Learning Lessons from the Santika Nightclub Fire Reply

For many years SafetyAtWorkBlog and its forerunner Safety At Work magazine reported on various tragic fires in crowded nightclubs around the world.  Several in recent memory include the 2003 Rhode Island fire that killed 100 patrons and for which, according to an Associated Press report from the time,

Superior Court Judge Francis Darigan Jr sentenced 29-year-old Daniel
Biechele to 15 years, but suspended 11 years of that sentence, and
also ordered three years of probation.

“Superior Court Judge Francis Darigan Jr sentenced 29-year-old Daniel Biechele to 15 years, but suspended 11 years of that sentence, and also ordered three years of probation.”

A brief report on the Rhode Island fire is in the OSHA media archives.

In March 2006, Safety At Work included an AFP report saying

“The municipal council has impeached Buenos Aires Mayor Anibal Ibarra after finding him guilty of dereliction of duty following a December 30, 2004 nightclub fire that killed 194 people.”

An earlier report on the mayor’s response is include at the CrowdSafe website.

Engineering and design company ARUP have provided SafetyAtWorkBlog with an article that analyses recurring elements of nightclub fires using the Santika fire in Bangkok from 1 January 2009 as a most recent incident.  Below is the introduction to the article which can be found in full in the pages listed above.

Our thanks to ARUP for the terrific article.

Kevin Jones


by Dr Marianne Foley and Travis Stirling, Arup Fire, Sydney

In the early hours of New Years Day 2009, fire engulfed Bangkok’s Santika nightclub, killing 64 people and injuring more than 200.  Our knowledge of the events of that night is based on media reports and publicly available information, and the precise cause of the fire is still unclear.  However, we do know that there are strong correlations between this and many similar tragedies at entertainment venues dating back as far as the first half of the twentieth century.  While we wait for the results of the official investigation and coronial enquiries, it’s timely to ask questions about these fires.  Why do they happen over and over again?  Why do so many people lose their lives?  What lessons can be learnt?  And what practical measures can be implemented to stop them happening?


Arup’s analysis of case studies has revealed six themes that commonly contribute to the severity of high-fatality nightclub fires: insufficient exits, the presence of highly flammable materials, a lack of good fire safety systems, confusing environments, pyrotechnics and open flames, and buildings used inappropriately and maintained poorly.  By addressing each of these themes, we aim to provide design solutions that could mitigate the risk of future nightclub disasters.

[The themes in the full article are

  • Insufficient exits
  • Highly flammable materials
  • Fire safety systems
  • Confusing environments
  • Pyrotechnics and open flames
  • Buildings used inappropriately or maintained poorly]

Vehicles are workplaces too 1

Radical Concept 1 – A vehicle can be workplace

Today the Australasian New Car Assessment Program (ANCAP) urged fleet managers to consider OHS obligations in their choice 0f work vehicles.  ANCAP said

“Our understanding of the OH&S principles is that there is an obligation on companies and fleet managers to ensure a safe workplace.

“Vans certainly constitute a workplace under the legal definition. We would urge fleet purchasers to examine the legislation and then factor safety into their fleet purchasing policies.”

But in practice this creates enormous challenges for the fleet manager who may only have chosen vehicles in the past that were fit-for-purpose without considering the needs of the driver.

Only recently have steps been added to trucks to allow for easier access to goods on the rear trays.  When technology became affordable tilt-down hydraulic ramps were installed, although these have their own work hazards. In both of these examples the changes occurred outside the cabin and related to accessing the transportable products.  Looking after the physical and psychological needs of the driver as a worker is different.

For instance, emergency fire appliances in Australia have had substantially improved design over the last ten years.  Many of the features are for the benefit of drivers and passengers, such as flip-out steps  for when the vehicle is stationary or special seating to allow for personal protective clothing.  But the cost of each of these new “safer” vehicles is such that the introduction is phased in and most likely as replacement vehicles.  This process could take years.  How can a workplace justify allowing only some workers to use “safer” workplaces?  The churn of vehicles could establish an inequitable safety standard ion the workplace.

ANCAP’s argument seem to be that a fleet manager who chooses a vehicle that does not have the  highest level of safety available are not providing a safe workplace.  We could be back to determining what is reasonably practicable.

Radical Concept 2 – A road can be considered a workplace.

Some bus drivers consider their regular route to be a workplace.  To some extent this is supported by the road traffic authorities who only allow certain speed control mechanisms on the roads that have bus traffic, such as speed islands rather than speed humps.  Although this may be due to the needs of not knocking the passengers around as well.

Regardless of the whether it is passenger safety, pedestrian safety or public liability insurance that creates these design decisions, bus drivers take some “ownership” of their routes.

Important Consideration 1 – Vehicles have drivers

A lot of attention has been given to driver distraction and how drivers drive.  Not only are there distractions from within the cabins from passengers, radios, phones, cigarette smoking and a range of driving activities, the relationship between external signage and driver response has also been high.

The complexity of the distraction issue can perhaps be summarized by a couple of recent links. In July 2009 a roadside memorial to a fatality itself is identified as having contributed to a fatality.  Research in the United States has begun on the impact of roadside memorials but at the moment the jury is out.

“Our results showed that the number of red light violations was reduced by 16.7% in the 6 weeks after the installation of the mock memorials compared to the 6 weeks before whereas the number of violations at two comparison sites experienced an increase of 16.8%.”

Managers, fleet and OHS, also need to assess the suitability of their workers for driving and consider the following matters.

  • Companies have an obligation to induct new workers.  Do companies induct new drivers on their vehicles or is a valid driver’s licence deemed sufficient?
  • Is a driving licence a certificate of competence?
  • Is a worker’s driving record considered when employing them?  Would one employ a driver whose record shows a propensity for speeding?
  • Are driving applicants asked whether there is a history of road rage?
  • How many demerit points are left on their licence when employed?
  • For car driving the same licence is used for personal vehicle use and driving work vehicles.  What would happen if the worker has their driver’s licence suspended thereby ending their capacity to drive for work?
  • It would be necessary to clarify in what circumstance transport accident insurance applies and when injuries relate to workers’ compensation?
  • Who should investigate a traffic incident involving work vehicles – the OHS regulator, police or some other authority?
  • Are traffic incident statistics collected for work-related vehicles?

Perhaps ANCAP could begin looking not only at the design of vehicles and additional safety features but also how these matters affect a driver’s perception of their own safety.  Does the elevation of the driver compared to other vehicles change the way the driver drives?  Could the safety features encourage the driver to drive recklessly?  Is technology deadening the driver’s instincts?

Similar questions have been posed in the occupational field for decades in relation to the operation of plant, the safe design of workplaces and the types and locations of safety signage.  Now these concepts must be considered for the mobile workplace.  Many will find this process challenging with some thinking that it is just another grab by the OHS “fascists”.

The issues do need considerable discussion in workplaces.  The recent WorkSafe Victoria “Guide to safe work related driving” is a good starting point but for the development of appropriate policies and, more importantly, to affect cultural change on the matter, companies require an elaboration by traffic authorities and from groups like ANCAP.

Kevin Jones

Depression and workplace stress rehabilitation 1

In January 2009, SafetyAtWorkBlog reported on the end of a political saga involving parliamentarian Paula Wriedt.  Ms Wriedt has since become a spokesperson for the treatment of depression and on 10 August she spoke with the Australian Broadcasting Corporation about more resources for the treatment of mental health issues in the young.

Kevin Jones

Do health professionals make the best OHS leaders? Reply

David Michaels has been nominated by President Obama as the new Assistant Secretary for the Occupational Safety and Health Administration in the Department of Labor.  (A brief profile of Michaels is available HERE.)  A posting at a US Workers’ Compensation website links through to a discussion on the potential impacts of the Michaels’ appointment.

There are several telling quotes in the podcast.  Sidney Shapiro, a law professor at Wake Forest University, says that OHS achieves more when run by someone with a health professional background.

“…I think it’s important that we know that David Michaels is a health professional.  And I think OSHA’s done best when it’s had administrators from the public health community.  It is, after all, a public health agency.  More times than many of us would wish, it’s been headed by someone who’s been an adamant critic of OSHA and has come from industry or been an industry lawyer.”

Whether this position can be applied to regulators in other jurisdictions is an interesting question.

The Chair of the UK HSE Board, Judith Hackett,  has a background in petrochemicals.  The CEO of the HSE, Geoffrey Podger, has a background in the civil service, health and food safety.   The chair of the Safe Work Australia Council, Tom Phillips was the former CEO of car manufacturer, Mitsubishi, and has served on a range of industrial company boards in South Australia.  The Chair of WorkSafe BC board, Roslyn Kunin, harks from human resources and the labour market.   Greg Tweedly CEO of WorkSafe Victoria has a background in insurance and compensation.  Nina Lyhne of WorkSafe WA comes from road safety and compensation.

This unrepresentative sample shows a mix of experience and not all from health promotion.  If the list was comprehensive, it would be interesting to see if Shapiro’s comments stack up and to see how many trade union officials have moved to “the top” or will simply remain “on the board”.

The Living on Earth podcast includes the following quote from Michaels from some time ago:

“What polluters have seen is that the strategy that the tobacco industry came up with, which essentially is questioning the science, find the controversy and magnify that controversy, is very successful in slowing down public health protections.  And so the scientists who used to work for the tobacco industry are now working for most major chemical companies.  They don’t have to show a chemical exposure is safe.  All they have to do is show that the other studies are in question somehow.  And by raising that level of uncertainty, they throw essentially a monkey wrench into the system.”

This statement could generate optimism for OSHA’s future but there are many examples of the views of environmentalists changing once they move into the corporate world.  Politicians like Australia’s Minister for the Environment, Peter Garrett, is an obvious recent Australian example.  Harry Butler in the 1970s was roundly criticised for “selling out” to the petrochemical industry.

However, the appointment of David Michaels pans out, it will be an interesting one to watch, particularly if the US Democrats can stay in power for more than Obama’s two terms.

Kevin Jones

Firefighter trauma 5

A major element of risk management  is business continuity.  This requires considerable planning, disaster recovery resources, and a long-term focus.

In early 2009 parts of Victoria, some not far from the offices of SafetyAtWorkBlog, were incinerated and across the State over 170 people died. In a conservative western culture like Australia, the bush-fires were the biggest natural disaster in living memory.

The is a Royal Commission into the Victorian Bushfires that is illustrating many of the disaster planning and community continuity needs in risk management.

The Australian Broadcasting Corporation’s “7.30 Report” provided a report on 5 August 2009 which originates from the views of the community and the volunteer firefighters.  One of the issues relevant to safety professionals and risk managers is the psychological impact on volunteer workers.  Many in the report talk of trauma.  Many in the disaster areas have not returned and their are many who remain psychologically harmed.

When a workforce is so closely integrated with a community, rehabilitation is a daunting task and changes a community forever.

Overseas readers may have experienced their own natural disasters such as hurricane Katrina, earthquakes, floods and wildfires.  Many of these stories are reported around the world.  In the recovery phase of any disaster, businesses need to rebuild but are often rebuilding with damaged people.  It would be heartening to see the OHS regulators and OHS professions becoming more involved over the long recovery period.

Kevin Jones

Share Solutions for the 21st century 1

SafetyAtWorkBlog has received several enquiries around the Share Solutions mentioned in an August 5, 2009 blog posting.  Coincidentally overnight WorkSafe Victoria released one of its “Health and Safety Solutions” dealing with falls through cellar trapdoors in the hospitality industry.

HSS0076-Hospitality-Preventing-1167006770801531700000000000000000000000000000000000000000000000000000000000000000000000000000.000000allsthrough                   ellartrapdoors_Page_148135104HSS0076-Hospitality-Preventing-1167006770801532000000000000000000000000000000000000000000000000000000000000000000000000000000.000000allsthrough                   ellartrapdoors_Page_148135104

For those of the “Youtube generation” the video below shows the risks of not controlling the hazard of an open cellar door.

Information distribution

This latest is a good example of how good old ideas can be updated, but it would still be good to see such solutions “harmonised” through a national process and disseminated more widely that relying on business finding these items on the website.

It is understood that WorkSafe believes that the OHS professionals are an important medium for this type of information, and this mention in SafetyAWorkBlog perhaps illustrates that strategy.  Looking at the websites of some of the OHS associations in Australia, none seem to be lining through to new WorkSafe content or reproducing the content on their own sites for their members.  The commercial sites are doing the work for regulators and the associations and funding their activities through advertising.

This certainly makes a low cost distribution model for WorkSafe but one that is short-sighted and of questionable sustainability.

Kevin Jones

Drugs in the workplace – small business blog Reply

The Age newspaper included a short article on drugs in the workplace in a small business pages on 4 August 2009.  For OHS professionals there is little new information but it’s a nice summary of some of the legal and management challenges on this workplace hazard.

Sadly some of the reply comments to the article online are demoralising.

Kevin Jones

Complacency and arrogance are the problems with mine safety in Australia Reply

The signs are not good for the future of BHP Billiton’s safety program.  At the Diggers & Dealers conference in Western Australia on 5 August 2009, Ian Ashby, the President of BHP Billiton Iron Ore expanded on his statements some months ago about the poor safety practices at the company’s Pilbara worksites.

According to one media report, Ashby has said that BHP’s safety performance was  “generally showing improving trends”. He also said

“We’re looking for systems to eliminate these tragic events….. There hasn’t been any epiphany but we need to increase the intentionality and focus.”

Ashby specified two particular occupational hazards

  • traffic management, and
  • “fatigue management to prevent excess working hours”.

In April 2009, Ashby identified the following safety areas as those requiring attention:

  • Reduce site access;
  • Improve contractor management;
  • Enhance existing strategies to prevent excess working hours;
  • Move rail operations from the Mine Safety and Inspection Act to the Rail Safety Act;
  • Enhance traffic management standards, and;
  • Suspend all non-essential work outside daylight hours

Ashby’s presentation to the conference is now available for download.

Pages from diggersAndDealersMiningForumPresentation cover

The concern for the future safety performance of BHP Billiton comes from Ashby statements that, according to the press report, “the root of the problem was a poor attitude towards safety in the Pilbara region.

“There is an element that I don’t like to dwell on, but there is a complacency generally in the Australian workforce and a bit of an arrogance. I think some of that is quite manifest in the Pilbara.”

Ashby must have read the comments by Warren Edney about the lack of “safety brainwashing” in relation to the Pilbara miners. [SafetyAtWorkBlog has tried to clarify Edney’s comments with his employer, Royal Bank of Scotland]

The machismo of mine workers and new mining employers may be part of the issue but, as has been pointed out before, a similar Australian company in the same industry sector in very similar geographies – Rio Tinto – does not have anywhere near the same amount of fatalities even though it draw from the same worker demographics.

The OHS issue at BHP Billiton seems to be developing into a classic study of safety versus production.

It may be useful to note the report in the business section of The Age newspaper entitled “China taking all the ore we can ship: BHP“, a  report generated from the same presentation by Ian Ashby at Diggers & Dealers’.

Kevin Jones

John Merritt and ‘reasonably practicable’ 4

On 4 August 2009, John Merritt, Executive Director of WorkSafe Victoria, spoke at an OHS function hosted by the Australian Human Resources Institute in Melbourne.  John is a lively speaker whose passion for workplace safety is obvious. I had the opportunity to ask the following question

“How is reasonably practicable NOT a ‘get-out-jail-free card’?”

Many readers will know that I am skeptical about “reasonably practicable” as is evident from the question.  However John’s response was the first from a non-lawyer that saw some positives in the concept.  John said

“I do think [the concept] is a real strength in the law.  In trying to move people to embrace this issue, for those who are in that denial phase, they often think we are asking them to do the impossible, and I find it really useful to say “no we’re not.  We’re asking you to do that which is reasonably practicable.

Our job, if  we say what you’re doing is not reasonably practicable, all we have to do is go and find someone who is just like you who is doing it.  We’re not asking you to do anything that somebody else, and usually in some critical mass of numbers, isn’t already doing, so why can’t you do it?” And I think that’s a reasonably sophisticated law.

You’ve got to have really good teams of investigators and lawyers and inspectors and all that sort of stuff to make that sort of law work.  But that’s good, that’s doable …. but I do think, in our field, its a reasonable proposition.

The alternative, which is an absolute duty – you must have a safe workplace and if someone is hurt, prima facie, you’ve failed and you need to prove to us that you’re innocent – can be made to work as well and most of the research is …. but in trying to move that hearts and minds of, particularly, our target audience, I think it’s the right way to go.”

It was refreshing to hear that “reasonably practicable” can be used as a tool for good instead of evil through illustrating an example of a control measure that has already been found to be reasonably practicable.  Tangible examples have been missing from OHS in Australia for a long time, ever since the OHS Solutions databases fell over in the 1990s.

If WorkSafe finds such examples useful for businesses, it would be good to see such databases resurrected. The images below show some pages from “Share Solutions” a hard copy database produced by WorkSafe’s predecessor, the Occupational Health and Safety Authority, in the late 1980’s.  It would be a good idea if someone like Safe Work Australia investigated the feasability of resurrecting this initiative.

Kevin Jones

Share Solutions 001 002

Share Solutions 003

Leadership, stress and performance reviews – interview Reply

Graham Winter is an Australian psychologist Graham Winter Book 001who was the chief psychologist for the Australian Olympic team and is now an author and business adviser.  In August 2009 he has a book released entitled “The Man Who Cured the Performance Review”.

SafetyAtWorkBlog managed to interview Graham last week about the book, stress and safety leadership.  The SafetyAtWorkBlog podcast is available for download.

SafetyAtWorkBlog Graham Winter Interview

Kevin Jones