How much significant information do workplace fatalities provide?

Workplace fatalities are terrible, lingering tragedies that generally don’t teach anything new about OHS failures.  I couldn’t find anything new in the frightening detail in the article below (dated 14th December 2010) or in scores of Google searches of industrial/occupational fatalities; though disease fatality epidemiology can be  informative.

If all workplace fatalities in Australia were stopped overnight, most workers wouldn’t notice a single improvement in their own workplace.  They’d still be working in the same cluster of hazards, useless risk assessments and a regular sprinkling of near misses and daily shortcuts.  Despite regulators’ and politicians’ shrieks of dismay at workplace deaths, such fatalities don’t represent the main OHS problem at work.

If any regulator was informed in advance – in some detail – that in a particular industry there would be three fatalities in the next three months (or even intolerable risk) they wouldn’t know how to prevent them.  Example?  Think of the insulation program, which still has some way to go and a few more surprises in store.  Example?  Over the next six months there are likely to be 3-6 quad bike-related fatalities in Australia, mostly as a result of rollovers.

Or think of the value of risk assessments:  example?  Consider the 60,000-80,000 barrels (10,000 tons) of the most dangerous hexachlorobenzene (HCB) waste stockpiled and being repackaged (ultimately, drum to drum) by workers in a primitive work process at Botany Bay Industrial Park, Sydney.  One of the world’s largest stockpiles of such dangerous wastes that no one around the world is prepared to handle.   This is the only place I’ve ever had to wear two layers of protection to inspect. What has the regulator done?

But it could be argued –


That there’s not much new under the sun, and, like so many proverbs this one has limited truth. There are many new things, but human behaviour, responses and emotions remain similar. “The more it changes the more it stays the same” is a wink in this direction. So it could be argued that health and safety failures at work have only a limited repertoire of how they can happen. Things can fall, they can explode, they can hit someone or someone can run into them. Biology means that workers can be poisoned, they can be made sick by various mists, smokes, dusts, aerosols, fumes, and by various organisms e.g. in agriculture. But the category list is really very small. Therefore, is it any surprise that those circumstances that kill workers tend to be from the same list?


Secondly, that series of events that led up to the fatality also makes up only a small list. That is –

  • The Kaboody was delivered to the factory by a truck;
  • It was unloaded at… by …;
  • Jack was asked to work on the round Linto on the Kaboody;
  • The employer was required by law to provide a safe workplace…etc;
  • But the gizmo wasn’t checked and…… then it exploded.


Any such biography of catastrophic events is likely to repeat the repetition of the last repeat after the last fatality at………. You see the point. And inquiry after inquiry, inquest after inquest will generate very similar findings and almost identical recommendations.

But it’s worse than just a small number of work life scripts.

Consider the evolution of an OHS catastrophe – its career, so to speak.  Pick one at random:  the Longford explosions and fires, Victoria?  The Beaconsfield Gold Mine, Tasmania?  The CrossCity Tunnel fatality in Sydney?  The BP Texas Refinery, US?   Walk the small, developing and often closely-coupled steps of the growing crisis, the insidious lining up of Reason’s Swiss cheese holes, so to speak.   At which exact point could the regulator have made a critical difference and how?

The fashionable and vague response (nowadays almost a reflex) about ‘culture change’ is – in my view – no more than hot air; ask most workers!  In practice, the utterance ‘It’s a problem of safety culture’ has become an obnoxious hazard all by itself; it’s a defence that diverts practical actions.

What lessons from the fatality at Beaconsfield Gold Mine in Tasmania (for example) would have helped the regulator in WA stop the BHP-Billiton repeated fatalities in mining?  Or the New Zealand Pike River coal mine horrendous explosions and tragedies.  I firmly believe there are ways, but not the way of the current way.

Just in passing, after all the closely argued and well-presented books where Andrew Hopkins wrote about ‘learning the lessons’ (actually in the title) post various catastrophes, his last book to date is called Failure to Learn (BP Texas City Refinery).   Is that failure really just a one of?

The ‘culture, attitude, behaviour, OHS systems, Step 5, Step 3…’ etc are – in practice – poor tutorial room exercises.  They may work, in part, in large, well-resourced and strictly supervised workplaces.  But since some 80% of workers work in small to medium workplaces………. you can see the rest of the argument.

Sprinkle into that daily cluster of hazards some OHS bullying and fear of job loss (“You don’t really like working here as part of The Team, do you, matey?!”) and you can see that the daily struggle by workers for OHS improvements is difficult and personally risky.

So what would make a difference? A vivid and effective intolerance of small daily risk (forget the big canvasses), and actively encouraging managers to talk with their workers and unions about the pervading OHS scepticism and daily problems at their own task.

Obviously workplace fatalities are appalling tragedies, but overall – from most workers’ point of view – they are rare events.  In themselves they inform very little about the real OHS standards in most workplaces.  Accurate knowledge of the constant, small, daily risks taken, and an aggressive intolerance of them would make a difference, almost over night.

Dr Yossi Berger
National OHS Co-ordinator
Australian Workers’ Union

reservoir, victoria, australia

5 thoughts on “How much significant information do workplace fatalities provide?”

  1. As usual, I find Yossi\’s no nonsense approach to OHSW insightful and very relevant.
    His contribution highlights in my mind the need to clearly understand the motivation factors at work with SME operators, with particular emphasis on less than 10 employee Micro business operators.

    The last point in Yossi\’s argument stands as strong today as it always has:

    \”So what would make a difference? A vivid and effective intolerance of small daily risk (forget the big canvasses), and actively encouraging managers to talk with their workers and unions about the pervading OHS scepticism and daily problems at their own task.

    Obviously workplace fatalities are appalling tragedies, but overall – from most workers’ point of view – they are rare events. In themselves they inform very little about the real OHS standards in most workplaces. Accurate knowledge of the constant, small, daily risks taken, and an aggressive intolerance of them would make a difference, almost over night.\”

    The only issue I have with this element is that talking to business proprietors/managers who have little incentive to make any change that is perceived as a cost has not achieved any measurable improvement in injury incidents that were preventable.

    \”Aggressive Intolerance\” could be the way forward provided that the \”hip pocket nerve\” was attached to any transgressions and for that to happen someone has to be watching, inspecting and aggressively prosecuting.

    We have laws and regulations that require and demand certain standards of OHSW yet we are pathetic in our application of those laws and regulations and it would seem we are still focused on \”dumbing\” down those laws and regulations via the fiasco of harmonisation and we still have ineffectual enforcement to contend with.

    Unless an organisation such as the ACTU can aggressively force the issue then there really is not much hope of workplace improvement or management care.

    Maybe privatisation of enforcement with a profit incentive might get the job done, or is that a little unpalatable?

    I am yet to be convinced that there is any organisation currently operating in the interests of those at daily risk rather than for their own interests.

    There are many caring individuals trying to make a difference, but their success is limited to small localised wins from time to time.

  2. Nothing is truly learnt from workplace fatals, and nothing is learnt from suicides as a result of the workplace or the workers compensation system.

    There is a lot of time and energy wasted by so-called industry specialist who pontificate about how things should be done to ensure workplace safety, but whilst the bottomline of business is held up as the only thing of importance and the workforce is expendible, then workers lives will continue to be put a risk.

  3. Note my emphasis in the post


    \’intolerance\’ not elimination. The effective point being not the results – which I believe, will take care of them selves – but the managers\’ and workers\’ head space. As I said, forget the big canvass, forget the fancy talk (pyramids, icebergs, holes in cheese, gigantic flow charts), and forget the statistics and any projections from them; at least at the start.

    The emphasis ought to be on what goes on in people\’s heads, and of course, on their emotions. If we can reach them much else will follow.

    I\’m very reluctant to be theory (or model) driven in relation to OHS. Your comments open a very rich area of discourse in OHS, and the place of theory driven discovery of \’facts\’ and construction of OHS programs.

    If the OHS program you install to protect against some injuries is driven by a limited (hard core) analysis of what managers and workers actually do (or don\’t do) that\’s implicated in leading to the injury then your logic is correct.

    My point of view is that that\’s the wrong type of analysis. Understand the head space (heart as well) and the rest will follow.

    A slowly growing and utilised strong sense of intolerance to obvious, everyday, small risks that are taken all of the time will lead to a much more severe and dramatic response to large and blatant risks… and the courage to react.

    Will that stop fatalities and a greater proportion of injuries? Only if such intolerance is truly embraced by managers, and carefully nurtured and promoted. But since a lot of productivity too often depends on workers taking short cuts I am not convinced that this will be popular for most managers.

  4. Hi Dr Berger and Kevin,
    Very well written and thought provoking article.

    I am interested in your thoughts on whether intolerance and elimination of the small, daily risks in the workplace will reduce the risk of fatality in the workplace, or only reduce the rate of injuries? My thoughts are that the approach to eliminating twisted ankles, finger amputations and strained backs needs to be different to that taken to preventing single or multiple fatalities, and that the \”iceberg\” model is not necessarily holding true (in that reducing the number of near misses and injuries doesn\’t reduce the number/likelihood of fatalities).

    Two cases in point – the Deepwater Horizon drilling rig recording 7 years LTI free before the multiple fatality explosion, and recent general trends in the mining industry where LTI rates continue to fall but fatality rates have flattend out and in some sectors started to rise.

    Do you think a focus on injury prevention reduce the attention and resources put towards fatality and mutiple fatality prevention?

    1. Jamie, I am also critical of icebergs and cheese.

      Yossi\’s article and your question appeared around the same time that I received the latest research journal of the Institute of Occupational Safety & Health, in which Joan Eakin of the University of Toronto had a research paper entitled \”Toward a \’standpoint\’ perspective: health and safety in small workplaces from the perspective of the workers\”. She seems to tip-toe around the issue of changing culture but I think her paper is worthy of lengthy consideration (sadly these papers are not available online – one of the benefits of IOSH membership). She concludes:

      \”It is important to understand the standpoints of the different players in the OSH system because people act on the basis of how they see the world, how they understand the situation they are in and the stakes at play, and how they conceive others in the system and their relationship to them. However, a standpoint perspective on the OSH system as a whole demands more than just an understanding of the individuals and groups that comprise it. The OSH system has \’emergent\’ properties that are more and different than the sum of individual standpoints. I would argue that the analytic integration and theorisation of multiple standpoints and their interrelations is critical to understanding OSH at an organisational level of analysis. This paper is a step in this direction.\”

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