By Gaby Grammeno Contributor

An employer has been convicted and fined after a young woman’s hand was dragged into a machine, highlighting the risk of bypassing machine guarding and safety systems.

The worker was in Australia on a student visa and her proficiency in understanding written English was poor. She was employed as a factory worker and machine operator at a small Sydney business that manufactured paper products including hand towels and toilet paper.  

The company's equipment comprised a series of machines in a production line, performing multiple processes such as unwinding, embossing, perforating, rewinding, tail sealing, cutting and packaging. 

In March 2023, the 19-year-old worker was directed to undertake work on the rewinder, a machine with 10 exposed rotating rollers.  

She was working alone inside the perimeter safety fencing of the rewinder when she noticed a spot of glue on one of the exposed rollers. Concerned that the glue might cause the machine to jam, she approached the exposed rollers and attempted to remove it. As she reached out to pinch off the glue with her fingers, her left hand was pulled into the roller and crushed. 

Her supervisor arrived at the rewinder moments later, having heard her screams. He immediately isolated the power and opened the electrical cabinet at the end of machine, cutting the cable drive to the roller which had trapped the worker’s hand. 

Emergency services were called, but it took about 90 minutes to free her hand from the rewinder with the assistance of NSW Police Rescue. 

In hospital she underwent emergency surgery for the crush avulsion injury (degloving) to her left hand, with four further surgeries over the next 12 days. A degloving injury involves the skin and soft tissues being torn away from the underlying structure of the hand. 

Following the incident, the worker continued to suffer from post-traumatic stress disorder. She attended a weekly consultation with both a psychologist and a hand therapist and a fortnightly consultation with an exercise physiologist. Twenty months later, she was still unable to return to work. 

The employer was charged and pleaded guilty to failing to comply with its health and safety duty and exposing the worker to a risk of death or serious injury. The maximum penalty for this offence is a fine of 17,315 penalty units ($1,860,843). 

The penalty was determined in the Industrial Court of New South Wales. 
 

In court 

Justice Jane Paingakulam heard that the rewinder was surrounded by perimeter safety fencing that included three access gates. Each gate was fitted with an interlock device to prevent workers from accessing the machines while they were operating.  

The rewinder’s control panel, however, was located inside the safety fencing, positioned and angled such that a person of small stature – such as the injured worker – would need to be inside the fenced area to operate the machine. 

At the time of the incident, all the access gates were fitted with devices to defeat the interlock system intended to protect workers, meaning that workers could open the gates and enter the fenced area while the machines were operating. 

Work health and safety laws mandate specific requirements for guarding machinery (‘plant’) such as the rewinder. Clause 208(2)-(3) of the WHS Regulation 2017 requires that guards be designed to make bypassing or disabling them, whether intentional or accidental, as difficult as reasonably practicable.  Additionally, operator controls must be positioned for easy and convenient use by all operators. 

Guidance material advises employers to find a long-term solution if frequent access to guarded areas to rectify a problem means workers are motivated to remove a guard or defeat an interlock.  

The relevant Australia Standard (4021.1601:2014, Safety of Machinery: Design Controls, Interlocks and Guarding – Guarding – General Requirements for the Design and Construction of Fixed and Movable Guards) says employers should instruct users in the correct operation of the guards and their interlocks. It also recommends warnings against reasonably foreseeable misuse. 

Australia Standard 4024.1201:2014, General Principles for Design – Risk Assessment and Risk Reduction, highlights the importance of conducting a risk assessment in relation to machinery. Compliance with the Standard requires risk estimation to consider the possibility of defeating or circumventing protective measures and the incentive to do so. It also requires risk estimation to consider the need to maintain the protective measures in the condition necessary to provide the necessary protection. 

Justice Paingakulam said the central issue was that the company bypassed the interlocking devices on the gates in the fence around the machinery, deliberately disregarding the requirements of cl 208 of the WHS Regulation.  

‘The provision of generalised access to the restricted area should never have been deemed an acceptable solution to that problem,’ she said. 

Moreover, workers did not receive adequate training in the risks and safety measures, and the operator could not easily reach the emergency stop button. 

By its plea of guilty, the employer accepted it could have taken a number of reasonably practicable steps to eliminate or at least minimise the reasonably foreseeable risk, such as re-positioning the control panel outside the safety fencing so that workers could operate it without entering the danger zone, and other measures to ensure the machine would not operate if the interlocks had been overridden. 

Mitigating factors were that the employer had no prior convictions, was of otherwise good character and had shown remorse, cooperated with the regulator and taken significant steps to reinforce its safety systems in the wake of the incident.  

The employer submitted it had replaced the rewinder with safer machines so there was little need for specific deterrence when deciding on the fine. However, Justice Paingakulam disagreed, noting that as long as the company employed people, there was still the potential for exposure to risks. 

The employer was convicted and fined $150,000 after a reduction of 25% to reflect the guilty plea. 
 

What it means for employers 

Bypassing safety mechanisms designed to protect workers from moving machinery to achieve productivity gains is ‘entirely unacceptable’. It’s not enough to have guarding in place if there are reasons people will be motivated to disable or defeat it. Employers must find a way to prevent reasonably foreseeable misuse. 


Read the judgment 

SafeWork NSW v Pacific Tissue Pty Ltd [2025] NSWIC 13 (19 September 2025)