Accident at Foster’s Abbotsford Breweries Ltd


Ensuring occupational health and safety is a management function that seeks to promote the safety, health as well as welfare of persons (employees) involved in work. The main objective of occupational health and safety initiatives is to enhance a safe work environment (Reese, 2008, p. 45). As a legal requirement, it is the responsibility of the employer to ensure a safe work environment. Failure to observe this requirement often attracts severe penalties and even losses. This paper focuses on the accident that occurred at Foster’s Abbotsford Breweries Ltd in 2006, that led to the death of an employee. The factors that contributed to the occurrence of the accident will be analyzed alongside the consequence of the accident. Recommendations on how to prevent such accidents in the future will also be discussed.

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Description of the Accident: Contributing Factors


Task refers to the procedure that was being used to complete the piece of work at the time of the accident and its contribution to the accident. The work conditions under which the victim worked had not changed prior to the accident. However, the work condition was not safe. This is attributed to the fact that the workers were expected to clear jams or clean the machine without stopping the depalletizers (Victoria Government, 2008, p.3). Consequently, the victim and his colleagues were directly exposed to the risk of being crushed by the door of the depalletizers while clearing jams or cleaning the machines.

Material/ Equipment

At the time of the accident, one of the photo-electric sensors used to control the metallic doors was not working since its reflector had cracked. The handrails behind the doors were also poorly designed since the clearances bordering the door ends increased the danger of entrapment (Victoria Government, 2008, p.4). The management had not made an effort to clearly define how the machine could be stopped in case of an emergency. Thus, its operators were not in a position to stop it in order to avoid the accident.


The environment refers to the surroundings of the workplace and its condition at the time of the accident. The machine operated in a very noisy area thus limiting the workers’ ability to call for help in the event of an accident. The hazardous areas on the depalletizer such as the point at which the door opened were not clearly marked with the aid of visible or audible markers (Victoria Government, 2008, p.4). Finally, the chain sprockets were not guarded thereby creating spaces in which the employees could be trapped.


There were no standard procedures or explanations on how jams could be cleared during production. Besides, most of the employees were not conversant with the procedures for isolating the machine. This is attributed to the fact that most employees had poor command of English (Victoria Government, 2008, p.3). Thus, they could not read and understand the procedures. The employees’ limited knowledge about the machine increased the risk of being crushed.


The management also contributed to the accident by failing to inform employees of the hazards at the workplace. Besides, it had failed to comply with regulations associated with the operation of plants and machinery in Australia.

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The Event

Mr. Cuu was trapped between the left door of the depalletizer and the adjacent handrail while working in the B1B depalletizer’s operating area (Victoria Government, 2008, p.2). He suffered severe injuries in his neck which led to his death after seven days.

The Outcome

The accident did not only lead to the death of the employee but also caused grief to his family members. It also led to a legal suit in which the company was fined to the tune of $1.125 million. The company further incurred expenses to the tune of $3.9 million in improving the safety standards at its brewery plant.

Analysis of the Contributing Factors

Hazard Identification

The hazard associated with the use of the depalletisers had been identified by the company on several occasions prior to the accident. The hazard was first identified in 2002 when an employee was injured by B2 depalletiser as he was replacing a damaged sensor. Risk assessments conducted in 2003 and 2004 also revealed that both B1A and B1B depalletisers could possibly crush an employee in the operating area (Victoria Government, 2008, p.3). Thus the management had full knowledge of the hazard associated with the use of the depalletisers.


Despite having identified the hazard correctly, the management failed to conduct an effective evaluation of the risk. The crush risk associated with the depalletisers was ranked as low even though it had led to the injury of an employee. This perhaps explains the management’s reluctance to implement the control measures which could have made B1 depalletiser safer. However, after the death of Mr. Cuu, the risk was ranked as high thereby prompting the management to implement control measures.


Having received complaints about the hazards associated with the B1A depalletiser, the management decided to implement corrective measures. However, a similar hazard was identified in B1B depalletiser, but the management did not implement any corrective measures (Victoria Government, 2008, p.3).

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Monitoring and Review

Since the year 2002, the company has been conducting regular risk assessments. It was thus able to identify the risks associated with operating the depalletisers and how such risks could be prevented. However, implementing the recommended corrective measures was not completed since B1B depalletiser was not guarded as was recommended. A review of the effectiveness of the remedial measures was also not conducted. This limited the company’s ability to explore alternative ways of improving the safety standards at the workplace (Bohle, 2000, p. 97).


Hazard Identification

This is the most important stage in eliminating hazards at the workplace since hazards that have not been identified can not be controlled. The management must conduct regular risk assessments in order to identify existing and potential hazards at the workplace. This can be achieved through the following ways. First, regular workplace inspections should be conducted with the aim of identifying the health risks that workers are exposed to (Tompa, 2011, pp. 340-351). Second, an effective incident reporting and investigations procedure should be put in place to enable employees to inform the management about the hazards at the workplace. Finally, there should be a register for recording existing hazards and how employees can avoid them.

Evaluation of Risks

Risk refers to the “likelihood of harm occurring due to exposure to a hazard and the likely consequences of that harm” (Creighton and Rozen, 2007, p. 88). The risk associated with the identified hazard should be considered high if the consequences are great. The risk should also be considered to be high if the event of an accident or injury is likely to occur.

Risk Control

The most appropriate risk control measure must be used to reduce or eliminate the hazard. The following hierarchy of risk control should thus be considered. The first objective should be to eliminate the risk. This involves removing the hazard through measures such as stopping a hazardous operation. Second, the management should focus on substituting the hazardous process with a less hazardous one if it can not eliminate it (Iaricoli, 2011, pp. 87-94). Third, the hazard should be isolated by restricting access to specific machines. Fourth, the management should focus on appropriate engineering. This involves redesigning a work procedure or equipment in order to make it less hazardous. Fifth, administrative measures should be taken to reduce the hazard. Such measures include adopting standard work procedures, training employees on how to respond to hazards and providing adequate information about hazards at the workplace (Dimitrov, 2009, pp. 889-902). Finally, the management should provide personal protective equipment to be used by employees in case of an emergency such as a fire breakout.

Monitoring and Review

Hazard management should be implemented as an ongoing process to enhance improvements over time. Thus, the monitoring and review process should include the following. The effectiveness of the existing control measures should be evaluated regularly (Kilic, 2009, pp. 903-921). New control measures should thus be formulated to replace ineffective ones (Bohle, 2000, p. 77). Data should be collected regularly to identify emerging hazards. Scheduled inspections should also be conducted regularly by independent organizations to give the company a better understanding of the hazards.

Analysis of the Verdict

The verdict was fair due to the fact that the company had ignored recommendations to implement control measures (Victoria Government, 2008, p.3). Besides, the offense was very serious since it involved the death of an employee.

The punishment in the form of a monetary fine was appropriate but not enough. Since the fine was significant, the company had to implement corrective measures in order to avoid such fines in the future. However, the fine did not help in reducing the loss suffered by the victim’s family. The victim’s family should have been given monetary compensation for the loss of their income earner.

Fosters is a large company with adequate financial resources. Thus it was in a position to pay the fine. Besides, the fine amount was set according to the legal provisions. We can thus conclude that the fine was neither too much nor too little.

The other ethical and moral issues involved in the accident include the following. The employee’s right to know about the occupational hazards was breached since the information was not provided by the management. The victim was not allowed to exercise “autonomy and free and informed consent” (Bohle, 2000, p. 56) to repair the machine while it was in operation. Due process in protecting employees against occupational hazards was also not followed. Finally, the employees were not fully involved in making decisions relating to hazard prevention since their recommendations were being ignored.


The accident at Fosters ltd was mainly attributed to the management’s reluctance to provide a safe work environment to his employees (Victoria Government, 2008, p.4). The accident could have been avoided if corrective measures were implemented in time. The fine imposed on the company was appropriate since it led to the implantation of corrective measures. However, the family of the victim should have also been compensated for the loss of an income earner. In order to avoid such accidents in the future, the company can consider implementing the recommendations discussed above.


  1. Bohle, P. 2000. Managing Occupational Health and Safety. London: Macmillan.
  2. Creighton, B. and Rozen, P. 2007. Occupational Health and Safety Law in Victoria. Sydney: Federation Press.
  3. Dimitrov, P. 2009. Measuring Occupational Health and Safety Risks. Ege Academic Review, 9(3), 889-902.
  4. Iaricoli, S. 2011. Occupational Health and Safety Policy and Psychosocial risks in Europe. Health Policy, 101(1), 87-94.
  5. Kilic, G. 2009. The effect of Occupational Health and Safety Risk factors on Job Satisfaction. Ege Academic Review, 9(3), 903-921.
  6. Reese, C. 2008. Occupational Health and Safety Management. London: Taylor and Francis.
  7. Tompa, E. 2011. Economic Evaluations of Interventions for Occupational Health and Safety: Developing Good Practice. Health Policy, 2(1), 340-351.
  8. Victoria Government, 2008. In the County Court of Victoria: The Queen Verses Fosters Australia. Melbourne: Victoria Government Reporting Services.
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