, once
released, stopping further movement.

JLG published crushing hazard safety information

On 25 August 2010, JLG published an ‘Operation and Safety Manual’ for the 600AJ MEWP.
The safety manual specifies measures operators should take to avoid the risk of crushing due to
sudden or unintended movements. The safety measures identified in the manual included:
‘Safety Precautions’ – ‘Crushing and Collision Hazards’
1. Approved head gear must be worn by all operating and ground personnel.
2. Check work area for clearances overhead, on sides and bottom of platform when lifting
or lowering platform, and driving.

3. During operation, keep all body parts inside platform railing.

4. Use the boom functions, not the drive function, to position the platform close to
obstacles.
5. Always post a lookout when driving in areas where vision is obstructed.
6. Keep non-operating personnel at least 1.8 m away from machine during all driving and
swing operations.

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7. Limit travel speed according to conditions, visibility, slope, location of personnel, and
other factors which may cause collision or injury to personnel.
8. Be aware of stopping distances in all drive speeds. When driving in high speed, switch to
low speed before stopping. Travel to grades in low speed only.
9. Do not use high speed drive in restricted or close quarters or when driving in reverse.
10. Exercise extreme caution at all times to prevent obstacles from striking or interfering with
operating controls and persons in the platform.
11. Be sure that operators of other overhead and floor level machines are aware of the aerial
work platform’s presence. Disconnect power to overhead cranes.
12. Warn personnel not to work, stand or walk under a raised boom or platform. Position
barricades on the floor if necessary.
JLG informed investigators that the presence of the control system interface features and the
specific warnings and instructions outlined in the Operation and Safety Manual appropriately
mitigated the risk of crushing when the MEWP is operated by a competent operator.

JLG recommends minimum training and competency to operate MEWP

JLG has identified that it is not a registered training organisation or approved trainer of the
Elevated Work Platform Association of Australia (EWPAA) and does not offer high risk work
training. However, JLG does offer familiarisation training to customers in Australia which is
intended to complement the training provided by registered training organisations and EWPAA.
The training includes technical, servicing and maintenance requirements of the 600 AJ MEWP.
JLG recommends the following minimum training required to operate the MEWP. In section 1-1
of the JLG Operation and Safety Manual for the plant, JLG directs operators as follows:
• Read and understand the manual before operating the machine.
• Do not operate the machine until complete training is performed by authorised persons.
• Only authorised and qualified personnel can operate the machine.
• Read, understand and obey all dangers, warnings, cautions and operating instructions on the
machine and in the manual.
• Use the machine in a manner that is within the scope of its intended application set by JLG.
• All operating personnel must be familiar with the emergency controls and emergency
operation of the machine as specified in this manual.
• Read, understand, and obey all applicable employer, local and governmental regulations as
they pertain to operation of the machine.
• In addition, per WHSA Regulations of 2011, operators are required to possess a licence to
perform high risk work.

JLG recommended minimum operating distance measurements

JLG provided information in the Operation and Safety Manual identifying minimum operating
distances to structures:
• Keep the chassis of the machine at least 0.6 m (2 foot) from holes, bumps, drop-offs,
obstructions, debris, concealed holes and other potential hazards on the floor/surface.
• Do not place boom or platform against any structure to steady the platform or to support the
structure.

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• Exercise extreme caution at all times to prevent obstacles from striking or interfering with
operation controls and persons in the platform.
9. Coates Hire Operations Pty Ltd the owner of the plant
Coates Hire Operation Pty Ltd (Coates Hire) is a major equipment rental company operating
across all states of Australia.
Coates Hire bought the MEWP involved in the incident from JLG on 4 March 2011.
Coates Hire held a copy of the JLG statement of importers design adherence ‘Certificate of
Assurance’ for the model 600AJ dated 29 March 2010.
The hire of the MEWP involved in the incident was supplied by Coates Hire under a supply
agreement for hire of plant and equipment with Thiess Sedgman. The MEWP arrived at the coal
mine on 22 March 2014.
As at 21 May 2014, Coates Hire owned 381 JLG 600 AJ boom lifts nationally.
Coates Hire maintenance records identify that after the incident, between on 21 May 2014 and 7
November 2014 JLG has provided Coates Hire with five replacement platform control console lift
swing joystick rubber boots as a result of inspection and replacement of damaged rubber boots.
The rubber boots are designed and supplied to be used on all current series JLG diesel powered
boom lifts. Coates Hire (at the time of writing) owned 1639 JLG units.

Coates Hire modifications to the JLG 600 AJ MEWP

Coates Hire modified the 600 AJ MEWP to align with MDG 15 specification which included:
• battery isolator
• fan and belt guards
• extinguisher on base and in basket
• conduit on leads
• reflective tape
Coates Hire added further safety information signs to the existing JLG safety information
signage on the 600 AJ MEWP based on Elevated Work Platform Australia (EWPA)
recommendations.

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Figure 8: Coates Hire signage modification to platform control console.

Figure 9: Coates Hire signage modification to base ground control.

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Figure 10: Coates Hire signage modification to engine bay side.

Figure 11: JLG signage on base identifying crushing hazards.

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Coates Hire inspection and maintenance of the MEWP involved in the incident
Coates Hire maintenance records identify the MEWP involved in the incident had received a pre-
hire three monthly safety check on 7 March 2014 at which operational functionality of platform
controls was checked before hire.
Coates Hire maintenance records identify the MEWP received a ‘B’ service annual inspection
and service conducted by maintenance employees on 6 March 2014. The hour meter was
recorded at 883 hours.
The platform arrived at the coal mine on 22 March 2014. A folder containing the ‘EWP safety
check and routine maintenance logbook’ was found attached to the platform of the MEWP.
Coates Hire was asked to identify if they were aware of any reported or repairs to issues
concerning the platform control functions. Coates Hire stated:
‘No reported issues with basket control function prior to 21 May 2014’ and ‘No reported
issues with basket raise speed prior to 21 May 2014’.
A JLG warranty service dated 26 October 2011(hour meter 153.0) identified an electrical fault
with a joystick lift on the MEWP. The lift swing joystick was replaced on 27 October 2011.

Coates Hire published crush injury safety information

Coates Hire provided an ‘EWP safety check and routine maintenance logbook’ which was
attached to the MEWP and included a ‘Hazard and Risk Assessment – Plant Operation’
document dated 23 July 2013.
The Coates Hire risk assessment identified the hazard and risk of crushing (squashing). The
addition to the assessment of the hazard and risk of crushing was made in October 2011.
The identified risk stated:
‘Person(s) in basket being crushed between the basket and overhead structure(s) if the
boom is driven under overhead structures on uneven ground or up and down kerbs or
slopes’
The control measure in the assessment stated:
‘Remember the leverage factor and ensure ample clearance above the basket to cater for
any unexpected amplified upward basket movement’.

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Figure 12: Coates Hire hazard and risk assessment – plant operation knuckle booms page 2

‘Serious crushing injury or death if person(s) in basket collide with an unseen overhead
structure.’
Another control measure stated:
‘When working near or in between steel beams or other overhead structures always “Look
up, Around and Behind” BEFORE elevating, driving or reversing.’

Figure 13: Coates Hire hazard and risk assessment – plant operation knuckle booms page 2

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Another identified risk stated:

‘Being trapped between the plant and materials or fixed structures’
The control measure to the risk stated:
1. Avoid congested work areas
2. Remain within the confines of the platform when operating
3. Ensure sufficient clearance between the platform and overhead obstructions.

10. The plant

The plant involved in the incident was a JLG 600 AJ 60 foot (18.3m) rough terrain diesel knuckle
boom type mobile elevating work platform (MEWP). Coates Hire web-based information states:
‘Knuckle booms are specifically designed to access areas that require an up and over
approach. This helps work around obstacles such as fixtures, machinery, walls or other
restrictions in the path’. 14

MEWP specifications
Machine model: JLG 600AJ
Item asset code: 1058702
Serial number: 0300144012
Date of manufacture: 28 February 2011
Date of commissioning: February 2011
Date of purchase (CHOPL) 4 March 2011
Last date of
Annual inspection: 6 March 2014
Max. height: 18.29m (60ft)
Boom length: 18.42m
Working radius: 12.07m
Platform SWL: 230kg
Overall width : 2.44m
Engine: Deutz Diesel F4M2011F
Drive: 4 wheel drive
Transport weight: 11.9 tonne

14
www.coateshire/access-hire/knuckle-booms-hire

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Figure 14: JLG operational and safety manual 600AJ machine nomenclature page 2-9

The 600A model articulating boom lift was design registered (registration number N7070) in the
Northern Territory to design code AS1418.10 (classification GP-B-SUB-GP3) on 25 June 2007.
The NT design registration was granted based upon the supplied manufacturer’s specifications
from JLG Industries Inc. and reciprocal to the design approvals from Queensland Workplace
Health and Safety design No. Q15939 (26 November 1996), Victorian WorkCover Authority
design No. V964019 (27 November 1996) and WorkSafe Western Australia design No. 086690
(27 September 1996).
JLG has two statement of importers design adherence ‘Certificate of Assurance’ for Boom Lift
600 series dated 28 February 2007 and the 600 AJ dated 29 March 2010.
JLG stated on the certificate that they complied with duties required of a person who imports
plant under Australian Occupational Health and Safety Regulations 1996 and the design process
required by Regulation 4.25.
JLG Industries Inc, Pennsylvania, sold the incident MEWP to JLG Industries, Australia, on 1
April 2011. JLG Industries, Australia, sold the incident MEWP to Coates Hire on 4 March 2011.
Platform control console
JLG provide a standard platform control console across the range of JLG MEWP models.
The platform tilt lift and swing joystick is on the left hand side of the console. The joystick on the
right hand side of the console operates the drive and steer function to move the base of the
MEWP.

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A dial to select the speed function (low to high speed) is on the left hand side adjacent to a bank
of functional switches, which are between raised mouldings and are an integral component of
the console.
A power emergency stop button is in the middle top area of the console.

Figure 15: Incident MEWP control console – platform returned to ground level on 23 May 2014.

Figure 16: JLG 600 AJ operational and safety manual platform control console

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Figure 17: JLG 600AJ operational and safety manual platform control indicator panel

Platform rise controls

JLG identified six individual platform console controls that cause a rise in the platform.

Figure 18: Identification of the six platform raise controls on the platform control console

1
2 3 4 5

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1. Main lift swing joystick move forward

2. Tower lift toggle switch to forward position
3. Tower telescope toggle switch to forward position
4. Jib toggle switch to forward position
5. Telescope toggle switch to backward position
6. Platform levelling over ride switch to forward position
There are two directions of switch operation that can cause the platform to rise i.e. forward or
backward. Potentially an incorrect raise or lower operation could occur if the operator moves a
switch in the wrong direction.

OEM Controls Inc. lift swing joystick

The ‘hall effect’ lift swing joystick (Model HJS9M 14133) is manufactured by OEM Controls Inc.
(America) and supplied to JLG (USA) for the 600AJ MEWP. 15
The joystick has a centre detent (mechanical maintained centre detent, lift under cap to allow
joystick movement or function).
The device has an international protection (IP) code of IP54. 16
The joystick model HJS9 has received a TUV Rheinland of North America certification for
electromagnetic compatibility (EMC) testing against various electrical testing standards (EN and
IEC standards).
Control speed range
JLG identified the control speed range (lowest to highest speed) for each control function to
raise the platform upwards as:
Main lift up: 26-32 seconds
Tower lift up: 37-50 seconds
Tower telescope out: 15-23 seconds
Jib up: 22-34 seconds
Telescope out: 35-50 seconds
The platform speed control knob is set to full speed (turned clockwise completely). Function
speeds may vary due to cold, thick hydraulic oil.
Available upward force applied to the platform
JLG identified the maximum available force that can be applied by the MEWP to raise the
platform upwards as:
Platform level up: 2800 psi (19.305Mpa)
Jib up: 1500 psi (10.342Mpa)
Main lift up: 3000 psi (20.684Mpa)

15
The ‘Hall Effect’ is the production of a voltage difference (the Hall voltage) across an electrical conductor, transverse to an electric
current in the conductor and a magnetic field perpendicular to the current
16
The IP Code, International Protection Marking, IEC standard 60529, sometimes interpreted as Ingress Protection Marking,[1]
classifies and rates the degree of protection provided against intrusion (body parts such as hands and fingers), dust, accidental
contact, and water by mechanical casings and electrical enclosures. It is published by the International Electro technical Commission
(IEC).

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Tower lift up: 3000 psi (20.684Mpa)

Telescope out: 3000 psi (20.684Mpa)
Tower telescope out: 3000 psi (20.684Mpa)
When the maximum upward force is applied and the relief pressure is reached the hydraulic fluid
will bypass the valve and not build any more pressure in excess of the relief pressure.

11. The incident site

The incident occurred at the partly constructed coal bypass and sizing station referred to as
ST202.

Figure 19: The incident site known as ST202.

ST202 was partly constructed to three floors comprising structural steel, steel mesh, steel
stairways and conveyor equipment. Mr Galton was working under the third floor section
comprised of four steel beams and covered by a mesh floor.
The underside of the steel beam that Mr Galton was crushed against was 12.5 m above the
concrete floor ground level.

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Figure 20: Incident site – top view.

The left hand side of the platform was observed after the incident to be over the handrail of the
second floor walkway.
In this position, the platform would need to be moved sideways (to the right from the operator’s
perspective) before the platform could be lowered to prevent contact with the handrail.
The position of the platform was rotated to the right relative to operating the platform control
console and approaching parallel with the raised jib and boom.

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Figure 21: Incident X-X1 cross section plan – view towards north east.

Figure 22: Incident Y-Y1 cross section plan – view towards north west

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Figure 23: View east towards ST202 and equipment in vicinity of the scene.

Figure 24: Incident site and the installed steel components of ST202 on 21 May 2014.

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Figure 25: View north west towards main access stairway onto ST202 taken during the process of lowering
the platform from under the third floor level.

12. The incident chronology

A chronology of events has been compiled from various sources.
The working at height permit dated 20 May 2014
A Working at Height Permit (WAH permit) was signed by Mr Galton and the leading hand rigger
on 20 May 2014. The permit was countersigned by two supervisors.
The work location was ST 801 for installing steel work and chutes.
The ST801 WAH permit was not applicable to the work undertaken at ST202 on 21 May 2014.
Another permit for ST202 was signed by two other operators for work at heights conducted at
ST202 on 20 May 2014.
Thiess Sedgman told investigators that Mr Galton did not have to create a new permit for ST202
because the other permit for ST202 continued to apply. However, it is noted that Mr Galton had
not actually signed onto the ST202 WAH permit.
6.30 am - The prestart meeting on 21 May 2014
Mr Galton logged onto the mine site gate log at 5.55 am on 21 May 2014.
Mr Galton attended the pre-start meeting at 6.30 am in the site offices at Boggabri Coal Mine
and during the meeting signed onto the Theiss Sedgman prestart sign on sheet for the ‘green’
crew roster.
There were 10 other people listed on the ‘green’ roster who signed onto the same pre-start
sheet. There were 11 other people on the ‘purple’ roster who signed onto the same pre-start
sheet.
The pre-start meeting was presented by Supervisor 1. Other staff also attended the meeting.

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Supervisor 1 filled out a pre-start meeting record that identified issues of:
• reading out timber email
• no pedestrian access to CPP yet-vehicle only
• keeping on top of calling up when entering other areas.
There were no recorded issues raised by the work team on the sheet.
The record identified that union representatives would be on site at 9 am. Work activity included
ST ‘202’. A hand written notation was made to ‘hand out safety slogan stuff’.
Mr Galton’s role was typed onto the two pre-start sheets as ‘rigger’.
The allocated daily work task sheet attached with the prestart sign on sheet was filled in by
Supervisor 1 and the allocated work area for Mr Galton was handwritten as ‘bolts’ and the task
was handwritten as ‘bolts’.
There were four other ‘green’ crew workers assigned to ST202 or the ‘bolts’ task. There were
two people from the ‘purple’ crew also allocated to work at ST202.
The lead hand rigger was also allocated the task of ‘bolts’.
Information provided by people who attended the prestart meeting said there were no
instructions at the pre-start meeting that Mr Galton was to operate a MEWP that morning.
The pre-start meeting was a roster cross over between the ‘green’ and the ‘purple’ crews, which
meant that the two allocated crew supervisors were present during the day and that people from
the two different crews could be allocated to work together on the day.
7 am - The ‘Start Card’ created on 21 May 2014
A Thiess Sedgman ‘Start Card’ was created at 7 am on 21 May 2014 at ST202.
The specific JSEA nominated on the ‘Start Card’ was No. 0258.0 dated 5 March 2014 which was
for the ‘180t Kobelco Crawler Crane for general lifts and operation’. This was not the correct
JSEA for the work being undertaken by Mr Galton on 21 May 2014.
However, it should be noted that a Start Card dated 20 May 2014 for work described as ‘rattling
steel’ on which Mr Galton and the lead hand rigger had signed, stated that the specific JSEA
was No. 0292-2 dated 6 April 2014 which was for ‘Sizing station structural erection of structural
steel at ST202’. JSEA 0292-2 specifically addressed the potential hazards with use of MEWP
and rattling bolts.
Mr Galton had signed onto JSEA 0292-2 on three separate occasions on 5 April 2014, 6 April
2014 and 18 April 2014.
JSEA No. 0292-2 had been reviewed by a health, safety and environment employee on 10 April
2014 and amended on 20 May 2014.
The description of work was listed as steel erection, general lifts and in a different coloured pen
the words ‘& bolting’ were added. Supervisor 1 was identified on the ‘Start Card’ as being the
supervisor however he was not present during the creation of the ‘Start Card’.
The main hazards listed on the ‘Start Card’ were;
• pinch points
• working at heights
• swinging loads

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 Investigation report – death of Mark Galton

There were seven signatures including Mr Galton’s on the ‘Start Card’. There was no
supervisor’s name or signature identifying that a review of the ‘Start Card’ had taken place.
7.10 am - Prestart inspection by Mr Galton
At 7.10 am on 21 May 2014, Mr Galton signed the MEWP operator safety check record sheet in
the platform.
Mr Galton also filled out and signed the Thiess EWP operator’s prestart inspection and defect
report No 75239 and recorded the MEWP start hours were 949/4. All of the tick boxes on the
report were ticked ‘OK’ and ‘Yes’ and no defects were reported by Mr Galton.
The work task allocated to Mr Galton
Spotter 2 for the second MEWP being operated at ST202 on the day of the incident told
investigators he had been doing exactly the same task in a MEWP in the same location as Mr
Galton the previous day.
Supervisor 1 allocated Mr Galton to the ‘bolts’ task but it was not clear if the role was to be the
spotter or working from the MEWP. Spotter 2 said that they would talk between each other to
decide which operator did what task.
Spotter 2 told investigators that he had not continued with the bolt rattling task on 21 May 2014
and he had a conversation with Mr Galton concerning how many more bolts needed rattling.
However Spotter 2 could not recall how Mr Galton was allocated the task to rattle bolts on the
day of the incident. It appears that the task allocation was a decision made by the riggers at
ST202 on the morning of the incident.
Spotter 2 told investigators the second MEWP began work at 7.45 am and Mr Galton lifted his
MEWP platform into the air after that.
8 am - Supervisor observes and speaks to Mr Galton
About 8 am Supervisor 1 walked past ST202 and recalled seeing Mr Galton in his harness and
getting ready to use the platform. In passing he spoke with Mr Galton about how he was going
and Mr Galton replied: ‘It’s all good’.
Supervisor 1 also recalled seeing two people wearing the spotter’s identification vests and that
no machines were working at the time. Supervisor 1 then left the area to inspect the stacker pad.
8.45 am - Verbal warning given to Mr Galton
Mr Galton’s spotter (Spotter 1) was normally the crane driver and this was the first time he had
undertaken the spotter role at the Thiess Sedgman site. Spotter 1 remained at the ground level
for the duration Mr Galton operated the platform.
During the task, Mr Galton asked the leading hand rigger, who was on a walkway at an adjacent
level to assist him with observing the platform movement. The leading hand rigger was not the
nominated spotter for the task and was not wearing a spotter identification vest.
Spotter 1 was aware that the leading hand rigger was assisting Mr Galton during movement of
the platform.
The leading hand rigger saw Mr Galton move the platform from where he had been tightening
bolts. During this, another rigger (Rigger 1) walked through the area and discussed attendance
at the 9 am union meeting with the leading hand rigger. The conversation took place about 8.45
am in close proximity to where Mr Galton was working.

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Rigger 1 left the walkway area and the leading hand rigger said to Mr Galton:
‘Ok Mark, you’re free to go’.
The leading hand rigger turned back towards where he was working. It was at this point in time
that the leading hand rigger noticed from the corner of his eye the platform go upwards.
The leading hand rigger said to Mr Galton:
‘Stop, what are you doing?’
Mr Galton stopped the platform movement and acknowledged the verbal warning with the
response:
‘Yeah okay.’
In this position the leading hand rigger observed that Mr Galton’s head was about 5 cm below
the horizontal steel beam and he was standing upright with both hands on the platform controls
and facing towards the mine (facing towards the jib, boom and base of the MEWP).
The leading hand rigger turned away after hearing Mr Galton’s response and his next
observation was:
‘Then I saw Mark facing east still in a standing position leant forwards over the control
panel in the EWP. He had both hands still on the controls with his head coming forward
but still upright as if he was looking forwards towards the mine. His head was jammed in
between the beam above and a hand rail which is over the control panel.’
The lead hand rigger then made an emergency call over the two-way radio system.
8.48 am - The emergency radio call
At 8.48 am Supervisor 1 heard the leading hand rigger’s emergency radio call in which he said:
‘Emergency, emergency, emergency. Worker trapped in basket.’
Spotter 1 was on the ground talking with Spotter 2 (who was allocated to the second MEWP
operating on the other side of ST202).
Spotter 1 did not see the actual incident take place however he heard the leading hand rigger
call emergency over the radio.
Spotter 1 saw that Mr Galton was at the controls looking upwards but he was unable to identify
from the ground level that Mr Galton was in a crush position.

8.50 am - Supervisor attends the scene

At 8.50 am Supervisor 1 reached the bottom of the stairs and shouted to people in the vicinity to
“mark the time 8.50” for the start of the rescue process.

The rescue attempts and recovery of Mr Galton

Initial unsuccessful attempts were made by workers who were on the third floor level and directly
above Mr Galton to relieve the crush pressure exerted by the platform.
The workers on the third floor level pushed down on the platform handrail using a steel bar but
could not release Mr Galton.
Rigger 1 then went down ST202 stairways to the MEWP base control station where he used the
controls to move the platform and released Mr Galton.
Mr Galton was then seen to fall to the floor of the platform.

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Another supervisor (Supervisor 2) heard the leading hand rigger’s radio call and went up the
walkway adjacent to the platform, where he saw Mr Galton lying in the platform.
Supervisor 2 then got into the platform and unsuccessfully tried to return it to the ground level
(The engine was running at ground level but he was unable to operate it from the platform).
Supervisor 2 then made the decision to recover Mr Galton from the second floor level. He asked
for the MEWP ground controls to be used to move the platform, which was located above the
walkway handrail. The platform was then lowered to the handrail.
Supervisor 2 cut the compressed air hose into the platform. He recalled that the hose was not
under tension at the time.
Several workers then recovered Mr Galton from the platform onto the second floor walkway. Mr
Galton did not respond to the resuscitation efforts made by workers.
At 9.16 am the scene was attended by NSW Ambulance paramedics. Paramedics instructed site
workers to cease CPR about 9.30 am. NSW Police officers attended the incident scene about
9.30 am.

13. Examination of circumstances of the incident

Electronic recording devices at the site

There was no electronic/video recording of the work area from surrounding buildings available to
assist the investigation. There was other areas of the site being monitored but not where this
work was taking place.
Background circumstances to the incident
1. Mr Galton was operating the platform control console and was alone in the platform.
2. There is no evidence that the ground control console was being operated by another person.
3. Environmental conditions were not considered to be contributory.
Site weather recording data identified the following:
• Cool and sunny autumn morning
• Temperature ranged from a minimum of 7.7°C to a maximum of 23.2°C
• A low wind speed was recorded at 1.1 m/s from 144 degrees at 8.45 am
• Previous rain fall was recorded nine days earlier on 12 May 2014 at 0.2 mm and on
11 May 2014 at 1.8 mm
4. The incident MEWP log book operator safety check record was signed by Mr Galton on two
dates (7 April 2014 and 21 May 2014). It appears likely this was the second occasion that Mr
Galton was operating the MEWP involved in the incident.
5. A single compressed air line hung from equipment in the platform to the ground level. There
is no evidence that release of excess tension in the compressed airline caused the platform
to rise.
6. The maximum upward force available that could be applied to the platform ranged from the
‘jib up’ pressure of 10,342kpa (1500psi) to ‘main lift up’ and ‘telescope out’ pressure of
20,684kpa (3000psi).
7. It was observed after the incident that the platform console speed control knob was
positioned to the slow (turtle) speed setting.

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8. Mr Galton was working the 9th day shift of his roster and had logged 88 hours and 15
minutes on the 10-day roster at the time of the incident.
9. Mr Galton had arrived at the site at 5.55 am and he had been at the site for 2 hours 53
minutes when the incident occurred.
10. Mr Galton’s personal safety equipment included a working at heights harness, a safety
helmet without any additional sun protection devices attached and clear safety glasses.

The position of the wheels on the MEWP base

The MEWP base was on smooth concrete flooring of ST202. The front wheels were on a flat
concrete slab within ST202. The rear tyres were on a concrete ramp that provided access onto
the slab. It was identified by survey that there was a 4 cm difference in height from the front to
the rear axle due to the slope of the ramp.
There was no evidence of any ground movement (failure of concrete) underneath any of the four
rubber tyre wheels of the MEWP.

Figure 26: MEWP base on concrete floor.

There was no evidence that any of the MEWP tyres had failed or deflated causing instability on
the raised platform.
It is not known whether Mr Galton selected the base drive/steer joystick to move the platform
sideways across the top of the walkway handrail by moving the base of the MEWP.
As the rear wheels moved down the ramp it potentially caused the platform to move in an
upwards direction (a pendulum effect on the platform).
The load contained in the platform
The maximum operating load (SWL) permitted in the platform was 230 kg.
The investigation has not determined the exact load in the platform at the time of the incident.
However, it is considered unlikely in review of the items removed from the platform that the
combined total load in the platform exceeded 230 kg.

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Witness accounts are not clear as to whether Mr Galton’s yellow tool bag, which was fully loaded
with tools and was found on the gantry walkway after the incident was in the platform at the time
of the incident.

Figure 27: Mr Galton’s yellow tool bag and a working at heights harness found on the walkway adjacent to the
platform.

The investigation has not determined the load applied to the platform created by the suspended
weight of air hose going down to the ground level compressor.
The combined load most likely supported by the platform included:
1. Mr Galton and his working at height equipment PPE
2. air receiver box
3. rattle gun (equipment referred to as a nut runner)
4. air hose (black colour) to rattle gun
5. air hose to ground level (red colour to compressor)
6. tools, rattle gun sockets and various size nuts and bolts

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 Investigation report – death of Mark Galton

Figure 28: Photograph of a person holding the rattle gun and air hoses leading to and from the air receiver
box all of which were in the platform with Mr Galton.

Figure 29: Photograph of items found in platform console storage bin.

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Figure 30: Photograph of items including tools rattle gun sockets, various size nuts and bolts found in the
platform console storage bin and from the platform floor.

Figure 31: Photograph of PPE lanyard, shifter, red hose remnants, shifter and small plastic bottle found on
the platform floor near the exit door.

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The platform control console speed setting

Supervisor 2 was the first person into the platform following the incident but could not recall the
speed setting on the platform control console. Supervisor 2 said there were no alarms or other
warning systems that indicated any issue with the MEWP when it was moved using the ground
control. Supervisor 2 remained near the platform until police arrived. The platform was not
moved again after the movement to recover Mr Galton.
A photograph of the platform control console taken by a department officer at 5.07 pm on 21
May 2014 identifies the speed control was turned towards the slow speed setting. The platform
was lowered to the ground on 23 May 2014 and a photograph of the platform control console
identifies the status of the speed control knob turned towards the slow speed setting.

Figure 32: Platform control console position at 5.07pm on 21 May 2014.

Figure 33: Platform control console at 2.12 pm on 23 May 2014 when returned to ground level.

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The position of the platform, jib, fly boom, base boom and MEWP base
The platform was observed to be rotated to the right (in relation to the operator console position)
and close to being parallel with the raised jib. The fly boom was raised but not extended. The
base boom was raised.

Figure 34: View from the walkway of the position of the raised base boom, fly boom and jib in relation to the
rotated platform.

Figure 35: View looking down from the walkway of the positioning of the jib, fly boom and base boom in
relation to the position of the MEWP base.

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Lowering the platform after the incident

The position of the platform after the recovery of Mr Galton was observed to be rotated on the
articulating jib rotator parallel with and to the left hand side of the turntable of the MEWP. The
platform was across the top of two yellow painted handrails of steps on a walkway under the
third floor level of ST202. The platform was lowered onto the top handrail of the steps during the
recovery of Mr Galton.
Figure 36: Platform and articulating jib position in relation to the stairway handrail.

Figure 37: Platform, jib, fly boom and base boom position
in relation to the turntable of the MEWP and ST202. Photo
taken while lowering of the platform from the ground
control box of the MEWP on 23 May 2014. Spotters were
positioned on the second floor walkway and on the ground
level during the lowering of the platform.

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Figure 38. View of the base boom, upright and main boom
position in relation to the second floor and third floor
horizontal steels, the angled cross brace connecting floor
the two floors and the handrail of the second floor walkway.
The spotter is standing on the second floor walkway
observing the platform movement controlled from the
ground control box. Photo taken during lowering of the
platform on 23 May 2014.

Observation during lowering of the platform after the incident identified that the platform initially
required to be moved horizontally sideways to clear the top of the handrails and then lowered
adjacent to the walkway handrail. The main boom moved closer to the steelwork.

Figure 39. View of the platform moving parallel with the

steelwork and lowered adjacent to the walkway steps
handrail. Photo taken during lowering of the platform on 23
May 2014. The spotter is on the second floor walkway. The
articulating jib and main boom have moved closer to the
steelwork of the structure.

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The platform was then rotated 90° to allow movement parallel to the walkway handrail and then
moved horizontally through a space bounded by the second floor steelwork underneath the
platform, the underside of the angled cross brace pipe work above the platform control console
and the walkway handrail adjacent to the platform. The platform was also tilted downwards
towards the handrail to pass underneath the angled cross brace.

Figure 40: View of the platform rotated adjacent to the walkway steps handrail and tilted underneath the
angled cross brace pipe. Photo taken during lowering of the platform on 23 May 2014.

When the platform was outside of the steel frame work of the second and third floors it was able
to be lowered vertically back to the ground level.

Figure 41: View of the platform outside of the second floor

main frame and being lowered vertically past the first floor.
Spotters relocated to the first floor area and the ground
level. Photo taken during lowering of the platform on 23 May
2014.

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Figure 42: View of the platform outside of the main frame and being lowered past the first floor. Spotters
relocated to the first floor area and the ground level. Photo taken during lowering of the platform on 23 May
2014.

Deflection of the platform control console bar

The platform control console protection bar had an 8 mm permanent downward deflection.
The maximum force that could be applied by the MEWP hydraulics was 20.684 Mpa or 211
kg/cm².
It is considered plausible the downward deflection in the console protection bar was not present
before the incident and was caused as a result of the crush incident.

Figure 43. Measurement of the 8mm downwards deflection on the platform control console protection bar.

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The work task at the structure

ST202 was partly constructed to three floors. Mr Galton was working under the third floor
section.
The underside of the steel beam that Mr Galton was crushed against was 12.5 m above the
concrete floor ground level.
Mr Galton had completed the task of tightening nuts and bolts on the structure frame using a
compressed air powered rattle gun.
Construction work was finishing at ST202 for the purpose of workers to attend a union meeting
which was planned to start at 9 am.
Mr Galton was in the process of relocating the platform across and over a stair walkway handrail
and then to move downwards negotiating the articulating jib and upper boom of the MEWP
through steel diagonal cross-members of the partially constructed steel frame building to return
the platform to ground level without contacting any of the steelwork.

The spotter allocated for the task

A leading hand rigger was on a walkway adjacent to the platform Mr Galton was operating at the
time of the incident.
The leading hand rigger was not the designated ‘spotter’ allocated to Mr Galton.
Mr Galton had asked the leading hand rigger to assist him by observing the platform as it moved
into the area of bolts requiring to be tightened. The leading hand rigger did not observe any
issue with the operation of the MEWP during the platform positioning task.
The leading hand rigger was on his second day of duty at the site and had previously given
instructions to Mr Galton at the Thiess Caval Ridge construction site in Queensland. However
the leading hand could not recall previously observing Mr Galton operate any MEWP at the
Queensland site. The leading hand rigger’s role on the day was to familiarise himself with the
site and inspect and mark any bolts or other components that needed further work.
Another person was designated the role of ‘spotter’ (Spotter 1) for the MEWP Mr Galton was
operating on that morning. 17 Spotter 1’s role was normally a crane driver and this was the first
occasion he was designated ‘spotter’ at the site.
Spotter 1’s training records indicate that he held ‘spotter’ authorisation’ and a VOC for JLG 600
AJ MEWP, which were both dated 1 May 2014 at the mine.
Spotter 1 was not carrying a two way-radio with him on the day of the incident.
Spotter 1 was aware that the leading hand rigger was assisting Mr Galton with observing
platform movement from the upper level and he considered that this was undertaking a ‘spotter’
role.
Spotter 1 said Mr Galton was elevated for about an hour before the incident and he had made
no observation of Mr Galton having any issues operating the MEWP.
Spotter 1 told investigators that he had observed on other occasions MEWP operators bending
down in the platform while operating MEWP close to fixed structures at the mine site.

17
The spotter has to undertake a specific site training course and is required to wear a specific vest with large identification of
‘SPOTTER’ on the rear

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The working at heights permit was not applicable for ST202

Mr Galton and the leading hand rigger had signed onto a ‘Working at Heights Permit’ (WAH
permit) dated 20 May 2014 (the day before the incident) for another structure (ST801) for the
purpose of installing steelwork and chutes. The WAH permit for ST801 was not applicable to the
work Mr Galton was undertaking at ST202. A different WAH permit for ST202 had been signed
by two other workers on 20 May 2014 but not by Mr Galton or the leading hand rigger.
Mr Galton, the leading hand rigger, Spotter 1 and four other workers had signed onto the Thiess
Sedgman prestart work document on the morning of the incident. The main hazards identified in
the prestart document were pinch points, working at heights and swinging loads.

Plant defect investigation

The plant defect investigation findings are based upon the following sources of information:
1. The MEWP involved in the incident was inspected by an independent assessor on 11 and 12
June 2014. The assessor was of the opinion that it was in correct and proper working
condition at the time of inspection. The assessor’s opinion was that the MEWP appeared to
be generally well maintained and serviced, operated as expected and within the bounds
specified by the manufacturer.
2. The rubber boot on the main lift-swing joystick on the platform control console was found to
be damaged (a cracked rubber boot) on inspection. It is not known how long the rubber boot
had been cracked before the incident. There was no evidence of reporting of any damage to
the rubber boot on prestart inspection records or Coates maintenance records. The cracked
boot enabled ingress of moisture and foreign particles onto internal electrical circuit board
components.
3. A visual examination of the lift-swing joystick control conducted by Bureau Veritas identified
evidence of corrosion from the top gimbal shaft to the bottom electrical circuit board. The
encapsulating resin on the hall-effect sensor/transistor was found to have been ground
during manufacturing. Corrosion was identified on the hall-effect transistor however no
obvious sign of tracking could be visually identified.
4. On 26 October 2011, a JLG service record No. 78699 identified that the MEWP involved in
the incident had a joystick lift fault. The lift swing joystick was replaced on 27 October 2011.
The Coates Hire service mechanic could not recall the actual electrical fault with the MEWP.
5. Coates Hire maintenance records identify the MEWP had received a pre-hire three monthly
safety check on 7 March 2014 at which operational functionality of platform controls was
checked before hire.
6. Coates Hire maintenance records identify the MEWP received a ‘B’ service annual inspection
and service conducted by Coates Hire maintenance employees on 6 March 2014. The hour
meter was recorded at 883 hours.
7. The MEWP arrived at Boggabri Coal Mine on 22 March 2014. A ‘Hired-In Plant Inspection
Report’ was completed by a Thiess Sedgman employee and a Theiss Sedgman sticker was
issued on 22 March 2014. The hour meter was recorded at 885 hours
8. A ‘Boggabri Coal Expansion Project Plant and Equipment Hazard Assessment’ was
undertaken on the MEWP to introduce the machine to site on 22 March 2014.
9. The potential hazard of being trapped between plant and fixed structures was identified in the
assessment. Two controls for the hazard identified were:
a) Operator to be ticketed and deemed competent to operate equipment with additional
controls of VOC and familiarisation carried out on equipment.
b) Spotter present in EWP basket to guide operator.

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10. The investigation obtained information from all operators who had completed pre-start
inspection reports for the incident MEWP and none identified any issue with unintended
activation of the MEWP platform before the incident.
11. The Theiss Sedgman EWP operator pre-start inspection and defect record (No 7538) were
completed on 20 May 2014. There were no issues identified in the report. The start hour
meter was recorded at 947/2 hours.
12. Mr Galton had completed a Theiss Sedgman EWP operator prestart inspection and defect
record (No 7539) before operating the MEWP on 21 May 2014. There were no issues
identified in Mr Galton’s written report. The start hour meter was recorded at 949/4 hours.
13. The MEWP hour meter had recorded a total of 66 hours running time at Boggabri Coal Mine
from the last service record to the incident date.
Wenn Wilkinson Associates report on MEWP
Mechanical Engineering consultants Wenn Wilkinson Associates inspected and tested the
MEWP involved in the incident on 11 and 12 June 2014 at JLG premises in Port Macquarie.
In summary the Wenn Wilkinson Associates report identified:
1. In general the machine appeared to be well maintained and logs were completed.
2. The last 25 significant operations were downloaded from the control system. There were no
signs of repeating fault. Error messages were consistent with events attributable to errors in
operation and the events were resolved enabling operation to continue.
3. Machine settings were within manufacturer specification including control function ramp time
settings.
4. Personality settings were different to default settings. Operational speed settings were within
manufacturer specification.
5. Protective mechanisms associated with the footswitch operated as expected.
6. The rubber boot on the lift/swing joystick was broken and replaced.
7. A hydraulic oil sample was taken from the machine and tested within specification for water
content and viscosity for the type of oil.
8. It was the opinion of the assessor the JLG MEWP was in correct and proper working
condition at the time of inspection (noting the observed damage to the rubber boot on lift
swing joy stick). It appeared to be generally well maintained and serviced, operated as
expected and within the bounds specified by the manufacturer.
Bureau Veritas report on the lift swing joystick
The damaged OEM Controls Inc. manufactured Lift Swing joystick (HJS9M14133 part no
1001118417 serial no 330763 153) seized from the JLG MEWP was inspected by consultants
Bureau Veritas Asset Integrity and Reliability Services Pty Ltd (Bureau Veritas) on behalf of the
department.
In summary the Bureau Veritas report stated:
‘Visual examination of the joystick unit indicated the absence of mechanical-related failure
which could have caused the possible malfunction of the unit. The primary damage was
identified to be the rubber protective boot cracking. However the condition of the circuit board
was also found to be less than optimal which had been introduced during the manufacturing
process. Further investigation would be required to verify the functionality of the circuit
board.’

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Figure 44: Extract of Bureau Veritas report – Figure 3.

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Figure 45: Extract of Bureau Veritas report – Figure 6.

Austest Laboratories report into the lift swing joystick

Based on the recommendation of the Bureau Veritas report, the department engaged Austest
Laboratories to conduct environmental damp and heat cyclic testing conducted in accordance
with AS60068.2.30 Climatic Testing standards.

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Two climatic tests were conducted inside a climatic chamber:

Test cycle 1: Climatic variable conducted over 12 hours 40 minutes powered with periodic
functional checks at 25°C at 50% relative humidity (RH) then down to 0°C then to 30°C at 95%
RH then to 25°C at 50% RH
Test cycle 2: Climatic variable conducted over 12 hours 40 minutes powered with periodic
functional checks at 40°C at 93% RH then to 25°C at 50% RH.
During the two cycles the state of the electrical output lines were continuously monitored and
recorded by a data logger. Functional testing was tested by periodic manual movement of the
joystick lever through all possible positions with a minimum 10 second dwell time at each
position.
In summary the Austest Laboratories report stated:
‘JLG lift swing joystick control unit identified by Model No HJS9M14133, Part
No.1001118417, Serial No. 330763 was submitted for climatic testing. The test item was
subjected to combined temperature and humidity testing in accordance with AS60068-2-30
standard for a total of 24 hours.
The test item was assessed for correct electrical output during application of the required
climatic severities.
The test item functioned satisfactorily during exposure to the required climatic test severities.
The test item has responded correctly to all manual inputs applied during climatic testing. No
abnormal electrical outputs were observed at any point during the tests.
All spikes visible in figures attached to the report correspond to the time when the chamber
was opened and manual movement of the joystick arm performed.
No apparent mechanical damage was observed on the test item during the external visual
inspection carried out upon completion of the climatic testing.’

Electromagnetic effects on the operation of the JLG MEWP joystick unit

OEM Controls Inc provided an Electromagnetic Compatibility (EMC) Report for the hall-effect
joystick model HJS9. The test report was conducted by TUV Rheinland of North America to
various EN and IEC standards for electrical discharge, electromagnetic radiation and voltage dip
and variations applied to the joystick.
Based on the manufactured joystick standards identified in the TUV report and from visual
observation at the site there was no visual evidence of any significant sources of EMC in the
vicinity of ST202 (e.g. welding lines, HV power lines, signalling cables etc) that would have
caused the console lift swing joystick to create an incorrect signal to the MEWP base control to
cause the platform to rise.

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14. Incident causation review

Mr Galton received fatal injuries as a result of a crushing force to his head and neck area applied
by the MEWP as a result of becoming trapped between the steel bar located above the platform
control console of the MEWP and the underside of a large horizontal steel beam in ST202.
The cause of the upwards movement of the platform toward the underside of the steel beam was
created by a force (actual pressure unknown) applied by the electro/hydraulic functions of the
MEWP.
The specific cause of the platform rise cannot be established.
The platform was positioned over a walkway handrail and rotated to the right (relative to the
operators control console) and nearly parallel to the alignment of the raised jib and boom.
The incident occurred during a day shift. Mr Galton had arrived at BCM site at 5:55am on 21
May 2014 and had been at the site for 2 hours and 53 minutes when the incident occurred.
Mr Galton was working the ninth consecutive 11 hour shift of a ten day roster pattern. The
investigation is unable to establish if Mr Galton’s fatigue level was contributory to the incident.
The investigation has reviewed and ranked the following likely causation theories in the order of
most likely to least likely.
The investigation has identified five potential causation theories:
1. That it is possible to achieve an unintended sustained platform rise caused by an
operators body coming in contact with one or more control switches located in the lower
row of switches on the platform console within a seven second time window permitted by
the machine.
The unintended rise was achieved in the circumstance where a switch on the platform
console is activated by bodily contact within the seven second time period permitted by
the timer following activation of the foot switch.
Platform rise can be achieved in this circumstance without operating the joystick control
or any other raise function.
It is considered that an unintended activation of a control switch potentially may have
occurred when Mr Galton either moved forward, or was forced into a forward leaning
positon over the platform control console by the steel work above his head.
In the circumstance of unintended switch activation by clothing the MEWP would
continue to apply an upward force even though Mr Galton may not have operated the left
hand joystick control.

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Figure 47: Simulation of an operator in forward leaning position and bodily contacting platform switches can
activate platform ‘rise’. In this position the left hand can apply forward motion to the lift swing joystick and
activate platform ‘rise’. The right hand can be placed on the drive/steer joystick. The operator’s right foot was
able to activate the footswitch to permit platform control function.

The platform lift/swing joystick control device (when the detent device is lifted on the
joystick) is moved in a ‘forwards’ direction to achieve a ‘rise’ in the platform.
It is noted that Australian Standards provide differing guidance as to the direction of
control ‘action’ to achieve ‘effect’. Safety of Machinery standard AS/NZS 4024.1906:2014
recommends an ‘away from the operator’ action to achieve an ‘upwards’ effect. 18
Whereas remote control mining equipment standard AS/NZS4240.1:2009 recommends a
‘rearward’ control action to achieve a ‘rise’ effect. 19
In consideration of the circumstance of the event it is possible Mr Galton moved his body
forward over the control console either:
• Voluntarily (his own decision to lean forward to look forward over the console) or,
• Involuntarily (he came into contact with the steel beam which moved his head and
body forward over the console)
Although Mr Galton’s body position at the time of the crush was not directly observed by
the LHR it is plausible that Mr Galton had leaned forward over the console to obtain a
better view of the position of the platform boom or jib in relation to the ST202 steelwork
which was underneath the platform.

18
AS/NZS 4024:1906:2014 Table 1 classification of final effects and Table 2 Classification of actions
19
AS/NZS 4240.1:2009 Remote control systems for mining equipment Part 1. 2.3.10.4 Direction of control movements Table 1
Function Up or raise – rearward, Function Down or lower - forward

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2. Mr Galton intended to lower the platform after hearing the verbal warning, however:
a. Mr Galton selected the wrong control switch.
i. There were six control options available to cause the platform to rise and
these control functions could be used in combination.
b. Mr Galton selected the correct control switch but applied the incorrect direction of
movement to the control device.
ii. Forward motion of the lift swing joystick caused the platform to rise
iii. Other control switches required different direction of movement to lower
the platform
iv. A simultaneous combination of control switch and joystick control caused
the platform to rise. Control switches had differing direction of movement
application including: move forward and move backward to achieve a
platform rise.
c. Mr Galton intended to move the platform sideways and operated the base
drive/steer joystick which moved the rear axle down the concrete ramp and
caused an upward movement in the platform (platform pendulum effect).
3. Mr Galton intended to raise the platform after hearing the verbal warning:
a. Mr Galton accepted the risk created by the steel beam above his head.
b. Mr Galton’s situational awareness was reduced due to focussed attention
directed to looking over the control panel and down towards the position of the jib
and boom to prevent any contact with ST202 steelwork.
c. Mr Galton’s situational awareness was affected by the base of steel beam ‘D’
located directly in front of his eyesight was 230mm higher than the base of steel
beam ‘C’ that he was directly located underneath.
d. Mr Galton was wearing a safety helmet and clear safety glasses. The safety
helmet remained on his head during the incident. There were no additional sun
protection devices fitted to the safety helmet which could potentially reduce
situational awareness.
e. There is no evidence that any of Mr Galton’s actions were intentional self-harm.
4. The investigation has examined the potential for an unplanned movement of the MEWP
platform due to a malfunction of a platform control device.
The was no evidence that a defect in the MEWP caused the platform to rise however the
potential for causation cannot be totally discounted in light of finding the damaged rubber
boot and corrosion on the electrical circuit board on the lift swing joystick.
To corroborate the finding all operators who had signed pre-start inspection reports for
the incident MEWP prior to 21 May 2014 could not recall to investigators any unplanned
movement of the platform during operation.
There was no evidence of an unplanned movement of the platform during the post
incident inspection and testing program of the MEWP undertaken after the incident at
JLG premises at Port Macquarie.

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During the assessment of the MEWP the manufacturers electronic analyser device was
connected to the electrical control system of the MEWP. The analyser device did not
detect any defects with electrical or hydraulic control systems.
The control function ramp time settings for the incident MEWP were found to be within
manufacturer specifications. Ramp time settings allow for a specified time period for the
hydraulic functions of the MEWP to completely stop to reduce equipment damage.
5. External force applied by the environment to the plant caused the platform to rise.
There was no evidence of causation due to a wind gust, electrical interference source
acting on the MEWP electrical system, movement of the base of the MEWP caused by a
wheel sinking in soft ground, another person operating the base control or release of
tension in the compressed air hose attached from the platform to the ground level.
The operational speed of the platform was low as the control dial was set to ‘slow’ speed.

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Incident causation ranking diagram

Voluntary or involuntary
bodily contact with
console switch caused
unintended platform rise
Mr Galton leant (Covered footswitch was
over the platform activated, seven seconds
console for potential activation)
Most likely cause
Unintended forward
activation of joystick
caused platform to rise.
Mr Galton Or incorrect selection of
intended to lower another control function
the platform
Base drive/steer selected
Rear axle moved down
ramp & caused platform
Verbal The to rise
warning warning
given by heard by Mr Galton Intended activation
the LHR Mr Galton intended to raise caused platform to rise
the platform

Inspection and testing did

Plant defect
not identify causation.
Electro/hydraulic
Identified a damaged
malfunction joystick rubber boot

Platform rise There was no evidence

movement that an external force (e.g.
caused by an wind gust or air hose
external force, tension) or MEWP base
Least likely cause MEWP base movement caused the
movement or platform to rise.
incorrect platform Evidence that the platform
speed selection speed control was set to
slow.

Note: Causation ranking from most likely to least likely based on the findings of the investigation.

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15. Health and Safety Management Systems

Documentation from the Theiss Sedgman Health and Safety Management System (HSMS) was
collected from the site during the investigation. TPL has identified how the HSMS operated as at
21 May 2014.
The HSMS is informed by:
1. The Thiess Health and Safety Policy
2. The Thiess Group Health and Safety Standard
3. Thiess Group level procedures
4. Thiess Construction Business Stream procedures
The Health and Safety management Plan (HSMP doc No 950324-1100-M0-0001 revision dated
27 March 2014) included a range of tools that address how risks on the project are managed
including:
1. Work Area Plan (WAP) and Work Area Plan Risk Assessment (WAPRA)
2. Work Pack (WP)
3. JSEA and
4. Start Card
The systems of work documentation for MEWPs at ST202 at 21 May 2104 included:
1. CSC 2 Prevention of falls (TM-CSC-ST-200)
2. Prevention of falls - core procedure (TM-CSC-PR-200)
3. JSEA 0305-0 ST202 exiting EWP basket
4. JSEA 0266-0 EWP general ops use of EWP to access heights
The risk assessment for work at ST202 prior to 21 May 2014 included:
1. WAP 950324-WAP -03-00
2. Risk assessment incorporated in JSEA 02909-2 sizing station structural installation ST202
erection of structural steel
3. Risk assessments incorporated into JSEA 0258-0 180t Kobelco crawler crane, general lifts
and operation
Safe Work Method Statements (SWMS) relating to the task at ST2020 on 21 may 2014 included:
1. JSEA 02909-2 sizing station structural installation ST202 erection of structural steel
2. JSEA 0258-0 180t Kobelco crawler crane, general lifts and operation
3. WP for ST202 sizing station structural installation (WP-03-03-10)
4. JSEA 0266-0 EWP general ops use of EWP to access heights
Tool box talks for tasks at ST202 prior to 21 May 2014 included pre-start meeting conducted at
the start of shift each day.

Machine risk assessments introduction of JLG 600 AJ to site

Theiss Sedgman undertook a plant and hazard assessment for the JLG 600 AJ MEWP on 22
March 2014.
The assessment identified the potential hazard of being trapped between the plant and materials
or fixed structures. The hazards identified 1) operator error and 2) working within close proximity
to structures.

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The controls were listed as requiring the operator to be ticketed and have VOC and for a spotter
to be present in the basket to guide the operator.
However it was noted during the investigation by a supervisor and other operators of the MEWP
that they had not seen the risk assessment document before the incident.
Thiess has indicated that the MEWP plant and hazard assessment document was prepared for
the purpose of assessing the suitability of the plant for use at Theiss Sedgman. The document
was not required to be circulated to other staff but the document was accessible to a majority of
staff.

Thiess critical safety controls

Thiess critical safety control (CSC TP-CSC-FO-231) identified MEWP verification of competency
and operational requirements for the MEWP. Mr Galton had undertaken MEWP VOC on 4
March 2014.
The requirement of the MEWP CSC was to plan elevation procedures in consultation with other
relevant personnel including appropriate hazard control strategies and implement planned
hazard control strategies. There was no evidence of MEWP hazard control strategy planning
taking place by the operators on the day of the incident. Individual operators had to determine
the best path to get the platform in and out of a tight area.
There was evidence of documented lift plans created for lifting items by crane that identified the
direction the lift was to follow into structures.
On 24 March 2014, Mr Galton signed onto the CSC prevention of falls – core procedure.

Work packs
There were two work packs for ST202.
Structural installation work pack (WP-03-03-10 rev 0 signed 29 January 2014) had been signed
onto twice by Mr Galton.
Mechanical work pack for ST202 (WP-03-03-20 rev 0 signed on 29 January 2014) had not been
signed by Mr Galton.
The work packs included a range of reference procedures, JSEA, permits and construction
documentation. The work packs identified risks identified in WAPRA control measures including
use of MEWPs.

Job Safety Environment Assessment

There was a significant number of Job Safety Environment Assessment (JSEA) documents that
identified the risks associated with use of MEWPs.
Mr Galton had signed multiple JSEA documents related to use of MEWPs at the Theiss
Sedgman site.
The JSEA referred to on the Start Card dated 21 May 2014 was JSEA 0258-0 was not
applicable to the task Mr Galton was undertaking on 21 May 2014.
JSEA 0209-1 revised on 18 March 2014, for ST2020 structural installation identified use of
MEWP during erection of steel work. Mr Galton signed onto JSEA 0209-1 on 23 March 2014
and 5 April 2014.
JSEA 0321-1 revised on 12 May 2014 for ST202 installation of mechanical components
identified MEWP interaction with structures. Mr Galton had not signed onto JSEA 0321-1.

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Working at Heights Permit

Mr Galton did not sign a Working at Heights permit (WAH permit) for work conducted at ST202
on 21 May 2014. Mr Galton had signed a WAH permit on 20 May 2014 for ST801. Two other
workers signed the WAH permit for ST202 dated 20 May 2014.
Mr Galton signed two earlier WAH permits for ST801 on 22 and 23 April 2014.

Operators pre-start inspection and defect report

The original white copy MEWP operator’s pre-start inspection and defect sheet No. 75239
undated and marked Wednesday day shift (assumed to be 21 May 2014) and signed by Mr
Galton was found in the pocket of a work jacket identified with ‘Mark’ hand written on the jacket
label.
All of the inspection checks boxes for the MEWP were ticked ‘OK yes’ and no further defects or
comments were recorded on the report.

Safety observations at site

Thiess HSE observation sheet records identified that Thiess HSE staff and engineering and
supervisory staff were conducting task observations at the site on a regular basis.
Comments were made in relation to MEWP usage on numerous HSE observation reports and
feedback comments reported being given to operators.
Records of safety leadership audits were also made available conducted by senior staff at the
site.

SAI Global external audit

An external audit inspection was conducted at the site from 28 April 2014 to 1 May 2014 by SAI
Global Services.
The external assessor noted that a pre-assembly area was visited and observations made of
workers using a MEWP. While the assessor did not comment on the MEWP use he identified
strong supervisor oversight and effective communication between workers before conducting
lifts. There were no areas of concern raised in the audit report concerning use of MEWPs at the
site.
Controls to prevent the risk from occurring
The risk of a crush injury while operating a MEWP platform under a fixed structure was foreseen
in documents created by the manufacturer, importer, supplier and the end users of the JLG
MEWPs.
There were guidelines and information published by Australian regulatory agencies including
NSW WorkCover and the Australian EWP industry association (EWPAA Inc) concerning the risk
of crush injuries under fixed structures before the incident.
There was significant amount of published information available before the incident, published
by overseas regulatory agencies (UK HSE) and end user groups (IPAF) concerning the risks
and control measures to prevent crush injury under fixed structures.
The Australian construction industry placed significant reliance on lower order hierarchy of risk
controls to reduce the risk of crush injury when using MEWPs.

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The risk controls included:

1. Operator training and national ‘High Risk Licence’ accreditation to operate EWP.
2. Registered Training Organisation (RTO) competency training and certification of
competency to operate the specific JLG MEWP.
3. Verification of competency (VOC) to operate the specific JLG MEWP at the work site by
the end user.
4. Risk assessment documents created by the manufacturer and plant owner.
5. Plant registration to operate the JLG MEWP within Australia.
6. Plant periodic inspection, maintenance and reporting systems by the plant owner.
7. Plant site introduction assessment, operator pre-start inspection and site reporting
systems by the end user.
8. Work area plans (WAP), Work Area Plan Risk Assessment (WAPRA), Critical Safety
Controls (CSC).
9. Safe Work Method Statements (SWMS) and Job Safety Environment Analysis (JSEA) for
the use of MEWP’s.
10. Task JSEA documents created by the end user and review by MEWP operators.
11. Working at height permit (WAH permit) (noting that Mr Galton had not signed onto a
WAH permit for MEWP tasks at ST202).
12. Shift tool box talks.
13. ‘Start Card’ created by operators at the start of the work task.
14. Spotter being present during the work task.
15. Inspection and auditing of EWP activity by the end user.
Ultimately, the controls put in place to reduce the potential of realising the risk of crush injury
under a fixed structure in this circumstance were not sufficient to prevent the incident from
occurring.
The risk controls did not address the specific risks when operating MEWPs under fixed
structures with regard to the application and use of higher order hierarchy controls such as
secondary guarding for the MEWP.
Secondary guarding on MEWP
1. On 25 June 2007, the 600A model articulating boom lift was design registered in the
Northern Territory to design code AS1418.10 (classification GP-B-SUB-GP3)
2. In July 2010, best practice guidance documents were published discussing how to avoid
trapping and crushing injuries using platforms by the United Kingdom HSE regulator. The
Australian hire and rental industry was informed of the guideline in February 2011. 20
3. JLG Industries (United Kingdom) Ltd had representatives placed on the Construction
Strategic Forum that had created the UK HSE MEWP best practice guidance material.

20
Hire and Rental News published February 2011 page 22

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4. In October 2011 a secondary guarding device registered as SkyGuard® was designed

and manufactured by JLG (America). By late 2012, the device was made available to
European MEWP user groups.
5. In May 2012, JLG informed the Australian hire and rental industry that SkyGuard® could
be previewed at the 2012 hire and rental industry convention. 21
6. On 1 September 2012 the operator of Heathrow T2 terminal construction project
mandated for all contractor MEWPs to be fitted with anti-entrapment devices from 1
January 2013. 22
7. In February 2013, JLG informed the Australian hire and rental industry that SkyGuard®
was available as an aftermarket kit on all JLG booms manufactured from 2004. 23
Australian Design Registration (ADR) had not been obtained for SkyGuard® at that date.
8. In May 2013, a United Kingdom equipment hire registry web page published information
to MEWP user groups related to SkyGuard®.
An extract of the publication stated:
‘JLG SkyGuard® provides operators with enhanced control panel protection. When
activated by approximately 23kg of force, SkyGuard® stops all functions in use at the
time. The reverse functionality momentarily “undoes” most functions that were in use at
the time of activation for less than a second’s worth of time.’
24
Figure 48: JLG SkyGuard® secondary protection device

9. On 14 May 2014, JLG Industries Inc made an application for design registration for the
SkyGuard® secondary protection device to WorkSafe Western Australia.
10. Before 14 May 2014, JLG had not received any purchase orders from Australian JLG
MEWP users to fit the SkyGuard® secondary guarding device.

21
Hire and Rental News published May 2012 front cover and page 3
22
Vetikal.net/en/news/story/16102/ HETCO Health and Safety Information Bulletin Heathrow T2A – Anti Entrapment Devices
23
Hire and Rental News published February 2013 page 34
24
http://rermag.com/aerial-work-platforms/skyguard-aftermarket-accessory-jlg-boomlifts publication date 1 May 2013

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11. On 30 May 2014, ADR for SkyGuard® was awarded by Worksafe Western Australia and
received by JLG for the 600 AJ model on 10 June 2014.
12. It was clearly identified in the machine operation manuals created by JLG and CHOPL
that crush injuries using MEWP underneath fixed structures was a foreseeable risk.
13. Apart from the raised bar protecting the platform control console, which was directly
involved in the crush injury, there were no other secondary protection devices on the
platform of the MEWP to prevent Mr Galton from being crushed during operation of the
MEWP.
14. The risk of crush injuries from interaction of MEWP with fixed structures was a
recognised risk in documented risk assessment and work procedures of TSJV. The
identified controls to reduce the known risk were by reliance on the use of a ‘spotter’,
operator competency training and VOC of operators at the site. Ultimately the selected
control measures did not prevent the incident from occurring.
15. In November 2014, Safe Work Australia (SWA) identified seven fatal incidents involving
the users of elevating work platforms being crushed against roofing beams between
2006 and 2011. SWA stated some manufacturers were responding to the risk with caged
platforms with anti-entrapment devices such as a frame fitted to the basket that provides
a ‘safezone’ within the platform and sensor bars or pads that stop the movement of the
platform should the operator be pushed onto them. 25

16. Australian Standards and State regulatory guidelines

The Work Health and Safety Act 2011 (the Act) and the Work Health and Safety Regulation
2011 (the Regulation) places obligations on designers, manufacturers and suppliers of plant,
and any people responsible for its use, to ensure that it is safe and does not present a risk to
people using it or who may otherwise be exposed to its use. Chapter 5 of the Regulation
specified the provisions that apply for types of plant considered to be high risk, with most types
of cranes, hoists and winches included.
Boom type elevating work platforms require plant registration under the Regulation. 26
Appendix A provides detail related to extracts taken from Australian Standards.
Australian Work Safety Regulators
The following information is provided by Australian federal, state-based and international work
safety regulators:

NSW WorkCover
NSW WorkCover published guidance material for the provisions of cranes, hoists and winches
under WHSA legislation.
On October 2011, NSW WorkCover published safety information relating to overturning an
EWP. 27

25
Safe Work Australia report November 2014, Work related fatalities associated with unsafe design of machinery, plant and powered
tools,2006-11
26
NSW WorkCover guidance material Cranes, Hoist and Winches Appendix A
27
NSW WorkCover WCO3042

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On 26 March 2013, NSW WorkCover published safety information relating to EWP use following
a fatality and serious injuries received during the previous twelve months.
The March 2013 information release stated ‘Since July 2012 WorkCover Inspectors have
conducted almost 200 inspections of EWP throughout NSW to help operators understand their
responsibilities and improve safety’.
During April 2013, NSW WorkCover published safety information relating to working with or
around mobile plant including EWP. The safety alert identified NSW WorkCover had published a
Code of Practice outlining the risk and hazards of mobile plant on construction site. 28
Safe Work Australia published a Code of Practice ‘Managing the Risks of Plant in the
Workplace’ on 18 July 2014, which was adopted by state-based regulatory agencies.

Victorian WorkCover Authority

On 7 June 2012, the Victorian WorkCover Authority obtained a conviction relating to offences
that occurred on 7 October 2009. The deceased was fatally crushed between an EWP and the
ceiling of a shed. There was no overhead protection for the EWP and the deceased had not
received adequate training on the use of the EWP. No SWMS or JSEA was performed and no
operating manual was provided in that instance. 29

NSW Department of Industry, Resources & Energy Mine Safety

NSW Department of Industry, Resources & Energy, Mine Safety published guidance notes for
certification for high risk work and registration of plant designs including elevating work
platforms. 30
On 27 June 2006, the department published a safety alert relating to unplanned movement of a
EWP platform and crush injuries suffered against a fixed structure (mining machine). 31
On 31 August 2009, the department obtained a conviction in the Industrial Court of NSW related
to a person being trapped between an EWP and a fixed steel bucket at an open cut coal mine on
21 March 2006. Particulars of the charges included issues related a faulty drive joystick on the
platform control console and failure to ensure that safe systems of work were in place. 32

Worksafe Queensland
On 24 April 2009, Workplace Health and Safety Queensland published a guideline ‘Safe
Operation of an Elevating Work Platform, Learning Guide for operators of EWP. 33
The learning guide was published to help operators gain the knowledge and skills needed to
operate EWPs.
Western Australia Government
On 12 February 2009, the Western Australia Department of Mines and Petroleum Resources
Safety published a Significant Incident report (No.151) concerning a fatal incident involving a
person crushed in a pinch point of a fixed EWP.

28
NSW WorkCover WC03987 and WC 01310
29
Victorian WorkCover Authority prosecution summary - Court Number B12850145
30
Department Guidance notes and GNO-001 GNC-005
31
Mine Safety - Safety Alert SA06-15
32
NSW IRC365 of 2008 and NSW IRC366 of 2008
33
Workplace Health and Safety Queensland PN10042 version 1 updated 24 April 2009

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On 16 March 2010, the Western Australia Department of Mines and Petroleum Resources
Safety published a Significant Incident report (No.162) concerning a serious head injury
sustained when dismantling a roller shutter door from a EWP platform.
In 2012, the Western Australia Department of Commerce WorkSafe published a Safety Alert
(No. 14/2012) concerning a fatal incident when a person fell with the platform when the MEWP
jib failed.

Elevating Work Platforms Association of Australia

The industry Elevating Work Platforms Association of Australia (EWPAA) has identified that it
was not aware of any issues concerning:
• MEWP operators sourcing secondary guarding devices before 21 May 2014.
• MEWP suppliers and users obtaining design registration for secondary guarding devices
before 21 May 2014.
• MEWP suppliers and users seeking design registration through the Northern Territory
WorkSafe regulator before 21 May 2014.
• Adequate provision of MEWP safe use information provided by MEWP importers and
suppliers before 21 May 2014.
• Development of Australian Standards for the application and use of MEWP fitted with
secondary guarding devices before 21 May 2014.
EWPAA identified it did not make any recommendations to current Australian Standards, Codes
of Practice or guidance material.
EWPAA identified it did not make written submissions to the relevant MEWP Australian
Standards Committee or Australian regulatory agencies concerning the introduction and
application of MEWPs fitted with secondary guarding devices.
EWPAA identified that there are no official guidelines in respect of verifying the competence of
MEWP operators. EWPAA has published articles to industry concerning the Verification of
Competency of MEWP operators.

United Kingdom Health & Safety Executive Safety Regulator

In July 2010, the United Kingdom Health and Safety Executive (UK HSE) in a partnership with
the Strategic Forum for Construction published a best practice guideline for MEWP titled
‘Avoiding trapping/crushing injuries to people in platforms’.
The publication provided significant review of the risk and guidance controls associated with
crush injuries against fixed objects whilst operating platform controls. The working group
membership listed a UK JLG group member.
International Powered Access Federation and European MEWP Standards
The United Kingdom International Powered Access Federation (IPAFF) produced publication
and guidance information related to options available to reduce the identified risk of entrapment
whilst using MEWP and secondary guarding devices. 34
Appendix B details IPAFF published information related to secondary guarding of MEWP.

34
IPAFF MEWP guidance to reduce identified risk of entrapment UKT3 04/14-002

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18. Post incident response

Post-incident actions by the department

On 21 May 2014, the department began an investigation into the cause and circumstance of the
incident involving Mine Safety Inspectors and the Investigation Unit.
On 22 May 2014, NSW Mine Safety Inspectors issued a WHSA section 195 Prohibition Notice to
BCPL prohibiting use of any boom type EWP at the BCPL site where there is risk of collision
between the EWP and a fixed object.
Ongoing interaction took place between inspectors and site operators related to the actions
taken related to the WHSA section 195 Prohibition Notice.
On 4 June 2014, the department published an information release to industry containing safety
observations identified from the preliminary investigation concerning Mr Galton’s incident. 35
On 14 January 2015, the Investigation Unit notified the Chief Inspector of Mine Safety
Operations under the Coal Mine Health and Safety Act 2002 section 153 – Additional Functions
of interim recommendations as a result of findings from the investigation.
Post-incident actions by Theiss Sedgman
Theiss Sedgman undertook an assessment as required in part G of the WHSA section 195
Prohibition Notice from 26 May 2014 to 7 June 2014 to assess and control activities around use
of MEWP and working at heights at the BCPL site.
The Theiss Sedgman review identified at ST202:
‘Station 202 is substantially complete, except for construction of CV 201 which connects to
the top of this structure. Tightening of bolts internal to the structure is still required, and will
require the use of EWP. There are overhead obstructions, and access is restricted, therefore
this work is considered complex and will require the operator protective structures (OPS) or
pressure sensor EWP. As a final option, a scissor lift with a height limitation to avoid
contacting the underside of the top floor could possibly be used or scaffolding can be
constructed within the structure itself. Scaffolding will require more time to construct and
remove than the actual activity of tightening bolts.’
Theiss Sedgman identified to the investigation the following actions that have taken place after
the incident involving Mr Galton:
• 28 May 2014
o Commenced discussion with EWPAA and operators as to available design
registered secondary guarding systems,
• 9 June 2014
o Arranged for another brand of MEWP with secondary guarding system for two
MEWPs to be sent to site,
• 29 May 2014 to 3 June 2104
o Developed and implemented a JSEA for use of equipment to work at heights,
• 29 May 2014 to 19 August 2014

35
NSW Trade and Investment Information release ‘Worker crushed while using MEWP. IR14-04 dated 4 June 2014.

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o Developed and revised SOP 067 Use of elevated work platforms that included
roll out of EWP permit and work at heights rescue plan.
• 9 June 2014 – ongoing
o Maintained ongoing discussion with manufacturers of MEWPs concerning
secondary guarding devices available in Australia,
• 18 June 2014
o Site visit and inspection of two secondary guarding devices.
• 29 July 2014
o Meeting with JLG and other MEWP manufacturer to retrofit secondary guarding
systems to current Theiss Sedgman MEWP fleet.
o Attended demonstration of secondary guarding devices by JLG and other MEWP
manufacturer.
• 20 August 2014
o Confirmed in writing with Coates Hire requirements for secondary guarding
devices of TSJV MEWP fleet.
• 10 October 2014
o A design registered secondary guarding device was operational on all Theiss
Sedgman MEWP fleet operating in or under structures at Boggabri Coal Mine.
Theiss Sedgman also identified a range of continuous improvement programs including:
• Revised MEWP spotter training package was completed in July 2014.
• Supervisors MEWP presentation and Supervisors MEWP scenarios assessment
program was developed and implemented in August 2014 to help supervisors and
leading hands to better understand the specific controls that should be used in various
circumstances.
• VOC authorisation assessment for Level 3 was developed and implemented in August
2014.
• The generic site induction assessment and the Boggabri Coal CHPP induction
PowerPoint presentation was updated in July 2014 to incorporate information from the
MEWP skills review (VOC) package.
• Other initiatives have progressed as part of Work Area Pack Risk Assessment (WAPRA)
for working in MEWP (undertaken in August 2014), developing toolbox talks on MEWP
selection (August 2014), revising and processing work packs to incorporate information
identified in the WAPRA, referred to above and revising the WHS Area Inspection Form
(August 2014) to incorporate a MEWP section based on the Critical Safety Control
(CSC), Prevention of Falls.
• Theiss Sedgman is continuing to implement and monitor the effectiveness of the actions
taken and have no additional actions which Theiss Sedgman proposes to undertake at
Boggabri Coal Mine as at 5 December 2014.

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Appendix A - Applicable reference extracts to Australian Standards

Relevant references extracted from applicable Australian Standards include:

1. For boom type elevating work platforms have a specific design standard:
AS 1418.10:2011 Cranes, Hoists and Winches Part 10 Mobile Elevating Work Platforms
Section 2.6.4 Work platform controls: Location, accessibility, protection states:
All control devices shall be protected against activation other than initiated by the
operator.
For foot controlled MEWP’s, where the risk of inadvertent operation is eliminated by the
constant foot positioning of the operator standing on the controls, a separate
continuously activated control is not required.
A guard shall be provided and located at least 50mm above the highest point of the
controls.

2. For boom type elevating work platforms have a specific safe use standard:
AS2550.10-2006 Cranes, Hoists and Winches Part 10 Mobile Elevating Work Platforms
Section 1.3.7 Mobile Elevating Work Platform definition:
A mobile machine (device) that is intended to move persons, tools and material to
working positions and consists of at least a work platform with controls, an extending
structure and a chassis, but does not include mast climbing work platforms.
Section 1.6 Risk Assessment
A risk assessment shall be undertaken by a competent person before carrying out
operations involving the use of a MEWP. The assessment shall be in writing and shall
take into account the following:
a) The task to be carried out
b) The range of methods by which the task can be carried out
c) The type of MEWP that will be required
d) The hazards involved and the associated risks
e) The actual method and other requisite plant and material
f) Emergency and rescue procedures
Section 2 Planning
m) Where a MEWP is required to operate in or near buildings or structures, that there are
sufficient clearances between the operational path of the MEWP and the building or
structure.
Section 4.12 Proximity hazards requires consideration of proximity hazards including:
d) fixed hazards including the risk of elevating or travelling into overhead structures

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Other sections in the standard provide guidance detail including:

Section 5: Operation
Section 6: Maintenance, Inspection and Repair.

3. A standard that provides general safety of machinery guidance on control action and effect is
provided in:
AS 4024.1906:2014 Safety of Machinery : Part 1906 Displays, controls, actuators and
signals – indication marking and actuation- requirements for the location and operation of
actuators
Table 1 Classification of final effects
Group 1 Upwards motion of the object
Table 2 Classification of actions
Group 1 Away from the operator direction of action

4. A standard which provides alternate guidance on control action and effect is:
AS 4240.1:2009 Remote control systems for mining equipment
Part 1 Design, construction, testing, installation and commissioning
Section 2.3.10.4 Direction of control movements:
Table 1 which specifies directions of control movements that shall be adopted for various
control functions unless machine operations dictate otherwise.
Control function: Up or raise: Direction of control action: Up or rearward
Control function: Down or lower: Direction of control action: Down, forward

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Appendix B - International Powered Access Federation information

IPAFF identified:
‘The European Union MEWP design standard EN280:2001 Mobile Elevating Work Platforms
paragraph 5.7.1’
‘All controls particularly foot operated controls, shall be constructed to prevent inadvertent
operation’. This resulted in ‘built in’ features such as foot pedals, shrouds, stand-off bars,
guards and sunken controls being fitted as standard by MEWP manufacturers.
The built in ‘primary guarding’ systems are designed to prevent inadvertent operation.
Despite these ‘primary guarding’ systems being present, accident data shows incidents still
occur where the operator becomes trapped between the MEWP and a structure.
Following review of EN280:2001 , the revised EN280:2013 paragraph 5.616 states
‘Operators on the platform shall be protected against being crushed over the control panel
when the platform is moving. This requirement can be fulfilled e.g. by controls according to
5.7.1’.
EN280:2013 paragraph 5.7.1 states ‘All controls shall be constructed to prevent inadvertent
operation. Hand controls in the platform shall be protected against sustained involuntary
operation. This protection should either prevent further movement of the machine in the
direction of trapping or allow the operator to reverse or stop the trapping movement’

IPAFF identified the two main secondary guarding devices available as being:
• Physical barriers
• Pressure sensing devices
IPAFF have published a range of design options as secondary guarding devices:

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Figure 49: IPAFF published range of secondary guarding options.

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IPAFF stated:
‘Once the most suitable type of MEWP has been selected for the work task to be undertaken,
consideration to further reducing any remaining risk of entrapment may include the selection
of an additional secondary device.
There is no one particular secondary guarding device that will prevent entrapment in all
known circumstances. Therefore the following five points should be considered as of the risk
assessment process to assist the employer to select, where available within the industry, the
most appropriate secondary guarding device.
1. Reasons for selecting the MEWP for the intended work task
2. Identification of foreseeable entrapment situations expected to be encountered whilst
carrying out the work task
3. Identification of types of secondary guarding devices available, their suitability for the
work task, and their compatibility with the selected MEWP.
4. Consideration of additional hazards compared with the potential benefits that may be
gained with the introduction of a secondary guarding device.
5. Need for additional familiarisation of operators and emergency rescue personnel for
the selected device.’

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