The circumstances were:
- Linas Mataitis was a temporary worker.
- He was working near a large shredding machine that had been powered down for essential annual maintenance, with surrounding safety zones and interlocking gates opened up to allow worker and vehicle access.
- Linas was one of a team of workers using hand shovels to scrape and clear dirt near conveyors feeding the shredder, which they placed into piles for colleagues using machines to clear.
- On the morning of 18 July there were three vehicles operating alongside the team on foot; a bobcat, a mini excavator and a wheeled loading shovel.
- The smaller machines were being used to fill the bucket of the loading shovel, which then drove away to be emptied.
- The loading shovel was being driven by a partly trained operator who may have been unauthorised to use it.
- Although EMR had a documented procedure for clearing dirt from around the conveyors, which mentioned the use of a bobcat, it did not cover the shutdown operation when the safety gates were open, when more vehicles were operating nearby and when there was increased pedestrian movement.
- The loading shovel was returning to be refilled for a fourth time when it struck Linas and crushed him against a conveyor support.
- There were inadequate arrangements for safely managing the movement of people and machinery.
- The company had confusing and conflicting records of who was trained and authorised, highlighting failings to properly manage and audit training and supervision.
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