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?