Lessons Learnt…?

I would like to pose a question, or questions: are OHS professionals and the community in general, in all honesty, learning and applying the lessons we are being taught from workplace events?

Are we, or our organisations, being truly effective in preventing the recurrence of events in our workplaces, work processes or activities?

Do we, in truth, actually prevent risk before it has the opportunity to arise, or do we at best eliminate it once it does?

Most, if not all, will answer “yes, yes and yes”.  And mean it.  But let us take a good, hard look in the mirror.

Almost every day, most of us will become aware of another work-related fatality, another court case won or lost, another event which has resulted in significant harm to person, property, environment – or a combination thereof.  What makes these events of note?  Often it is the fact that someone has suffered a serious injury, illness, or has died in the course of their employment.  That is what makes us and society as a whole, sit up and take notice.

I have led investigations into many events, including workplace fatalities.  Dissecting and analysing the facts of an event, regardless of the severity of the outcome, piecing together the actions and conditions that led or contributed to the event often reveals one common element – that all of these events were so easily, and readily, preventable.  The severity of an event’s outcome can be influenced, mitigated or enhanced by seemingly small and insignificant elements.  I will not reiterate various accident prevention models, but you get the picture.

I have completed an investigation into one workplace fatality, only to – a matter of days later – witness in another location almost exactly the same circumstances and sequence of events.  This time however, no harm resulted, and the event was written up by the frontline manager as just another ‘near miss’.  How many events, including those tragic, cruel deaths, can you look at, consider the circumstances and see commonality in the circumstances in another ‘low-level’ event or near miss?  Person A was not killed, in fact walked away unscathed because they did X and not Y?  Because they were in Location 1, and not Location 2?  And because no one died, little or nothing was done – the risk was downgraded or not truly and accurately assessed due to the failure of Person A to be maimed and/or be killed?

My point is that we are seemingly so focused, so fixated on an event only if it actually hurts – that the level of severity of outcome is what gets our attention.  Yet are we not taught, educated, experienced enough to know that any event, regardless of outcome, should be treated based on its level of potential risk… even if – this time – that risk is not realised?

This, in turn, raises another point regarding our assessment of risk.  Risk is all too often based on history, rather than current or future events or conditions.  Commonly used qualitative risk assessment tools (such as risk matrices) often do little more than offer a subjective view of risk, often based on the involved person’s perceptions or experiences of the hazard.  I have seen nuisance dust risk-rated as ‘extreme’; conversely I have witnessed the risk of a structural collapse rated as ‘low’.  Quantitative tools, although based on hard data, commonly offer the same trailing review, and again risks qualitative influences through the person translating and inputting that data.

If I may, I will ask you to consider those questions again. Are we truly, in industry, society or our profession, learning those lessons?

Eane Watson

reservoir, victoria, australia
Categories death, ethics, hazards, OHS, Professional standards, risk, safety, UncategorizedTags , ,

8 thoughts on “Lessons Learnt…?”

  1. As usual Col Finnie is right on the money and his reference to \”Micro Business\” (5-20 employees). This is a cultural thing, in that, businesses in this category, who are the majority employers and usually afflicted by serious cost pressures, are very adept at prioritising allocation of funds. Unfortunately, OHSW barely rates on the radar of expenditure for these businesses.

    In a large number of these businesses you will find the first aid cabinet is deficient, so any presumption of compliance with the overly complicated OHSW regulations is a forlorn hope. In terms of time allocated to thinking proactively about OHSW I would suggest it would be close to zero.

    The conundrum is, do we give this sector credit for being proactive and concerned OHSW citizens, or do we treat this sector as recalcitrant in all matters relating to OHSW and force it into compliance. I think the answer is in the results we see today, given the decades of safety education and promotion that has cost millions of dollars with appalling results.

    I think we need to re-evaluate the emphasis on how we teach OHSW from school level through to company ownership level. It would seem we prioritise the \”wagging finger\” rather than a \”genuine care\” approach to how we should be viewing injury prevention and by doing that, it always seems to take the personal responsibility element out of the equation, which means the system is responsible and no one takes responsibility.

    Rosemary comments on attending many conferences in relation to OHSW, I wonder how many micro business owners attend???. I have a very good idea of the numbers, because I work in this sector exclusively as a mentor, consultant, marriage counselor and many other things that go with small business assistance and let me tell you emphatically, from over 25 years experience as a management consultant the emphasis placed on OHSW in this segment is most definitely not \”front of mind\”.

  2. The questions raised by Eane are baffling OHS professionals for a long time.
    The reasons for accidents are know to most of the persons, as pointed out by Col Finnie and others. As the world famous safety professional and author many books, Mr Trevor Kletz stated in his book that \”Corporate Memory is Short\”, accidents keep recurring at regular intervals in an organization.
    Unless otherwise the site in-charge is not serious, I feel there will not be any remarkable improvement at a work place with regards to safety. As every activity is viewed in terms of profit and loss, OHS professionals have to calculate the cost of every accident/nearmiss. And this should be communicated to all concerned to make them realize about its impact on the profits.
    Further, it is my understanding that many site in-charges and down below do not know about their legal obligations and penalties/punishments and thus do not care much about workplace safety. May be if we, the OHS Professionals communicate these legal obligations, in the form of \’Safety News\’ through internal e-mail or other suitable form, all concerned may understand where they do stand and contribute towards workplace safety. The subject line of the e-mail should be eye catching and the content should be simple and limited to 3-4 lines to enthuse interest in the target audience.

  3. Events that are promoted to bring in the industry providers do little more than preach to the converted. All too often even the attendees know about unsafe workplace practices in their own workplace, but they fail to address that situation which is potentially life threatening of life ending.

    OHSW needs the onus of workplace safety to be placed on everyone, not just the shop floor workers, but everyone regardless of what position is held by the observer.
    I have spoken several times to owners of coffee shop owners about unsafe usage of electric knives or sillages in front of hotplates.
    Only to be told to mind my own business, when I have pointed out the workplace safety is my business and that I am quite happy to make a call to SAfeWork SA, then the attitude of the owner changes.

    Like many others I attend many conferences semminars focus meetings training events every year.
    I also admit every International Day of Mourning I arrange memorial tree plantings in the Deceased Workers Memorial Forest here in Adelaide.
    It is beyond my understanding as to how the information from the various industry trainings does not appear to filter down from the very good information provided.

  4. To your concluding question, in that excellent piece Eane, I would say yes. I reckon the lessons are there for all to see, the information is right in people\’s faces; the problem is the lessons and information are wilfully and categorically ignored.

    One of the first things I tell a new client is to forget what they have heard about OH&S being simple and just commonsense. It\’s nothing of the sort. But as we all know, it can be dealt with systematically and practically if there is one critical component in place, and that is the boss being fair dinkum.

    The newish idea of \”respectful leadership\” is a big part of being fair dinkum. So is the well known essential component of risk awareness. And then there is the hard-core, but unmentionable element of being fair dinkum – the boss coughing up the money.

    Personally, I think the hammering about OH&S being simple and commonsense has done huge damage. It\’s allowed the view to develop that OH&S shouldn\’t cost much at all to get right. Sure, it doesn\’t necessarily have to cost lots, but give people an inch….

    I have just posted a tips article for an industry association I help out. The article is about the \”horrible\” topic of cost. Some members of that association might have a sphincter snapping moment when they read I\’ve recommended an annual benchmark budget of $21,000 for OH&S; for the places that have 5 – 20 employees, a pretty typical business size for that association. But we gotta get real.

    The figure is based on the average expenditure on OH&S that respondents to the AIM/SIA \”The Business of Safety\” survey nominated. For 5-20 employee sized businesses the average expenditure revealed by that survey is close to $17,900. Given the spread of industry types in that survey I think it was sound to add 20% to the average figure, because the association has members in a high risk industry.

    It\’s gunna be interesting to find out what reaction we get from getting down and dirty with some hard numbers.

    A fair dinkum boss who at least understands what \”respectful leadership\” is, and a budget that gets serious about OH&S: for mine that\’s what has been missing in the OH&S mix. Enough of pussy-footing about.

    PS: The survey I mentioned can be found at: http://www.sia.org.au/research/reports/thebusinessofsafety

    Col Finnie

  5. Eanne,Yours is a vey good submission and I will attempt to respond from the perspective of many years in safety that has left me quite cynical about the value of traditional safety efforts.
    No one would question the fact there is much safety activity nowadays,I just wonder how purposeful some of that activity is.
    I suspect much safety activity is a displacement activity-A displacement activity is something we do, something we put a lot of energy into but when we analyse it properly there is no really valid reason to do it.
    I agree with your comments on the subjective nature of risk assessment, personally I think far too much reliance is placed on this technique.
    I was involved in a detailed critical incident (or near miss) process awhile ago where critical incidents were reported and observed, a fantastic bit of work, the overwhelming conclusion of all involved was without this work fatalities would inevitably have occurred.People will tell you they have near miss reporting systems, I assure you that unless you have a highly organised process to surface them you will only get to hear about a small percentage.
    To my mind critical incident recall is a must do in organisations.
    We get to hear about a small number of the fatalities but hear virtually nothing about the non-fatal life altering personal damage, in terms of cost this is a far more significant area according to studies I have seen.
    My safety mentor Geoff McDonald says the only way to make meaningful progrss in safety is to concentrate on the personal damage occurrence (Accident) phenomenon.
    The more I see of people trying and failing with traditional approaches to safety the more inclined to Geoff\’s view.
    Many companies examine their past injury experience, if there was a consistent, standardised personal damage system in their industry or better still in their state or country it would be a much more powerful data base to learn from.
    The problem with enterprise personal damage occurence data is unless you are very big and have a lot of incidents it is hard to develop statistically significant determinations.
    At the monent in Australia it is not easy to learn from past personal damage occurrences that are relevant to your enterprise.
    This seems to me to be a priority area for government to address

  6. One of the reasons we may not be learning the lessons is that information on accidents and near-misses is kept very close to the vest. If more information on all these incidents were available we might be able to learn from them.

    I pass along information on in-house incidents to relevant facilities as it becomes available to me. External events usually have inadequate information to present a lesson.

    There are lots of little pools of data on the net though – and NIOSH provides an example of how to communicate accidents properly. http://www.cdc.gov/niosh/face/inhouse.html

  7. I have been watching the discussion on the role of risk assessments in Europe and, in some ways, Australia is testing fundamental OHS practices but not including risk assessment as a require process in its new OHS legislation. It follows the controversial Victorian decision to \”not waste business\’ time\” by requiring risk assessments on hazards that already have established control measures.

    Recently an industry representative asked me what was the use of requiring a risk assessment for the hazard of entrapment in a machine when the machine is missing the required guard. Replace the guard (in other words control the hazard) and the risk is removed and a risk assessment was not required.

    Risk assessments are very useful for new hazards or to engage a workforce in the OHS management process but my colleague questioned the wisdom of obligating a risk assessment through legislation for all hazards.

    Your other comments go to the heart of the \”near-miss culture\” where lucky events are re-categorised as a \”report only\” meaning that no investigation is required even though analysing the near-miss may illustrate a substantial shortcoming in a management system. The dismissive attitude to near misses clearly indicates a workplace culture that does not value OHS and worker health to the extent they profess. Downgrading of incidents often occurs when a company perceives a shortage of resources yet, if an investigation was to occur, the preventive benefits would be clear.

    Many thanks for submitting this article. I look forward to future contributions.

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