Poultry supplier Inghams has copped a fine of $450,000 after a worker's leg got caught in machinery and had to be amputated on-site at a Tahmoor factory.
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John Evans was working at the turkey processing plant in an 'ice room' between 7am and 8am on February 19, 2020 when a grate in the floor became dislodged and his legs fell into an auger.
Mr Evans was able to free his right leg but could not free his left.
He was working in the room alone and the gruesome scene was only discovered when another worker outside heard him yelling. It is not known how long he was trapped.
Mr Evans drifted in and out of consciousness until emergency service workers arrived.
They were also unable to free Mr Evans' left leg and a decision was made to amputate it at the top of the knee, there in the factory.
Mr Evans was then taken to Liverpool Hospital, where he underwent multiple operations and remained for two weeks.
Inghams Enterprises Pty Ltd pleaded guilty in the District Court to failing to comply with its duty to protect the health and safety of workers, exposing them to risk of death or serious injury.
In December 2023 Judge Wendy Strathdee fined the company $450,000, dropped from $600,000 because of the guilty plea.
Judge Strathdee said Inghams had failed to undertake a number of measures that would have mitigated the risk to its workers, such as providing suitable fasteners for the grates, conducting monthly inspections and having two workers present in the room at any time.
Before February 2020, inspections of the ice room were carried out every three months, but there were no specific instructions on checking the grates and there was no requirement to empty the room of ice, even though the grates at the back were often covered in ice and could not be inspected.
The grates were made from stainless steel, galvanised steel and aluminium, and an expert said stainless steel and aluminium grates were susceptible to increased corrosion from exposure to chlorine - a chemical used in the production of the ice in the factory.
However, exactly how the grates - which had been bolted to the floor - were able to move has not been identified.
It was not the first workplace injury Mr Evans suffered at the plant - the year prior, in January 2019, a large amount of ice had fallen and hurt him.
After this incident, Inghams proposed there should always be two people in the ice room, but only before 5.45am.
At some point before February 2020 the company had required two workers be in the ice room but this was later abandoned.
After Mr Evans' injury, Inghams made a number of changes, such as weekly inspections and preventative maintenance, including specific directions to check all grates were secured in place.
Emergency stop buttons were installed and the company made it mandatory that two people be in the ice room at all times.
Inghams has since removed augers from the factory under an overhaul planned before February 2020, spending $7 million implementing its new system.