During a staged two-site relocation in South East Queensland, a steel manufacturer’s cadet suffered a serious forearm crush injury while clearing an unisolated drill line. Production pressure, no supervisor and unverified competency contributed to the notifiable incident. OHSE Consultants used ICAM to review machine logs, CCTV and witness accounts. Its interim and Board reports found five system failures and proposed a four-stage competency framework, cross-site checks and quarterly Board safety reporting.

OHSE Consultants was engaged to conduct an ICAM investigation into a notifiable crush injury on the client’s drill line. Work included preserving evidence, interviewing witnesses, reconstructing the incident and analysing failed controls, work practices and site conditions. The engagement required an interim report on the facts and immediate causes, followed by a Board report on the underlying management-system failures. It also required practical recommendations to prevent recurrence and verify competency across all work sites.

The cadet operated the drill line unsupervised, without verified competency or training in the revised isolation procedure. The drill line’s drop-end access guard was not interlocked, so opening it did not stop the machine. The drill head recycled while he cleared the jam. Plant and staff had moved to a new site without there being a risk assessment. The cadet’s leading hand was not there to supervise. The staff left at the original site used a superseded isolation procedure due to a lack of supervision.

OHSE Consultants recommended four-stage competency checks: training, workplace instruction, supervised practice and formal assessment. No worker would perform high-risk work until every stage was verified for the task and site. Measures covered verification before assignment, annual renewal and reassessment after changes to site, equipment or procedure. Cross-site checks would prevent unverified transfers, with competency and safety performance reported quarterly to the Board.

The outcome was a practical, low-cost response to ISO 45001 clause 7.2. The four-stage framework used the client’s existing systems to record training, instruction, supervised practice and formal assessment, avoiding a separate platform. The result paired simple implementation with a sophisticated ICAM analysis and Board report. Australian Catholic University later requested the report as a model for postgraduate occupational health, safety and environmental management teaching.

The investigation showed the injury arose from failed controls as plant and staff moved between sites, not from one worker’s action. ICAM linked the live drill line to gaps in competency, supervision, change management and communication. The client gained a low-cost response: verify competency before high-risk work, reassess after changes to site, equipment or procedure, and report safety performance to the Board. This provided a repeatable control to prevent recurrence across all work sites.