OHS: The Pearl Harbour Syndrome

OHS:  The Pearl Harbour Syndrome[i]

– Poverty of Expectations –

The Japanese attack on US forces at Pearl Harbour in the Hawaiian Islands on Sunday 7th December 1941 was a military disaster for the US described as a totally unforseen and unforeseeable attack.  It shocked the American people and brought the US into WWII (essentially the next day).  The element of total surprise (‘Why were our forces so ‘unexpecting’ and unprepared?’) was defended with the implication that, ‘we were still negotiating with the government of Japan and its Emperor in good faith’ and there was no state of war between the two nations.  In a speech to congress the next day President Franklin Roosevelt called it, “… a date which will live in infamy – the United States of America was suddenly and deliberately attacked by naval and air forces of the Empire of Japan”.

Controversy surrounds various aspects of the attack[ii] but it has become synonymous with surprise and astonishment.  However, research over the years suggests that in fact it was preceded by a large number of misunderstood or ignored warnings and missed signs.   The reason these were so completely missed, according to one scholar, is because of ‘poverty of expectations’ – routine attention to the obvious and reduced horizons for imaginative projections.

And this is the basis for the analogy with workplace managers’ observed statement of surprise and astonishment after serious OHS incidents at work.  After an OHS catastrophe I have often heard many of them mutter statements like,

  • I would have never thought…[Fatality, demolition collapse]
  • I’d have never expected…[Hand ‘granulated’]
  • I can’t imagine why anyone would do that?…  [Arm amputation in conveyor belt]
  • How could you possibly see this happening?…[Sections of  refinery closed, plant integrity]

The manager had definitely heard of some OHS failures in his/her industry (e.g. offshore explosions, mining disasters, chemical contaminations, construction…… catastrophes); knew that OHS management systems weren’t full proof; knew of local OHS breaches; knew that short cuts are regularly taken at the work; knew that serious process failures do happen; knew that workers regularly get killed and injured at work.  Why then the astonishment?

Is it really likely that these apparently astonished managers didn’t even have an inkling (weak signs) about dangerous preconditions at their workplace?   Were there too many warning signs to deal with, or did impoverished expectations mislead the manager so that he/she displayed all the effects of the Pearl Harbour Syndrome?

Since the most fundamental and first step in any OHS management system, and risk assessment specifically, is hazard identification, this, I believe, is the basis of later astonishment.  That astonishment is not so much about the serious incident itself, but results from failure of imagination, ‘Not in my wildest dreams’.    

When poor occupational imaginative efforts result in a mind set based on impoverished expectations then necessarily the significance of a range of warning signs will be missed.  The manager will develop and maintain unrealistic and more comfortable expectations.  When these fail (a catastrophe happens) the mental cloak will be suddenly lifted and astonishment will follow.

Managers must replace impoverished expectations with active anticipation of the unlikely (not a new or heroic idea).   By doing so they may be able to overcome complacency spawned by the solace that written documents about routine OHS programs can generate, and become more sensitive to early warning signs.

Yossi Berger
National OHS Co-Ordinator
Australian Workers’ Union


[i] I use the word ‘syndrome’ to refer to the ‘running together’ of a number of characteristics where no clear explanation is known for some event.  Almost in a manner that allows the prediction of some characteristic from the presence of some others.

[ii]  Some controversy and conspiracy theories surround the event but these aren’t central to the point made in this article.

reservoir, victoria, australia
Categories evidence, hazards, imagination, Leadership, OHS, safety, Uncategorized, visualisationTags , , , ,

12 thoughts on “OHS: The Pearl Harbour Syndrome”

  1. My view Yossi is that OHSW is an industry must have and an industry hazard in and of itself. We now take for granted the very basic safety tools all around us, -the reflective vests, the asbestos warning stickers, the gaffer tape holding extension cables even the hard hats and sunscreen lotion- if safety equipment is required and is provided we use it. We don\’t think about it, we complain if it is not in place.
    None of us relate end of shift tiredness to OHSW, none of the excess over time to cover \”Charlie\” not coming in is considered in the realm of OHSW.
    End of shift means getting home have a meal that is freshly prepared, having a shot shower, spending time with family/friends and sleeping.
    There is no room in those thought for OHSW.

    You may note that I still use OHSW.
    It is my view that the \”W\” is the part that is missing and is the part where all the key safety requirements can be found.
    If my \”W\”elfare is in place, then your \”W\”elfare is also in place because I \”W\”elfare relies on your \”W\”elfare, just as my \”S\”afety relies on your \”S\”afety.
    Sadly though the industry has put all its focus on \”S\”aftey and forgotten/overlooked/underestimated the need of the \”W\”elfare in everybody\’s life.

    At change of shift if there was a focus on \”W\”elfare the shift boss would not need to ask where the pump is, where the trucks are or the tool boxes, because the hand over would be team mate to team mate, with each hand over would be all the added information that would be required such as how much fuel is left in the truck, anything about the pump or a missing tool from the tool box.
    There would also be the time for the shift manager to ask if some one will cover \”Charlie\” and then have 2 team mates agree that 1 will stay for another 4 hours and that the other will start 4 hours early, and that the extra time is spread widely so no one team member is carrying a tiredness burden.

    \”W\”elfare is the key to OHSW, put the \”W\” into any situation and the who culture will change because once again everyone will understand that my \”W\”elfare relies on your \”W\”elfare.

    Some of you will say that my concept is far to simply to work, yet reflect on the need of everyone to be safe, which means I must be safe for you to be safe, then simply exchange the word welfare for safe.

  2. Now let me drill down a bit. This is a workplace, say, a mine (but it could be any workplace). It\’s 6 a.m, the night crew has just come up from the hole, more than 1 km down. The day shift is about to go in. Both are in a large room blazing with light for the change over.

    The night crew members are all standing clustered close to the door, almost blocking it, the incoming crew is seated at the long tables. The superintendent goes through a kind of tool box/change over routine: \”Where have the trucks been left?\”, \”Who left the pump where?\”, \”This is what has been done\”, \”Charlie won\’t be in today….\”.

    All of this is done in quick, single-breath comments and mostly gets done in 5 minutes. The tired night crew disappear before you can say, \”Well done mate\”. They don\’t want to be there one minute longer, you can actually see their \’desperation\’ to just get out and go home.

    Can you tell me how in this kind of setting where the long arm of the regulator is non-existent, OHS theory irrelevant, notions of OHS \’culture\’ trivial, the manager\’s \’by the book\’ approach a cynical joke to be ridiculed…….. how in this setting adequate and meaningful exchanges about daily OHS matters, let alone in depth, insightful conversations about weak signs of pending OHS troubles are going to happen?

    Keep in mind the impatience in the room, the supervisor\’s urgent intent to get record tonnage during this shift and workers\’ unease talking about OHS matters.

    What does it take in your view?

  3. Gavin,

    Excellent paper, thanks for sharing!

    Yossi,
    Really enjoyed your article, the analogy of Pearl Harbour Syndrome is an excellent one, and unfortunately all too common.

  4. I find Gavin\’s points thought provoking. The \’one year ten times…\’ is very rich with possibilities for specialised OHS education, e.g. Lessons from history. Whilst his comment about \’imagineering\’ is spot on; a rich imagination without wisdom can generate too much \’noise\’ in the process. I\’m thinking of producing a \’Least Likely\’ to \’Most Likely\’ Index with an emphasis to concentrate careful consideration of the \’Least Likely\’, where the \’likelihood\’ refers to presumed probability of the hazard actually turning into a monster that bites. Obviously the \’most likely\’ should get immediate practical attention.

  5. Kevin, my argument is based on the capacity of legislation to be manipulated by case law to defeat the intention of the legislation. In many cases this subverts the true intent of the legislation, usually to the detriment of injured workers.

    The various OHS&W legislation was never designed to support the plethora of hangers on, it was designed to look after the welfare of workers both at the injury prevention stage and post injury stage. Clarity in the legislation is critical to the provision of certainty of protection of workers and any ambiguity diminishes that protection and feeds those who do not further the cause of worker protection.

    If we stop demanding better legislative standards and just as importantly, the management of that legislation then we are damned to a continuing shambles that represents OHSW in Australia.

  6. After the occurrence of an accident, managers say that they did not foresee such a thing to happen. I feel that they know the hazards. But because they are seeing the same everyday and nothing happened before, they stopped recognizing them as hazards and thus there is no action. Further, if importance is given to production or work performance rather than safety performance, then we fail to read or ignore the warning signals. After the occurrence of any accident, managers say that for the first time in their life, it happened though they know occurrence of similar accidents elsewhere.
    As remarked by Gavin, inaction is also because of \”paralysis through analysis\”. Viewing through magnifying glass to predict all possible accidents causes a sort of depression in the managers leading to no action and to handle the accident whenver it occurs.

  7. \”blind criminal stupidity\” seems an apt description for the those who know or ought to know they have a responsibility for providing a safe work place yet feign shock and horror when an avoidable injury happens in their business.

    The article by Yossi is right to the point and anyone associated with business that does not understand the basic need for hazard identification and risk assessment, or how to go about it, is the primary problem and until these people are forced to confront their responsibilities and act in a responsible manner we will still be banging on about matters for little result.

    Until our elected representatives get off their collective backsides (with a few notable exceptions) and rewrite the legislation in a more humane manner and provide unambiguous law that cannot be interpreted to the detriment of injured workers then we will have this ongoing fetid mess around for quite a while to come. I am not sure which talk fest came up with \”Harmonisation\” as the catch cry but it would seem that is all they are capable of producing in a long line of diversions away from the key problem which is \”The system is Broken\” and can\’t be repaired based on its current foundations.

    Maybe a good idea would be to have Yossi provide a preliminary paper on what the system should provide an injured worker and how the system should treat that worker with a charter of rights. These would include the right to be treated with respect and dignity and the right to be fully informed of process requirements in an understandable manner, the right to representation of the injured workers choice not some arbitrary association that suits the Compensation Authority or its agents. There are many other areas we all know of, or should know of, if you are close enough to the day to day issues facing workers.

    1. Tony, I don\’t think we will get \”unambiguous law\” in OHS as the incoming laws rely on Court decisions to establish precedents and definition. My concern is that legislators embrace the reliance rather than trying to engineer this out at drafting stage.

  8. This is an excellent article.

    This Syndrome reminds me of \’The Failure Of Hindsight\’ by Professor Brian Toft. It seems to have similar traits as to why organisations and people fail to learn from incidents.

    The article raises the issue of a human\’s limited horizons for prediction and lack of ability to identify potential for failure. Question: Do these managers have ten years of experience of one year of experience repeated ten times?

    How does competency management/competency assessment deal with those kind of thought restrictions and lack of exposure within the workplace?

    The wider issue of culture is also a dominating factor in this syndrome I would suggest.

    I think one issue where care does need to be taken though is in this (seeming) suggestion from Yossi for more – \’Imagineering\”.

    Kevin recently posted a blog where he commented on the paucity of safety professionals giving relevant business focused safety advice.

    If not careful you could be identifying everything as a hazard (which of course it is in certain given states or conditions) and surround yourself with a plethora of controls but end up doing or delivering nothing – \’Paralysis through analysis\’.

  9. Very interesting analogy I must say. Comparing a World War to a Safety Management System, just highlights the complexity of communication required in the Occupational Health and Safety field…………..seems Risk Assessment deserves a \”front seat\” in our facilities management practices.

    Tina Johnson from BP ironically had just given a speech about Flow Assurance in January 2010 before the \”Big Spill\” and tragic death of 11 workers in the Gulf of Mexico, and being a technical/engineering type, I could relate to the \”Real Risks\” that
    were taken trying to operate a \”subsea BOP\” in this day and age reliably which would have prevented the spill now. The fire incident is still under investigation, but having worked offshore, I would have at least expected the ESD Fire Situation to close the BOP which did not happen as a result of a few \”short cuts\” and probably a lack of \”system integrity\”.

    Respectfully, Paul Koyich, CET, HSE Advisor, Al Khor Community(pop.9000+), State of Qatar c/o Qatargas OPCO

  10. I can only agree with the above article, it is as post workplace incident the very people who should have been ensuring that all was as safe as was possible suddenly discovered that poor OHSW is a part of the reason for the workplace injury or death.

    But by then it is too little too late, a life has been altered or ended.

    So often when I speak with injured workers or the families of the deceased, I hear the same lines of inadequate repairs done to machines, excessive over-time so the worker is over-tired, reports made of poor workplace practice just ignored etc etc.

    The price paid can never be measured in dollars.
    The price paid is human life restricted by injury or ended by death.
    Death in this instance may be slow and painful as the result of illness or disease generated by the workplace.
    Death in this instance may be sudden due to a workplace fatal.
    Death in this instance may be sudden due to suicide as a direct connection to the workplace or the WorkCover system.
    Death in this instance may be slow due to a suicide attempt that went wrong leaving the worker to linger for days/weeks/months/years in a vegetative state.

    I have had countless conversations with employers and shift managers who say \”I just didn\’t see this coming\” or \”we had a rush order to fill, we don\’t normall allow short cuts to happen, but we had a rush order to fill…\”

    There can never be any excuse accepted.
    There can never be any tolerance for life destroyed or lost.
    Yet we all turn a blind eye and allow sub-standard OHSW to go on all around us.
    How often have we gone into a coffee shop and seen the mess on the floor where the staff have spilt milk of coffee grounds, how often have we thought that the mess is a slip hazard yet said nothing.
    How often have we seen delivery people pile too many items onto a sack truck knowning the excess weight is causing pressure on the spine, arms, shoulders, knees, hips and ankles, and never spoke up.
    How many times have we seen junk mail delivery people walking the streets without a hat or even a bottle of water.

    Poor OHSW is all around us, and we say nothing because our own lives are filled with the need for the coffee being made, or the parcels being delivered or even the junk mail to be scanned for the bargain of the month.

    If we see it we need to say it.

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