Root Cause and Camels Reply

In tertiary risk management courses, one is urged to look for “contributory factors” to an event.  An event can be a specific action or failure but a good investigation looks at the factors that led, or conspired, to the failure – “contributory factors” – as well as the failure itself.

For example, a common phrase is “the straw that broke the camel’s back” meaning a specific event that caused damage.  The common application of this phrase focuses on a single event in an already overburdened situation.

However occupational health and safety (OHS) expands this single event over time and work to analyse the cumulative effects on the camel of carrying innumerable straws.  It just so happened that one particular straw broke the camel’s back.

OHS is also about the cumulative effect of hazards on a company’s health.  There are a multitude of camels and a multitude of straws but the focus remains the same – investigate the combination of issues or hazards that culminated in an injury, event or disaster.

Decades ago investigators would look for a “root cause”, a phrase rarely applied in the technical discipline now but one that remains in common parlance.  However, root cause is not something that OHS professionals should forget or ignore.  A root cause can be an aim of an investigation but not one that dismisses other possibilities.  This may be why the term is out of vogue because it implies a fixation, an “Ahab”, which is a perspective that leads to very poor decision-making in all of the areas of work, business and life.

Kevin Jones

UK workplace fatality data 6

New UK workplace fatality data was released by the Health and Safety Executive (HSE) this week.  It provides an interesting comparison to the recent Australian data.

The HSE says that

“The provisional figure for the number of workers fatally injured in 2008/09 is 180, and corresponds to a rate of fatal injury of 0.6 per 100 000 workers.

The figure of 180 worker deaths is 22% lower than the average for the past five years (231). In terms of the rate of fatal injuries, the latest figure of 0.59 per 100 000 workers is 23% lower than the five-year average rate of 0.77.

Comparison with data from other EU countries over a number of years reveals that the fatal injury rate for Great Britain is consistently one of the lowest in Europe.

There were 94 members of the public fatally injured in accidents connected to work in 2008/09 (excluding railways-related incidents).”

The industries with the highest number of fatalities, in descending order, are:

  • Services sector       63
  • Construction           53
  • Manufacturing        32
  • Agriculture              26

Agriculture has the highest rate of death per 100,000 workers at 5.7

Kevin Jones

Nanotechnology safety – literature review Reply

Earlier in June 2009 The European Agency for Safety and Health at Work released a literature review entitled “Workplace exposure to nanoparticles”

Pages from Workplace exposure to nanoparticles[1]The EU-OSHA says

“Nanomaterials possess various new properties and their industrial use creates new opportunities, but they also present new risks and uncertainties. Growing production and use of nanomaterials result in an increasing number of workers and consumers exposed to nanomaterials. This leads to a greater need for information on possible health and environmental effects of nanomaterials.”

The report is available for download by clicking on the image in this post.

Kevin Jones

Trained first aiders in “low risk” microbusinesses Reply

WorkSafe contacted me today concerning some issues raised in a previous post concerning their first aid information. Some small tweaks have been made to that post but one point required elaboration.  There is some dispute over whether low risk micro businesses require a trained first aider.   Below is my position.

FIRST AID NEEDS ASSESSMENT

The First Aid Compliance Code discusses a first aid needs assessment.   In our experience of assessing scores of workplaces, large and small, for first aid needs (including over 28 McDonald’s restaurants but that’s another story), we are convinced that a workplace that relies on others to provide an acceptable level of emergency first aid response would expose the employer to avoidable legal issues.   Unless, of course, one relies on “as far as is reasonably practicable” after someone may have been seriously injured or died on your premises.  It is doubtful that the relatives of the deceased would be so forgiving.  (Consider the actions of concerned relatives following the Kerang court case decision.)

Ask yourself, is it better to have a trained first aider on site just in case, or rely on an ambulance being readily available and render no assistance?

Time is crucial in an emergency, with the risk of a person’s condition becoming more serious the longer treatment is delayed.  Emergency ambulances, even in metropolitan areas, can be delayed and, in an emergency, waiting with an unconscious and/or non-breathing person will seem an eternity.  Any delay in rendering appropriate first aid treatment will complicate proving that an appropriate duty of care was applied in the circumstance.

The Australian Resuscitation Council has made its guidelines available online. For those interested in establishing an appropriate level of first aid response for their workplaces, the guidelines are recommended to read.  But more importantly is the need to have suitably trained first aiders on site, particularly after an assessment of the workplace’s  first aid needs has been conducted.  A first aid kit is next to useless if CPR is required.

Of course, the need for first aid is minimised if all the other OHS matters are dealt with first in an orderly safety management system.

Kevin Jones

New Australian OHS statistics Reply

Safe Work Australia released two OHS statistical reports in June 2009 – Mesothelioma in Australia, Incidence 1982 to 2005, Deaths 1997 to 2006 and Notified Fatalities Statistical Report, July 2008 to December 2008.

Both reports are recommended for those statistic junkies out there as the analysis and trends are sadly illustrative, however some of the highlights, if they can be called that, are:

  • In 2005, the age-standardised rate of new cases of mesothelioma was 2.8 per 100 000 population.
  • In 2006, the age-standardised rate of death due to mesothelioma was 2.3 deaths per 100 000 population.

The death rate has remained stable.

MESOTHELIOMA IN AUSTRALIA
INCIDENCE 1982 TO 2005
DEATHS 1997 TO 2006

More detailed information is available in the fatalities report however below are some main findings

There were 88 notified work-related fatalities.

The majority of fatalities were male.

Workers aged 55 years and over accounted for one-fifth (20%) of worker fatalities.

Four industries accounted for over three-quarters of all notified work-related fatalities, in descending order:

  • Agriculture, forestry and fishing,
  • Construction;
  • Transport and storage;
  • Manufacturing

The most common causes of work-related fatalities were, in descending order:

  • Vehicle accident;
  • Being hit by moving objects;
  • Being hit by falling objects;
  • Drowning/immersion; and
  • Falls from a height.

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Worker health continues to get government support Reply

Just because Victoria’s WorkHealth program is not functioning anywhere near its initial intention, it does not mean that the issue of workers’ poor health is being ignored.  In mid-June 2009, Australia’s federal government announced a targeted program called the Tradies Tune-Up.

The funding for this program is very modest in comparison with WorkHealth’s proposed riches.  According to a media statement, the government is allocating $A219,500 to “monitor and check on the health of building and construction workers.”  This sector was chosen because statistics show

“…that men working in manual occupations, like construction, have higher mortality rates, disability and serious chronic disease than other professions.  Statistically, they are also at greater risk of self-harm and suicide.”

This program has a greater opportunity for success as it is coordinated through  OzHelp Foundation, a partnership between the ACT branches of the Master Builders Association and the Construction, Forestry, Mining and Energy Union.  The construction unions, to the knowledge of SafetyAtWorkBlog, have always had strong mental health and wellbeing support programs, often run through chaplaincies, a much neglected form of employee assistance program.

As has occurred elsewhere in Australian workplace services, the program will operate with the support of a mobile assessment vans.  The program will have

“a specially equipped van and accompanying health staff including a registered nurse will set-up ‘pit-stops’ at construction and building sites testing workers in 20 minute sessions on their levels of cholesterol, blood pressure, blood glucose and waist size.”

The government has also committed to develop a National Men’s Health Policy to be finalised later this year.

Health assessment programs that go to the workplace and, importantly, have the support of the union movement have a good chance of success but that success is not just the number of visits.  They must have tangible health improvements to the workers.

Also assessments are not enough to simply inform someone they are fat and unhealthy. There must be a support program for health improvement and the reduction of unhealthy distractions.

OzHelp should not be seen as a Rudd government initiative or only something that can thrive under a sympathetic Labour government.  The foundation has existed for almost five years as can be seen by this media statement.

Such programs also must operate with specific performance benchmarks.  Currently there is no information available about program benchmarks or what timeline is being applied to the program.  As the  program is receiving government funding, it may be necessary to await for department annual reports, if this type of program is reported at all.

Kevin Jones

Flawed first aid information Reply

First Aid Complaince CodeSome time ago WorkSafe Victoria issued Compliance Codes on a number of workplace safety issues.  One was concerning First Aid.  The Compliance Codes were intended to replace Codes of Practice which had been around for decades.

The previous major change to workplace first aid was in 1995 when the First Aid Code of Practice was reviewed in Victoria.  Other Australian States vary between prescriptive and non-prescriptive first aid guidelines.

On 31 May 2009, WorkSafe released a factsheet on first aid for low risk micro businesses.  A low risk micro business is explained in the factsheet as those that

  • employ fewer than 10 people
  • are located where medical assistance or ambulance services are readily available
  • are businesses that don’t expose employees to hazards that could result in serious injuries (eg serious head injury, de-gloving, scalping, electric shock, spinal injury) or illnesses that may require immediate medical treatment.

First Aid for Low Risk Micro BusinessesSome examples of low risk micro businesses were included in the factsheet –  “retail shops and outlets, offices, libraries and art galleries” Why a one page information sheet for this sector was deemed to be needed is a mystery?  I asked WorkSafe several questions about this factsheet

  • What was the rationale for the production of this guidance for this sector? Given that the Compliance Code is specifically referenced.
  • Is retail really a low-risk micro-business?
    • What about the use of ladders?
    • Young workers?
    • Working alone or unsupervised?
    • Occupational (customer) violence?
    • Petrol stations?
    • Convenience stores?
    • Night shift security needs?
    • Knife cuts from removing stock from boxes?
    • Manual handling?
  • First aid kits are required but not first aid training. In the case of respiratory failure a first aid kit is next to useless for CPR.
  • Why is only St John Ambulance referenced on the guidance?

The factsheet misunderstands first aid by placing low risk microbusineses into the “paper-cut” sector.  This is doing micro-businesses a dreadful disservice.

TRAINED FIRST AIDER

Shortly after the First Aid Compliance Code was released St John Ambulance broadcast an email about workplace first aid compliance.  In that email St John wrote:

Low risk organisations (office, libraries, retail etc) should have at least one qualified First Aider for 10 to 50 employees…

The May 2009 fact sheet makes no mention of the need for a trained first aider but WorkSafe’s own Compliance Code states this as a compliance element.

A low-risk micro-business may not generate the potential hazards that WorkSafe lists in its definition above but employees in these businesses do have to respond to the injury needs of their customers.  In these times of public liability and the expansion of OHS obligations to include customers, neighbours, and others who are affected by work processes.

WorkSafe itself describes an employee’s duty of care:

“All workers have a duty of care to ensure that they work in a manner that is not harmful to their own health and safety and the health and safety of others.”

The omission of a trained first aider is unforgivable.  What would an employee do if a client collapses in the foyer of a convenience store with a heart attack or chokes on the food that they have just purchased?  What would one do if a stab victim stumbles into the only open retail outlet, perhaps a petrol station, at 2.00am? How would that petrol station attendant  treat someone who has had petrol accidentally splashed in their face?

These matters cannot be treated by a person who is untrained in basic first aid who only has a first aid kit available.  Training for all workers who work alone or in isolation in micro-businesses is a basic element of compliance, one that WorkSafe fails to list in its latest workplace first aid factsheet.

EMERGENCY NUMBER

Almost as unforgivable is that the factsheet makes no reference to the Australian emergency number of 000.  One of the first actions to be performed in a workplace where someone is seriously injured is to call for an emergency ambulance.  While waiting for the medical authorities, and if safe to do so, first aid should be rendered. WorkSafe needs to remember that CPR requires training and that a first aid kit is next to useless in this type of situation.

ST JOHN AMBULANCE

It is curious that only St John  Ambulance is listed on the factsheet for further information.  There are many first aid equipment and training providers in Victoria.  It would have been fairer to either recommend all providers or none at all.

[UPDATE: WorkSafe has advised SafetyAtWorkBlog that they will be addressign the St John Ambulandce and 000 issues raised.]

COMPLIANCE CODES

On 18 September 2008, the WorkSafe website described the First Aid Compliance Code as covering

“…first aid arrangements including first aid needs assessment, first aid training, first aid kits and first aid facilities.”

In a media statement at the time on compliance codes generally WorkSafe Executive Director, John Merritt was quoted:

“The codes were developed after extensive consultation with industry, employers, employees, governmental agencies and the community to provide greater certainty about what constitutes compliance under the OHS Act.”

“The codes include practical guidance, tools and checklists to make it easier for duty-holders to fulfil their legal obligations.”

Mr Merritt added that: “These codes will provide Victorian employers, workers and Health and Safety Representatives with certainty and assistance in meeting their responsibilities.”

The Compliance Codes are aimed at the many dutyholders yet one of the rationales for the new single sheet guidance is that dutyholders (employers) do not read Compliance Codes.  It seems that the Codes are now principally read by OHS professionals and advisers.

(This position may be one of the reasons WorkSafe is pushing so hard for a truly professional OHS structure through its HaSPA program – the establishment of an OHS middleman between the rules and their application in the real world.)

It is a considerable change to the readership the Compliance Codes were aimed at and is a substantial change from the Codes of Practice which, in the case of First Aid, were handed out to all first aid trainees, included in information kits for health & safety reps, and were read by dutyholders and integrated into their OHS management practices.

The significance of Compliance Codes and Codes of Practice at the moment is that these documents are to be part of the Federal Government’s move to harmonisation of OHS laws.  (Some eastern States have already begun joint publication of guidances). Variations in these documents, often the most referred-to OHS documents in workplaces across the country, will undercut the aim of harmonisation – the reduction of business compliance costs through harmonised OHS requirements.  If the practical application of laws are not harmonised, the aims will never be met and the process could be seen as seriously flawed.

Kevin Jones

Integrating climate change impacts into OHS and business management 1

Today the European Policy Centre in Brussels released the report Climate change: Global Risks, Challenges & Decisions. The findings of this report do not directly affect workplace safety but do indicate new ways in which businesses must manage the economic and social hazards that climate change produces.  These new ways of management must be anticipated and understood by OHS professionals.

Synthesis Report Web coverThe report says that

“Linking climate change with broader sustainable consumption and production concerns, human rights issues and democratic values is crucial for shifting societies towards more sustainable development pathways.”

The need for integrated management of business has never been greater.  The common threat of climate change can only be met with a business strategy that embraces the reality of the threat and has this reality on the table of all business discussions – a desire that many professionals have also been pushing for OHS for years.  The boardroom and management tables are becoming full of issues that some see as competing but are in truth complementary.

The report discusses two types of action that can be taken.  Businesses that produce large amounts of carbon should be well involved with mitigation measures and the political policy frameworks.  Other businesses can benefit substantially from adapation, that is

“…whereby society increases its capacity to cope with the impacts of climate change, so far as possible.”

The report gives developing countries a particular focus for adaptation but the concept is equally relevant, and perhaps more easily implemented, in Western countries.

“Adaptation to climate change cannot be successfully implemented if treated as an “add on” and implemented separately from other initiatives aimed at fostering economic and social development and increasing the resilience of societies.”

Climate change is altering the statistical possibilities of worst-case scenarios.  The one-in-a-million is becoming the one-in-a-thousand.  The once-in-a-hundred-years is becoming once-in-a-decade.  The rapidity of change and the greater extremes and fluctuations of these events are changing the way projects are handled, costed and managed.  These fluctuations will challenge the way that safety is managed and are broadening the scope of the profession.

OHS needs to be seen as a discipline that is as multi-faceted as risk management, as human as human resources and as responsible as corporate social responsibility.  The OHS professional will remain focused on the safety of employees but what used to be on the periphery is now moving to the centre – climate change, business continuity, infectious disease pandemics, travel, risk management, shareholder expectations, quality, auditing, governance and accountability, to name a few.

And none of these issues can be dealth with without an integrated and adaptive approach, an approach that can provide more wide-ranging social benefits than ever before.

Kevin Jones

Tasers as personal protective equipment 2

SafetyAtWorkBlog supports the use of tasers, or stun guns, as a control measure that eliminates or reduces the chances of a police officer being seriously injured but concerns continue around the world about the application of tasers. In 2008 the New South Wales government came to a decision of sorts on tasers.   Following the recent death of a man in Queensland from a taser, the focus has shifted to that States.

In an OHS context tasers could almost be considered a piece of active personal protective equipment (PPE), if there can be such a thing.

Recently Dr Jared Strote of the Division of Emergency Medicine at the University of Washington Medical Center said

“It is fairly clear that the use of TASERs on healthy individuals is rarely dangerous (there are hundreds of thousands of uses in the US without serious outcomes). The question is whether there is a subset of people for whom there is a higher risk.

The problem is that the individuals who have died in custody temporally associated to TASER use are the same types who are at higher risk of death during police restraint no matter what type of force is used.”

Dr Strote also illustrates the cost/benefit issue that OHS professionals must deal with constantly

“The issue is probably less whether or not TASERs can cause death (they probably can but very infrequently); the better question is whether their net benefits (potential to avoid using more lethal weapons (like firearms), potential to decrease risk to officers, etc.) outweigh the potential costs.”

Two studies by Dr Strote – “Injuries Associated With Law Enforcement Use Of Conducted Electrical Weapons” and “Injuries Associated With Law Enforcement Use Of Force,” were presented at a forum in New Orleans in mid-May 2009.

A UK expert, Dr Anthony Bleetman, a consultant in emergency medicine says

“Tasers have been used on human subjects probably about a million times, some in training and a lot in operational deployment. With any use of force there is a risk of death. But when you look at the big picture the death rate after Taser is no higher than with other types of force. But what we do know is that there is a certain type of individual who is at greater risk of death after police intervention – the so-called excited delirium state where somebody, usually a male in their 20s or 30s, often with a psychiatric history, often on illicit drugs or psychotropic drugs, has been in a fight or pursuit, physically exhausted, not feeling pain, dehydrated and hypoxic. And then you add on top of that physical restraint by police. These are the ones that die and they die whether you Taser them or don’t Taser them.”

Bleetman explains the role of tasers in comparison with other active PPP:

“Police officers have a whole spectrum of options to use in force from talking to people to laying their hands on people to using capsicum sprays, batons and dogs. And then there’s a gap until you get to firearms when you shoot people. So between batons, dogs, sprays and guns, Tasers sit quite nicely to use against people who are so agitated and so dangerous to themselves and others that the only way to take them down is something as lethal as a gun or as dangerous as a police dog.”

Many American studies and statistics must be treated with caution as tasers are readily available to the general public and therefore operate unregulated. However in 2005 the American Civil Liberties Union undertook a study of law enforcement agencies. According to an Associated Press report from the time written by Kim Curtis:

“The ACLU surveyed 79 law enforcement agencies in Northern and central California, according to spokesman Mark Schlosberg. Of those, 56 use Tasers and 54 agencies provided the ACLU with copies of their training materials and policies regarding stun gun use. Among the organisation’s major concerns was that only four departments regulate the number of times an officer may shoot someone with a Taser gun.”

This last point has been one of the most contentious points of the recent case in Queensland where a police taser was discharged 28 times.

Taser use is a very complex issue, as are most PPE and OHS issues when dealing with emergency services. It may be possible to take some hope from the deterrent effect of tasers identified by the Delaware State Police in some recent budget papers:

“We have encountered numerous incidents where the mere presence of the Taser on the troopers’ belts has discouraged defendants from resisting arrest.”

Kevin Jones

Prophet and Loss – review Reply

I bought tickets to the Jane Woollard play Prophet & Loss in almost totalProphet & Loss 002 ignorance of the play and, as a result, sat in the old church on a cold Winter’s night wondering what I was in for.  The program was detailed but I hadn’t time to read it.  I knew the play was about issues related to workplace death.  That’s the “loss”.  The “prophet” was Isaiah and that was the element that I could not understand without later reflection.

However, finding out about Isaiah could wait till we got home and then we could research a further dimension to what we saw.  The stories that told of the impact of workplace fatalities on families and workmates were compelling although a couple were familiar to me.  They told of bureaucratic confusion, the disinterest of insurance company call centre staff, the psychological legacy of a traumatic death and the inability to understand the survivor experience without having experienced it firsthand.

The venue was small but high and so the actors were close and the pain and grief was well presented.  All of the actors were very good even though I was sure I had seen one of them before somewhere.  It wasn’t till I looked at the program that the actor who looked like Helen Morse was indeed Helen Morse.

The stories’ subjects were frustrating and bleak, there is little opportunity for humour on this topic, but there was opportunity for theatricality and motion.  Fanny Hanusin broke the rhythm with her portrayal of Merpati who was hyperventilating in panic over the lack of understanding of her situation.  As Glynis Angell, the grief counsellor, Merrilyn, began breathing slowly to decrease Merpati’s panic, most of the audience were breath along.

All of the actors interchanged roles, with each taking a turn as an overcoated Isaiah writing on the wall and speaking ancient Hebrew (I later found out).  The role changes worked well on reflection but I could not work out the thematic structure of the play until three-quarters in.  The different outfits, the stories, Isaiah, were all confusing because the pairing of the characters with the stories took too long to establish.  I am not a great wearer of hats but the different characters could have been more readily identified by the audience with hats, as well as the changing of clothing.  Hats are more visible and illustrate different identities more clearly.  It may have shortened my confusion.

What differentiated this play from a series of monologues, given that I didn’t understand the Isaiah context, was the music.  The soloist, Deborah Kayser, the seraphim, sang beautifully and the acoustics of the venue were ideal although the 13th century language was totally lost on me. (A sample of Kayser’s singing can be heard online) I have never heard a double bass played to such beautiful effect as was played by Nick Tsiavos.  The depth of sound from a bow on bass could be felt in one’s chest and how he was able to pluck and stroke those strings at the same time was a mystery until he came into the light in the second half.

Kayser and Tsiavos, the seraphim, were a musical Greek chorus to the tales of grief and frustration.  This role was perhaps emphasized by their wings which were effective but initially confusing.  Kayser introduced the play in character with words that were cryptic but set the tone for the play.

The staging was effective in its industrial appeal and the use of 44-gallon drums as props and seats worked.  Early on the actors slowly rotated these drums to provide a chilling sound which I was hoping for more of throughout the play.

Each character laid out the clothes or uniform of their deceased loved one through the play, providing a useful personal profile that complemented each story.  I recall one character had worn her partner’s clothes for three days in a grieving intimacy.  She would only relinquish the clothes when they no longer smelt of her partner but now of her.

The play was being performed at the Centre for Theology and Ministry near the University of Melbourne for a limited season and as a lead-in to a major theological conference.  The play was supported by the Creative Ministries Network that provides a counselling service for those affected by workplace fatalities.

Prophet & Loss could travel well with its combination of an occupational/social theme, beautiful music and faith.  Please look out for it.

Kevin Jones