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NSW Company fined after Amputation Incident

Weekly WHS Article 22nd February 2024

What happened

Royal Touch Paper Products Pty Ltd, a company based in New South Wales, has received a $300,000 fine following an incident where a female worker, Ms. M, had her hand amputated during her second shift at a Sydney warehouse. Ms. M, who was on her second casual shift at the Milperra premises, arrived on the morning of March 13, 2021, where her husband was also employed.


Assigned to operate a core cutting machine for producing cylindrical cardboard cores, Ms. M received instructions from an experienced operator who assured her,


"…the machine is set up... all you have to do is just cut."


A few hours into the shift, Ms. M’s arms became entangled in the machine's rotating blades, resulting in severe injuries. As outlined in the Judgment handed down recently, the blades cut through her left hand up to her forearm and through her right hand.


Ms. M was working alone at the time and attempted to press the emergency stop button, but it was beyond her reach. For a duration of 10 minutes, she called out for assistance, until workers on the opposite side of the building heard her and rushed to provide assistance.


Ms. M’s arms were removed from the machine, and she lost consciousness.


The Court heard that the company had purchased and imported the core cutting machine in 2012 from Turkey. The machine came with no documentation. No training was provided to the defendant by the manufacturer when the core cutting machine was acquired.


When the core cutting machine first arrived at the defendant’s premises in 2012, it was suggested that a guard be placed in front of the drop blades. A drop guard was subsequently fixed to the core cutting machine by a third-party provider. However, the guard only prevented access to the blades from the top and did not adequately prevent workers’ body parts from coming into contact with the blades from other angles.


The Court heard…

  • There was no supervisor on site.

  • Ms. M was not being supervised in the course of her duties.

  • The company did not have daily start-up checklist and maintenance documentation for the machine.

  • The defendant did not have a system whereby plant and machinery were audited so as to assess the risk of workers being exposed to serious injury or death whilst using its machines.

  • The company did not provide adequate information, instruction, and training to workers such as Ms. M to enable them to perform tasks competently, including operation of the core cutting.


This case highlights….


  • Lack of Training: Injured worker had no prior experience, received minimal training.

  • Lack of Documentation: Lack of Procedures, daily checks, and maintenance records for the machine.

  • Inadequate Safety Measures, e.g., guarding.

  • Lack of Risk assessments – Plant Guarding risk assessment not conducted.

  • Insufficient Compliance and Governance Protocols: No established system for auditing plant, machinery, and associated systems to assess the risk of serious injuries.


How Courtenell can help….


  • Courtenell can support the business with comprehensive and tailored training programs for all employees, including WHS Risk Management, Consultation and WHS responsibilities of various Duty holders.

  • Conduct Risk Assessment of Plant and equipment to ensure compliance with the Legislation and applicable standards.

  • Conduct WHS Compliance Audits in line with the requirements outlined in WHS act, the Regulations and associated AS / ISO Standards.

  • Develop, review and update SWMS, JSAs, Work Instructions, checklists, risk registers to ensure on-going compliance.


If you have any questions or would like to discuss your needs, please feel free to call 02 9552 2066, or reach out to Stephen Georgulis @ or Kevin Gaskell @


22nd February 2024

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