The smell of ‘corruption’ 17


Such are the warning signs

It stopped at 2.32 pm of an ordinary day.   One string of events ended abruptly at the pinch point of a groaning conveyor belt when his arm was ripped off.  Do you think of Swiss cheese models of risk alignment?  Of complexity or failure to learn?  Of the Moura coal mine disaster, the Longford oil and gas plant disaster, the Baker report and the BP Texas City refinery fatalities, of 29 miners killed in the desolate and terrorising Pike River coal mine, NZ, 2010?  Do you think of precariousness lurking at work, of leadership, of productivity?

For me this was the 5th arm I was personally aware of disappearing violently at work, generating years of withdrawal and solitude unrecorded in any OHS statistics.  In that time I had also observed hundreds of missing or useless machine guards.  Such a well known and easy hazard to fix.  What exactly is the problem, what does it indicate about OHS generally, and what may go some way towards practical improvements?

Signs of increasing volumes of methane in a coal mine (e.g. Pike River) provide important safety warnings.  In hard rock mines signs of increasing seismic activity do the same, (e.g. Beaconsfield Gold Mine).  Numerous ammonia escapes from liquid storage tanks at a chemical facility are signs.  Increasing reports of bullying, fatigue and stress at work provide their own H&S signal information; something is wrong.  The events described below seem to me to be warning signs, but for the field of a romanticised OHS theatre, (“We’re in this together, Team!”, “My door is always open”, “H&S comes first”).

1.       “Ultimately, the worth of a system depends on whether health and safety is taken seriously by everyone throughout an organisation” (Pike River Coal Mine Royal Commission report, 2012, RC).  In 25 years of work in OHS I have observed (with few exceptions) that in smaller workplaces ‘doing’ H&S is typically regarded as non-critical, unimportant, at times trivial; that’s not taking it seriously.

In larger workplaces, some with terribly dangerous hazards, the talk about H&S verges on the quasi-religious, (“Oh, you must use ear plugs here, we’re very very strict about that”, “When you’re in the factory you must walk only between the yellow lines.  Only”, “You must wash your hands before eating here.  Lead is toxic you know?!”) but actual, daily H&S practice related to, say, plant integrity, plant safety features, difficult work methods, tortuous rosters is trivialised by a dishonest focus and shelves full of useless ‘how to’ documents.  This also helps to maintain the not-so-secret belief by too many managers that H&S is non-critical for productivity but you do need the paperwork ‘to cover your arse’, but generally you get away with most things.  That’s not taking it seriously.

So on the logic of the RC quote above the majority of these systems are heading towards worthless.

2.      A director of Pike River coal mine is reported to have said at the hearings –

“… the site managers were responsible for bringing the [safety] issues they considered important to the board’s attention.  These people were very competent and the board had every confidence in them.  There were plenty of opportunities for site managers to bring safety concerns to his attention in both formal and informal situations, and he was surprised [emphasis added] that they had not done so.”

And in the report,

“The board did not provide effective health and safety leadership and protect the workforce from harm.  It was distracted [!] by the financial and production pressures that confronted the company.”

These are neither new nor unique but they are signs of fake, of pretence.

3.      “There were numerous warnings of a potential catastrophe at Pike River.  One source of these was the reports made by the underground deputies and workers. For months they had reported incidents of excess methane (and many other health and safety problems).  In the last 48 days before the explosion there were 21 reports of methane levels reaching explosive volumes, and 27 reports of lesser, but potentially dangerous, volumes.  The reports of excess methane continued up to the very morning of the tragedy.  The warnings were not heeded.”(RC)

If a frequent pattern of management behaviour prevailed they would  have been unheeded  not because of ‘systemic problems’, poor ‘safety culture’ or losing the lessons of the past,  but simply because key managers didn’t forcefully and effectively  demonstrate that good H&S standards were absolutely non-negotiable, regardless of their relationship to productivity.

4.      “A serious problem was the workers’ practice of bypassing safety devices on mining machinery so work could continue regardless of the presence of methane.” (RC)

Short cuts at work are neither surprising nor a new discovery, particularly under productivity (and time) pressure and dishonest H&S programs, (“Our workers are our most important resource.  They always come first”), and often wrong proportion of inexperienced to experienced workers.  It’s a common practice tolerated with silence and a blind eye even in hostile working environments like mines, (Berger, 2009, Breaking the silence of known but unsaid things).  To pretend otherwise is a damaging corruption of information.  The elephant in the room: why is this common practice tolerated in silence by so many?  What does that really indicate about the daily practice of OHS?

5.      It doesn’t come as news  –

a) that risk assessments, seen as fundamental to H&S Management Systems, are much too frequently ineffective, (e.g. Beaconsfield Gold Mine, Coroner’s Findings).

b) that H&S matters are given low priority at board meetings (even if they are proclaimed as always the first item on the agenda). Or that most managers are reluctant to burden their boards with H&S detail.

c) that H&S and training departments struggle for credibility next to the relentless drive for profit, (“The safety and training department at Pike appears to have been marginalised”, “Generally, his department [H&S training] struggled for credibility alongside the more production focused departments”, “Comments made …..in November 2010 by some of the second intake of trainees indicated that the safety approach taught in the classroom was not always evident underground” (RC)).

d) that growing number of H&S problems are regularly ignored.

e) that a convenient abdication by top management and board members to ‘more OHS-competent people’ is regular. Such experts then generate 398 ‘how to’ documents that explain in great detail all the ins and outs of a duck’s bum but aren’t properly implemented for daily improvements.

f) that frequently former high flyers (in various organisations) on the way down that slippery pole, perhaps as a result of dramatic political or corporate changes, are offered responsibility for H&S, or given a safety ‘research’ project, even if they know little about it and have zero interest in it. For most this ‘pick me up as I come down’ becomes the equivalent of the depressing Japanese window desk that looks out onto everything and nothing at the same time.

All of these are warning signs about an entrenched practice of OHS and its values.  Not everyone is an eyewitness to all of these, but most of us are ear witnesses, and we ain’t all that naive.  We do know. 

The system is buggered

Somewhere in that event space between that worker’s arm being ripped off and what so many post-disaster reports repeatedly conclude (also see Penrose, 2007, Losing the Lesson of the Past) convenient distortions of information occur.  These result from an uncomplicated corruption of simple facts.  This, in turn, nurtures and sustains the current approach to OHS  and its implicit values, and spawns damaging ‘theorems’ (e.g. “H&S is a joint effort”, “We’re a team”, “It’s to do with safety culture”), and an invalid ‘how to think about it all’ (e.g. “A risk assessment-based Management System”).  The notions of a research or a social paradigm (Kuhn, 1962) are premature here.

This is an insidious two-stage corruption.  First, of reasonably accurate workplace information, and secondly, knowingly responding to that as a fair representation.  I believe the worst of it is the second stage, with people knowing that this information is inaccurate and misleading, but choosing to pretend that it isn’t; philosophers used to call this bad faith.  But this culpability is not shared equally.  Some are just brought up on and/or are educated in this OHS discourse with its thin concepts and accepted ‘wisdoms’ and then refuse to be seduced by the obvious.

“Nah, Mate” a worker once corrected me on the 10th day of a long and bitter strike triggered by regular exposure to a carcinogen.  The strike involved hundreds of workers.  “It’s the system that’s buggered!”  and then, along with over a thousand others ‘waved’ his hand meaningfully at the company HR executive who had provocatively stuck a video camera out of a window at the sea of angry workers’ outside the gate.

I tend to agree.  It’s ‘the system’, as he said, not….. “the systemic problems lying behind the tragedy” (RC).  This is a serious difference.  But what does that mean?  In simple terms, the way this society has come to talk, think and act about daily health and safety conditions for its children at work, (pick your preferred age, 18? 25? 35? 55?).  How can it be otherwise if its laws, regulations, codes of practice and the entire aspirational paraphernalia of limiting and standard-enabling documents specify and allude to (approximately) one kind of world view (e.g. responsible care and effective concern), and the very opposite happens daily in hundreds of thousands of workplaces?  The stark truth is that currently H&S programs (if there are any) in most small to medium workplaces – where most workers work -  do not have any relationship to productivity.  But a competent and decent manager will have an eye to both.  And it’s that decent manager who’ll make it appear as if good H&S standards and productivity are causally related.  As he/she gains respect, trust and loyalty improvements generally will increase.  Minister Shorten’s Centre for Workplace Leadership is a good move.  But it will only work if Decency&Dignity 101 is fundamental.

Chameleon-statistics vs. reality

Work-related fatalities, whilst obviously tragic, are not the main daily problem for the vast majority of workers, (more that 11 million who work about 50 million hours per day – think of how many separate tasks that spawns!).  Nor do they usually indicate these problems, despite what politicians and bureaucrats use them for in chameleon-statistics to make silly points.  The vast majority of H&S problems are to do with the constant, ever pressing crowd of hazards that workers work with every hour – one at a time – where, mostly, no injury (of the recorded kind) occurs.  Workers know 28 things that are going wrong every day, whereas the boss and H&S officer choose to know only 2 and 5 respectively.  For example: working in eye ‘burning’ caustic soda or menthol mists and fumes for 20 years; or in frequent breath-stopping SO2; or with asphalt-related daily nose bleeds; or suffering regular workplace asthma; or with permanently roar-ringing factory ears; or skin that had absorbed chemical mists, fumes, aerosols and smokes which then sweats out every night in unnerving multi-coloured body silhouettes on the sheets; or not sleeping well for years on end, humiliated, stressed, bullied, and frightened to lose their job.    By being orchestrated to shut up (or use bullshit terminology) they have essentially been banished from themselves.  Of course not everyone, but too bloody many!

This aggregate of one-at-a-time familiar hazards, with the one-at-a-time pattern of response behaviour is the process of normalised tolerance of such strings of daily events that creates the nursery for most OHS incidents.  This includes both personal and process safety.  Rigid personal intolerance of these daily hazards would have a profound influence on the career path of very serious hazards including growing process risks that have the potential for huge catastrophic consequences.  This is a different point of view about the personal vs. process safety discourse.  I do not believe that H&S incidents (personal or process) are unique, localised storms in a sea of tranquillity.  Rather, they are fomenting events in a sea of endemic tolerance of risk and regular near misses.

Since both politics and industry have not matured to a civilised stage where most workplaces and all machinery design are decently safer, and OHS matters are demonstrably paramount, one way to maintain practical attention on them is by strong and genuine encouragement of workers to practice a vigorous and open intolerance of all local, well-known hazards, including the destructive psychosocial ones.  This manner of defence would then tightly couple with the entire approach and turn it on its head.  It would become the gate keeper manner for all matters to do with H&S, including design.  Proper consultation was supposed to achieve that, but that method itself was corrupted beyond recognition.

Two main things would happen: first, workers would develop and practice an open, almost reflexive mental ‘posture’ about local, daily hazards, (“Not on your life, mate, not here!”).  This would have to be powerfully and loudly endorsed and welcomed by their managers.

Secondly, managers would become well aware of that approach and would never tolerate 21warnings about explosive volumes of methane in a coal mine, or be allowed to by their workers.  All managers would need to take some specialised (very solid) OHS training relevant to their industry (including some history) so their understanding of due diligence requirements would be sharpened, and they couldn’t just leave it to their workers.  But, this bottoms up approach is not enough on its own.

The IR monster has over reached 

The current (legalistic) approach of industrial relations (IR) as the main tool kit to deal with work life, with its focus on employment and pay, generates the basis for treating OHS as a second order activity, despite the common rhetoric, (“It’s our top priority”).

A counter argument could go: when managers employ people, or unions recruit members the essential condition is ‘to be employed’.  Since you can’t be safe at work unless you are ‘at work’ (employed) doesn’t that suggest that employment and wage conditions are primary?

No.  Consider if you’d like to be employed in a well-paid, unsafe, unhealthy and evil job, (e.g. cruel to animals; in a seismic, asbestos-containing mine)?  The majority of those who have a genuine choice would not.  What kind of job it is does matter.  But in a forced choice between being seriously unemployed or getting work in a workplace with low levels of, say, asbestos, or benzene fumes, or unguarded dangerous machinery I suspect the H&S issues would get only secondary consideration from too many people.  And that’s consistent with what the man said, “It’s the system that’s buggered”.

Tests of this tension (employment/safety) seem impractical and uninformative:  “Would you rather be unemployed for 10 years or dead for 10 seconds?!”, “Would you rather put food on the table for your family (and pay worrying bills), or keep looking for a safer and safer workplace?!”  These are indicators of the problem, not relevant tests of practical choices and correct messages.  When the CFMEU banned work across industry after any workplace death (in construction) that sent a firm message about H&S.  So do bans of dangerous/ poor/ injurious equipment (Australian Nursing Federation), toxic chemicals (Australian Workers Union), or shameful structures (Maritime Union of Australia).  But all of that is not nearly enough.

So, should employment and pay issues be secondary to H&S?  No; I am arguing that they are just another aspect of working conditions, but these conditions should begin by providing a safe, healthy and sustainably decent place to work; nothing else should be acceptable.  IR, as I see it, is a part of H&S conditions, not the other way around.

The point is to elevate the matter of workers’ daily H&S conditions to a primary status, to discourage treating workers as precariously employed pockets-in-waiting who also (in passing) need some attention to H&S standards.  Maybe it’s a good time to be doing OHS, there is so much fresh stuff to be re-discovered, rehabilitated and implemented by leaders with decent values.

The Pike River commission of inquiry was the 12th of its kind in NZ.   One of the comments made is that “….as a country we fail to learn from the past”, and it offers the suggestion that, “Government, industry and workers need to work together” (RC).  But does not identify what exactly should be learnt from the past or how working together will really make a difference.  Nor does it note the power of language to distort, (“Learn from past’, “Work together”), its persistence across the history of disasters, or its deep freezing of non-communications in the form of’ fashionable wisdoms’ (‘consult’, ‘jointly’, ‘learnings’).  The creation of yet another shopping list of recommendations on its own will not be enough, even if it’s a good one, in the scheme of things, in a difficult task.  The devil is in the daily detail at 2.32 pm of an ordinary day.

Dr Yossi Berger

17 comments

  1. Thanks Yossi, once again you succinctly tell it as it really is. If you apply your thoughts to the hundreds of thousands of micro businesses around Australia (20 employees or less) who in the main, struggle from one month to the next to make a profit then one only has to imagine where OH&S figures in the pile of priorities. These businesses need the services of the regulators to point out the deficiencies in safety in their organisations, of which there significant numbers in every business. An annual visit unannounced I am sure would rapidly improve the practical aspects of safety at every one of these businesses.

    I am a sceptic as a result of over 25 years of coal face involvement with safety in a variety of roles, including management of larger organisations and I know from first hand experience where the priorities are and they are most certainly with cost conservation to the point of bare compliance and usually failing the “Duty of Care” test.

    No one is being held accountable until after the fact and that’s the rub.

    Now I concentrate on bringing management to account for the many after the fact failures of “:Duty of Care” that result in injuries in the workplace. I do this on the basis that a few wins that embarrass and lighten the pockets of those businesses that habitually ignore their responsibility to their work force becomes known and might just influence others to lift their game and maybe save some poor bugger from death or injury.

    The rules are in place.

    Tony

  2. Do you agree, folk? This may be a really good time for new people to do really important things in H&S? Fresh, ground-breaking and accurate? And powerfully ethical…

  3. Very good analysis.
    The importance of safety is truly limited to stage talks, display of slogans and showcasing of awards, photos, reports and statistics. No doubt, without production and profit making, organizations can’t survive. The top management may be truly committed for safety. However, whether this has percolated to down below at all levels is the question.
    If a nearmiss/incident/accident happens, whether immediate investigation is carried out and discussed by top management is a check point. If not, then, the top management’s commitment for safety is not understood or received down below. Many times, occurrence of events having safety significance are not understood/recognized by shopfloor managers, not reported by shopfloor employees to their supervisors or do not come to their notice. And this is true at all levels up to the top management.
    If such incidents come to the notice even belatedly to higher ups, all concerned (shopfloor supervisor, manager, group head, safety officer, etc) should questioned by the top man for not reporting, investigating and implementing preventive measures. If this happens, then, I am sure that the message will go down to all levels. If not, then the commitment is only on paper and top man/management is responsible.
    Further, annual assessment and performance incentives have to be linked to reporting of nearmisses, incidents; proactive measures taken to improve shopfloor safety; daily pep talks; safety training programmes conducted by shopfloor manager (not by safety officer), etc apart from productivity. If any of these check points are not taken care by employees, then incentives should be reduced to spread the message of management’s concern for safe production.
    Regular safety audits (internal and external) have to be ensured and management should review on action taken within reasonable time.
    Role of safety professionals and regulators is limited as safety professionals require support from within and inspections by regulators are on sample basis and will not cover all areas.

  4. It is disappointing to read such a biased article…full of simplistic assessment of what is complex and multifactorial. This article offers no direction for the future other than to reinforce old prejudices and dated ideologies.

    Pointing the finger of blame rarely helps.

    Can we have an approach that is fact-based, even-handed and that applies solid research methologies to support a practical vision for the future?

  5. Then tell me

    John,

    why the Pike River commission of inquiry was the 12th of its kind in NZ? Why 21 warning about high levels of methane in that coal mine were not acted on decisively? Tell me why workers keep losing arms in unguarded machinery in Australia nowadays? Surely you don’t need ‘solid research methodologies’ to understand the fix to this?! Is that really all that ‘complex and multifactorial’?

    So far as the finger of blame goes: do you disagree with the conclusions of the Pike River coal mine Royal Commission? Or that of the Longford one? Or the conclusions of the Baker report?

    I hope that you accept that I’m genuine when I write that it would be pertinent to know exactly what you mean. I wonder if you’ be interested to provide some detail of your views here.

  6. In response to John Aps, the reason we have legislation, consequent law and prosecution of transgressors is to fairly point the finger of blame and it certainly would help a great deal more if examples were made of transgressors.

    The argument is basically very simple “BE ETHICAL AND COMPLY WITH THE LAW” sure there will always be genuine accidents but the hundreds of thousands of unguarded machines and other paraphernalia waiting to rip an arm off or similar along with other injury causing agencies, does very little to instill confidence that research methodologies will have any direct affect.on the reduction of injuries to any large extent.

    Even handedness you say, Tell that to the 1000′s of workers injured every year still waiting for the results of a myriad of reports to be action-ed that will stop their mates being injured.

    I’m with Yossi on this one.

  7. It may be fair to draw conclusions from Pike River, Longford and Baker about Pike River, Longford and Baker but it is quite a different matter to suggest that the failings therein identified apply to all organisations. While the difficult and complex tasks in managing organisations with significant hazards can be identified, what can be done to help those responsible to keep people safe. Blaming them, threatening them and punishment may create short term compliance but how can we build long term approaches that address the needs of all.

    I resist the temptation to simply blame and punish a few individuals and leave it at that.

    I know truly safety minded people at all levels of many organisations. Let’s try to help them with good research, solid data, effective education, coaching in the workplace and better ways of managing.

    Waving the rule book is only part of the answer that I would prefer.

  8. Even more egregious than the failures at Moura and Pike River, hard to believe though that may be, were those at Upper Big Branch in West Virginia that killed 29 men in April 2010. Management simply thumbed its nose at repeated citations from the regulators who were seemingly utterly toothless. Use of rock dust, for the best part of a century the accepted control to mitigate against coal dust explosions, was found to be deficient in 80% of samples taken after the explosion:

    http://en.wikipedia.org/wiki/Upper_Big_Branch_Mine_disaster

    http://www.msha.gov/Fatals/2010/UBB/PerformanceCoalUBB.asp

    http://s3.documentcloud.org/documents/96334/upperbigbranchreport.pdf

  9. Dr Yossi,

    Well said. This is so true.

    The only thing you didn’t say is that the main driver for engaging or not, compliance or non compliance or not caring is the almighty dollar.

    It drives so much and unfortunately the managers and supervisors of today can be hood winked.

  10. The rule book has been developed for a purpose and that is to reduce injuries in the workplace. Is that not the objective of all who have an interest in the promotion of safety?

    If we can’t play by the rules we should expect consequences and the rule book spells those out quite succinctly. Are we suggesting the rule makers and their myriad of specialist advisers have no idea of what constitutes a fair and reasonable approach to managing safety in the work place, I think not.

    Since the industrial resolution employers have been dragged kicking and screaming to the table to improve the lot of workers and nothing has changed that much particularly in the area of safety, so why would anyone think that employers will change attitudes. The only way an employer will be really proactive with safety is where a without doubt clear case is made for major cost benefit outcomes that are emphatically proven, that is the only incentive that will work and where the research money should be targeted.

    Create a no risk, win situation and you will change the attitude of the great majority of employers and the outcome for safety in the workplace can only be good, Then the non complying perpetrators can really pay the penalty of non compliance.

    Some times the answers can be simple and while the fiddling with after the fact statistics may have some effect on the fringes of the matter they are not in themselves, drivers of change. It will take a complete re-focusing of strategy to a different model to get this stalled safety vehicle moving again.

  11. Actually

    Bill,

    I think you’re onto something with the use of the terms ‘hood winked’. Given a choice between running a decent and safe workplace and a knowingly dangerous one I reckon most managers and supervisors would go for the safe one. You see why I sympathised with the worker’s comment that ‘the system was buggered’. The trick is to make it possible for managers – who know what’s going on – to insist on daily H&S standards they’d want for someone they loved. And that’s where the business of ‘hood winked’ could do with some accurate exploration.

    I think there’s something psychologically deep lurking in those terms used in this context.

  12. Not just small organisations but major ones. Look at the heavy penalties in the late 1990′s when the DuPont system was exposed for falsifying figures purely to make the system look so good.
    Had to deal recently with an HSE manager who had been in mining for over 23 years and had never once had to deal with an improvement notice (shades of extensive carpet sweeping!). Unfortunately the overt and covert pressure on personnel in so many ways is as rife today as it was 100 years ago in relation to reporting and industry leaders are to blame for this continuing. CEO’s who tell all the staff that their door is open, their email is available to bring concerns to them only for everyone to find out a few weeks later that various personnel who had taken that opportunity are no longer part of the workforce.
    Unfortunate as it is it still amazes me that companies – no sorry not companies, but the current crop of senior management, can think like this and in some cases the board and chairman are not aware as they are only being fed what senior management want them to hear, not the truth or reality. The advent of the various forms of WHS in OZ with the PCBU impact can only be a good thing to make management and boards wake up and accept the real responsibility. Unfortunately in some companies even getting HSE managers to promote the information to give guidance to the upper echelons is proving a hard struggle too.
    As Greg Smith recently said “HSE managers are managers too” and therefore are accountable. More power to this part of the OSH legislation.

  13. question

    why is it that employers have to pay their workcover premiums in advance but providers to workcover/worksafe are not paid for late payments for services rendered. recently we mentioned where a provider was paid 5 years or more after the provision of services

  14. Nice read
    It seems the more successful OH&S people are, the more problems we create.
    People get “safety fatigue”
    The longer we go without incidents the more complacent people become.
    Perhaps we need more synthetic, non lethal incidents to sharpen peoples focus

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