Coronial report into insulation deaths slams government actions

This week a Queensland Coroner brought down the findings into the deaths of three men, Matthew Fuller (25), Rueben Barnes (16) and Mitchell Sweeney (22). Each of these men were electrocuted whilst installing foil insulation in the roofs of Queensland houses as part of a Federally funded economic stimulus project during 2009 and 2012.

Since the Coroner’s findings were published on 4 July 2013, the Australian media has focussed its attention, principally, on Kevin Rudd.  Rudd was the Prime Minister and a major motivator at the time for the stimulus package, named the Home Insulation  Program or HIP by the Coroner.  Rudd recently regained the Prime Ministership providing a fresh political newsworthiness to the HIP issues.  But in this attention, the Coroner’s broad findings are often being overlooked.

According to the findings:

“The investigation into the deaths revealed, among much else, that:

• The deaths of Matthew, Rueben and Mitchell occurred between October 2009 and February 2010, in the context of a Program, which resulted in over one million homes being insulated in almost exactly a year.
• The three deceased were low-skilled installers with limited experience and minimal supervision.
• Foil laminate insulation and metal staples were in use in 2 of 3 of the deaths.
• Power was not turned off in the work space, in any of the houses involved.
• The aim of the HIP was to secure a fast roll-out and allow for low-level entry of workers, subject to appropriate supervision and skill level of the supervisors, together with the surveillance thought to be offered to this large-scale venture by the regulatory safety framework offered by the States and Territories.
• At the outset of the HIP the significance of electrical risk was not appreciated. It took Matthew Fuller’s death for this to occur.
• The supervision requirements under the HIP were not defined. As a result the supervision of untrained and unskilled workers was not to the standard assumed by the HIP.
• While industry and DEWHA [Department of Environment, Water, Heritage and the Arts] recommended mandatory specific training for all new entrants into the industry in the planning stages of the program, this did not occur due to the tight timeframe in which the program was to be rolled out.” (page 2)

The occupational health and safety shortcomings are clear even from this summary of the findings:

• workers had insufficient knowledge of the work tasks,
• there was minimal supervision,
• metal staples were used without the electricity power supplies being disconnected to the homes,
• the “fast roll-out” did not allow sufficient time for planning for the safe operation of the program,
• the electrical risk involved was known but “not appreciated”,
• training was inadequate.

If safe workplaces are best achieved through leadership and safety in design, this program was damned before it started.

In 2010 SafetyAtWorkBlog pointed out the hypocrisy of the government and Prime Minister on the HIP.   Safety was not the number priority of the program.

Although the summary of findings is above, it is important to look at the full text of Coroner Michael Barnes’ recommendations to better understand where he sees the faults and responsibilities to lie:

“While the evidence indicates it was primarily failings in the planning and implementation of the HIP by Commonwealth agencies that led to an increased risk of harm, state-based workplace safety agencies failed to proactively respond to that increased risk and no review of why that occurred or how it will be avoided in future has been undertaken. Accordingly, I recommend the Office of Fair and Safe Work Queensland undertakes such a review.” (page 73)

Three years after the program led to deaths, the State OHS regulator has failed to review its own role and conduct.  This is extraordinary and may indicate how politics can overwhelm and distract from good management.  It may also be that with so many accusations of blame being flung around at the time, keeping a low profile may have been advised.

Significantly, the primary failings, some may say root cause, were with the Commonwealth agencies who planned and implemented HIP.  Prime Minister Rudd may have instigated the economic stimulus policy but it was government agencies who interpreted the policy into a strategy.

The legitimate criticism of the Prime Minister would be the urgency he allocated to having the policy implemented.  And, guess what, proper safety management was sacrificed for speed, as has been seen in umpteen corporate disasters and workplace fatalities.

“In view of the apparent lack of awareness of the risk of electrical shock inherent in entering a residential roof space and the various measures available to manage that risk, I recommend the Office of Fair and Safe Work Queensland undertake a public awareness campaign giving guidance as to how home occupiers and relevant tradespeople can minimise their exposure to that risk.” (page 73-74)

Domestic roof space is rarely thought of by the resident and an awareness campaign is warranted but this is an administrative control and needs to be supported by more effective risk control measures.  The Coroner backs this control up with an investigation of Residual Current Devices on domestic homes.

“The various options for the extension of the requirement for the mandatory fitting of RCDs involve the balancing of the costs involved against the resulting improvements to electrical safety. The State Government is best placed to assess the competing policy considerations with expert advice from the Electrical Safety Office. I recommend the matter be actioned as a matter of urgency.” (page 74)

RCDs are a proven technology and the Coroner could have recommended their mandatory introduction but RCDs do not remove all risks and imposing mandatory safety devices in domestic homes is not foolproof as the initiative on smoke detection devices has shown.

Governments at both State and Federal level deserve Coroner Barnes’ criticism over the deaths of these three men.  However it is difficult to see that safety will not again be sacrificed for other agendas.  There are many tragedies in the HIP story (a story that deserves to be a book, in my opinion) but perhaps the most tragic is that where companies and CEOs are increasingly to be held to legally accountable for their actions and decisions that could lead to workplace deaths, politicians are not.

Kevin Jones

Below is a list of links to earlier SafetyAtWorkBlog articles around safety and the home insulation program in a rough chronological order:

The Safety of Green Jobs

Unintended consequences of inadequate preparation

Workplace deaths lead to reforms but not of workplace safety

Australian employer groups are out for blood

Small business OHS shortcomings

Public relations, OHS and a workplace death

Industrial Manslaughter mentioned in Australia’s Parliament

Non-mainstream media acknowledges the realities of workplace fatalities

“For the government, safety has always been the number one priority” – Really?

Too big to be held accountable?

What can OHS professionals learn from government program failures?

A safe (social) system of work

Tooma takes aim at the Environment Minister over accountability

Gov’t responds to insulation installer’s death

Missed OHS issues in insulation debate

Insulation debate shows flaws in OHS harmonisation plans

A sparky’s take on roofing insulation risks

Risk assessment report – insulation

New safety alerts for foil insulation

If safety culture begins at the top, what message is the Australian Government sending on insulation installer deaths?

First prosecution announced over insulation-related deaths

The politics of the insulation debacle become clearer

More OHS charges laid over insulation installer deaths

Company pleads guilty over insulation installer death