excerpts of the letter from Mr Nixon to Dr Glossop relevantly provided as follows: On the 11th August 2017, Mr wrote a letter to Laurie Glossop requesting a Subject Matter Expert Report "for the purposes of proceedings in the Industrial Relations Commission, sitting as the OSH Tribunal (the Tribunal), involving the review of a Prohibition Notice (the Prohibition Notice) issued under section 31AB of the Mines Safety and Inspection Act 1994 to Alcoa of Australia Ltd in respect of its Pinjarra Alumina Refinery (the Refinery). The Prohibition Notice concerns asbestos hazards. An issue that the Tribunal will need to consider for the purpose of its review is the circumstances in which asbestos containing material (ACM) may result in injury to a person or harm to a person's health". You provided the following "a brief description of some relevant features of the Refinery, and a question for you to answer. Please explain the reasons for your answer, including reference to any applicable principles, observations and matters of professional experience or judgement. We request that you set out your answer in a written report, which should also set out your qualifications, study and experience in your relevant field of expertise". In your letter you also had the following information: "The Refinery was originally constructed in 1972. It comprises a variety of thermal and chemical processing vessels, pipe circuits, electrical equipment, buildings, workshops, machinery and infrastructure. Common items containing asbestos at the Refinery include sheeting, cladding, floor tiles, asphalt wrapping, lagging, insulation, gilsomastic, Coro-kote paint, and gaskets. In addition to routine alumina refining operations, the activities carried on at the Refinery from time to time include construction work, electrical maintenance and installation, shutdown and general plant maintenance, refurbishment and replacement of parts and equipment". You asked the following question: "The question that you are to answer is this: Under what conditions does ACM have the potential to result in injury to a person or harm to a person's health? Please include in your answer: (a) an explanation as to how asbestos related diseases result from exposure to ACM; (b) a description of any particular state or condition of the ACM necessary for exposure to result in a risk of harm, and as to how each such state or condition may be produced;
8.0 Most Probable Causes The TSL employees were potentially exposed to asbestos fibers (sic) because they employed oxy-acetylene cutting to remove steelwork coated with Cora-Kote (sic). This method had the potential to disturb asbestos. The work team was not provided with the scope of work by TSL which identified the asbestos hazard associated with the steelwork. TSL did not have management processes that require the scope of work to be used in development of its own JSA / SWI. This represented a failure of TSL to understand, and/or recognize the risks of asbestos hazards and to properly instruct its personnel in relation to those risks. 9.0 Contributing Factors The following factors may have contributed to the incident: 1. Asbestos awareness training is not mandated for contractors 2. The potential asbestos hazard was not identified as a risk in the Authority to Proceed form because it does not contain a prompt to check the Asbestos Register 3. Scope of works that impact on structural steelwork do not include a requirement to consult the Asbestos Register 10.0 Other Safety Issues The investigation identified that some TSL employees continued to undertake cutting of steelwork after they were instructed to cease work. This is considered a violation. 11.0 Corrective Actions to Table 1 for a list of corrective actions that will reduce the likelihood of a reoccurrence of a similar incident. Corrective actions were recommended in the investigation report in relation to contractor management. These included: (a) amending Alcoa’s Authority to Proceed form, with a prompt to require specific consideration of asbestos hazards and to cross-check the Asbestos Register if work is being performed on plant that may potentially contain ACMs; (b) expand the induction process to include reference to examples of ACMs; (c) require asbestos awareness training for “embedded contractors”, who are likely to work on potential ACMs; (d) Transfield be required to introduce management systems that require the of work to be used when developing job safety analysis and safe work instructions with increased supervision; and