Root Cause is always found in decisions not things

Australian unionists are justifiably angry at the death of a worker at the construction site of a desalination plant in South Australia last week.  The worker was crushed when a beam slipped from a sling on a crane and crushed him.  The soft sling was being used so that the beams would not be scratched according to one report in The Australian newspaper.

It is hard to understand the sacrificing of the safety provided by the standard practice of chains for the aesthetics of the beams.

The media attention on the death is increased due to the incident occurring on a desalination plant site as many oppose the use of desalination plants to ease Australia’s water shortages.

On 17 July 2010 an AAP report included the following quote from the project director of the desalination plant’s operating company, Duncan Whitfield:

“At this time, our main concern is for the welfare of the deceased man’s family and any other personnel involved,” Mr Whitfield said. “This is a horrible tragedy and we will leave no stone unturned in discovering the root cause of the accident to ensure it never occurs again.”

“Root cause” is a phrase that is much bandied around in the aftermath of a workplace incident as it emphasis the importance of the investigation but whose “root cause” will the investigation stop at?  In OHS and risk management courses we are encouraged to investigate the “system of work” and to identify “contributory factors” and advised not to look for a root cause.  Looking for a root cause can provide too narrow a focus in an investigation.

An investigation is likely to identify an equipment failure or a specific decision that led to the immediate injury but what decisions led to the choice of that particular piece of equipment?  If we don’t look at the decisions, the only solution will be to use another or different piece of equipment which will fix the short-term issue but may not lead to prevention of similar occurences.

The project director of the incident above needs to face the prospect that his company’s decisions may have led to the incident as they had control of the workplace and the system of work.

The use of soft slings in the incident above is likely to generate a safety alert by a regulator or the union. But more last changes will come from investigating the decision-making process leading up to the incident.

On 21 July 2010, unions have suggested that painting over any scratches on a beam from chain use is a safer option, thereby eliminating the hazard altogether.

Kevin Jones

reservoir, victoria, australia
Categories business, construction, death, evidence, hazards, OHS, safety, UncategorizedTags , , ,

13 thoughts on “Root Cause is always found in decisions not things”

  1. I await the Coroners findings with great anticipation and then we can compare those findings with previous Coronal findings on workplace deaths to see if any lessons have been learned and if they have, how have they been articulated to the workplace.

    Maybe a research grant to an OHS organisation to look at the coronal findings of deaths in the workplace over the last 30 years might shine a light on common factors still not addressed.

    1. Tony, my understanding is that the Australian Coronial services are collating their data into a national database that will allow for such research. I don\’t think a grant to any OHS organisation will help in this but the coroners are releasing more and more OHS-related data on line, enough, I think, for connections to be made.

  2. The root cause points to the fact that the some organisational factors may have taken part in the unforeseen fatality. By this I mean considerations to other causal factors: time constraints, supervisory inclusion, human error, adminstrative, training or the method of lifting techniques, equipment: fit for purpose- chains,slings …availability.

    All these add up to causal events, unfortunately its another lesson learned that gets put on a safety alert, adding up to the fact that if we did it differently, WHAT IF??

    Anyway, good discussion, thanks,

    Yours in Safety,

    Mark Da Silva

  3. Kevin

    To clarify my comment of the \”Answer is in the Morgue\”. I infer, that had the answers to the two questions posed had adequate answers and appropriate actions then the answer would not be in the Morgue.

    I think the learning issue, in the main, is well behind us as it should be in matters of risk assessment for obvious workplace hazards. That is not to say we should not look to tweak our skills on a regular basis, however, the rules as they stand are very clear. Comply or people die.

    The aftermath of such an appalling breach of trust and responsibility is for the treating professionals to try and resolve and no expense should be spared in handling this matter.

    Anything that diminishes the sharpest of focus on those individuals responsible for the provision of a safe workplace and failed to do so is entirely unacceptable. The learning from the incident is down the track, the restoration of some bearable future for the grieving family is and quite rightly should be, the immediate focus followed by looking after those who were affected as a result of the death of a colleague.

    I can assure you from first hand experience with seriously injured workers that the family will in all probability want answers and will want to see blame apportioned as early as possible. Let us see how this pans out and how long it takes.

  4. I note Ross\’s comments and while his discussion is about decision making in the main, mine is about the consequences of obviously very poor decision making in the process.

    The reality is the focus at this point it should be on the people most affected by the entirely preventable incident, that is the family of the dead worker, who should receive an immediate payment of a substantial amount to ensure they are able to deal with their grief and financial pressures associated with their loss.

    We all know the usual approach to this is to bury matters in a great load of bureaucratic duck shoving and nonsense and wait for two or more years for some load of waffle, that dilutes the real issues at hand, usually accompanied by a woefully inadequate compensation payment and similarly inadequate penalties for the employer.

    I refer to the matter of Die-Mould in South Australia where a young man was killed in a machine and the penalties and compensation there were appallingly inadequate. Worse, the time taken to get answers and an outcome.

    The most important questions are. Was the cause of the incident preventable? was it obvious? the answer is in the morgue and this worker needs to be respected, after all, it is not his fault he is there, nor his family\’s.

    1. Tony

      I don\’t agree the answer is in the morgue. OHS learnings do not come from an autopsy of the dead but an investigation of what led to the death and, in some circumstances, how the death at the workplace was handled. There are important issues for those family members left behind and the workers who witnessed the death in both the before and aftermath.

  5. The ohs people / management responsible need re-education, big time. I have not seen soft slings used on beams (and not only beams) for a while for this exact reason. The use of soft slings is generally minimal and normally for items such as pipes, stainless steel products etc.

    Many loads should be double wrapped to ensure slippage is minimal etc.

    Normal practice is chains and if paint chipping or damage is a problem them pad the chain with carpet / hessian bag etc

  6. (Clarification: in that comment I don\’t mean it\’s down to \”operator error\”. The organisational factors that don\’t allow good decisions to be made need to be drilled into, to understand \”how could this be allowed to happen?\”

  7. We shouldn\’t leap to conclusions about the suitability or otherwise of the soft slings, or any possible cause of the incident, just because it gets reported in the media. For all we know, properly slung they may have been quite suitable.

    The real root cause, as Kevin implies, lies in the process for deciding how the lift should be done, which gets back to issues such as the relative importance of safety, processes for hazard identification and assessment of relative risk, how competent, well trained & supervised were the people involved in the job, etc. etc. etc.

    There are a myriad of factors that might be involved but if the beam fell because it wasn\’t secured properly, it comes down to this: how was a decision reached that this particular method of working was suitable for the task at hand?

  8. Thanks Kevin, I do not resile from my comments one whit.

    On the matter of use of sling types, and the concern over damage to paint, there are many protectors commercially available to sleeve chain or wire slings for protection of aesthetics, so any argument that tries to justify the us of a soft sling in a risky environment is specious to say the least.

    I have little faith in any rapid action by Safework SA which is another item of contention. Maybe they need to have obligatory reporting in the public arena at various stages of an investigation to ensure action is not stalled for want of prosecution.

  9. Has the company written a cheque to the dead mans family for say 5 million dollars to give them some comfort as little as that might be, I think not and I think their main concern will be to try and deflect as much of the blame as they can to minimise damage to themselves.

    The root cause is simple. Management failed in its responsibility to the dead worker so how much are they going to pay as a corporation and which individuals responsible for providing a safe working environment are going to be held accountable and also pay.

    This was not an accident it was in effect akin to premeditated manslaughter given the reported circumstances. failure to comply with the most basic of safety standards is a criminal act and should be treated as such.

    Too much waffle and deflection of attention from the end result of the incident does nothing to bring the \”Blow Torch Of Accountability\” to bear and another opportunity then slips away to have those responsible for safe working environments put on notice.

    1. Tony, I await further information from SafeWork SA on their future plans over the incident. From the information currently available I expect it would be difficult to justify the use of a soft sling when any potential chain marks could have been covered with paint and thus eliminate the need for the soft sling. Such issues are the reason for a formal investigation.

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