Such are the warning signs
It stopped at 2.32 pm of an ordinary day. One string of events ended abruptly at the pinch point of a groaning conveyor belt when his arm was ripped off. Do you think of Swiss cheese models of risk alignment? Of complexity or failure to learn? Of the Moura coal mine disaster, the Longford oil and gas plant disaster, the Baker report and the BP Texas City refinery fatalities, of 29 miners killed in the desolate and terrorising Pike River coal mine, NZ, 2010? Do you think of precariousness lurking at work, of leadership, of productivity?
For me this was the 5th arm I was personally aware of disappearing violently at work, generating years of withdrawal and solitude unrecorded in any OHS statistics. In that time I had also observed hundreds of missing or useless machine guards. Such a well known and easy hazard to fix. What exactly is the problem, what does it indicate about OHS generally, and what may go some way towards practical improvements?
Signs of increasing volumes of methane in a coal mine (e.g. Pike River) provide important safety warnings. In hard rock mines signs of increasing seismic activity do the same, (e.g. Beaconsfield Gold Mine). Numerous ammonia escapes from liquid storage tanks at a chemical facility are signs. Increasing reports of bullying, fatigue and stress at work provide their own H&S signal information; something is wrong. The events described below seem to me to be warning signs, but for the field of a romanticised OHS theatre, (“We’re in this together, Team!”, “My door is always open”, “H&S comes first”).
1. “Ultimately, the worth of a system depends on whether health and safety is taken seriously by everyone throughout an organisation” (Pike River Coal Mine Royal Commission report, 2012, RC). In 25 years of work in OHS I have observed (with few exceptions) that in smaller workplaces ‘doing’ H&S is typically regarded as non-critical, unimportant, at times trivial; that’s not taking it seriously.
In larger workplaces, some with terribly dangerous hazards, the talk about H&S verges on the quasi-religious, (“Oh, you must use ear plugs here, we’re very very strict about that”, “When you’re in the factory you must walk only between the yellow lines. Only”, “You must wash your hands before eating here. Lead is toxic you know?!”) but actual, daily H&S practice related to, say, plant integrity, plant safety features, difficult work methods, tortuous rosters is trivialised by a dishonest focus and shelves full of useless ‘how to’ documents. This also helps to maintain the not-so-secret belief by too many managers that H&S is non-critical for productivity but you do need the paperwork ‘to cover your arse’, but generally you get away with most things. That’s not taking it seriously.
So on the logic of the RC quote above the majority of these systems are heading towards worthless.
2. A director of Pike River coal mine is reported to have said at the hearings –
“… the site managers were responsible for bringing the [safety] issues they considered important to the board’s attention. These people were very competent and the board had every confidence in them. There were plenty of opportunities for site managers to bring safety concerns to his attention in both formal and informal situations, and he was surprised [emphasis added] that they had not done so.”
And in the report,
“The board did not provide effective health and safety leadership and protect the workforce from harm. It was distracted [!] by the financial and production pressures that confronted the company.”
These are neither new nor unique but they are signs of fake, of pretence.
3. “There were numerous warnings of a potential catastrophe at Pike River. One source of these was the reports made by the underground deputies and workers. For months they had reported incidents of excess methane (and many other health and safety problems). In the last 48 days before the explosion there were 21 reports of methane levels reaching explosive volumes, and 27 reports of lesser, but potentially dangerous, volumes. The reports of excess methane continued up to the very morning of the tragedy. The warnings were not heeded.”(RC)
If a frequent pattern of management behaviour prevailed they would have been unheeded not because of ‘systemic problems’, poor ‘safety culture’ or losing the lessons of the past, but simply because key managers didn’t forcefully and effectively demonstrate that good H&S standards were absolutely non-negotiable, regardless of their relationship to productivity.
4. “A serious problem was the workers’ practice of bypassing safety devices on mining machinery so work could continue regardless of the presence of methane.” (RC)
Short cuts at work are neither surprising nor a new discovery, particularly under productivity (and time) pressure and dishonest H&S programs, (“Our workers are our most important resource. They always come first”), and often wrong proportion of inexperienced to experienced workers. It’s a common practice tolerated with silence and a blind eye even in hostile working environments like mines, (Berger, 2009, Breaking the silence of known but unsaid things). To pretend otherwise is a damaging corruption of information. The elephant in the room: why is this common practice tolerated in silence by so many? What does that really indicate about the daily practice of OHS?
5. It doesn’t come as news –
a) that risk assessments, seen as fundamental to H&S Management Systems, are much too frequently ineffective, (e.g. Beaconsfield Gold Mine, Coroner’s Findings).
b) that H&S matters are given low priority at board meetings (even if they are proclaimed as always the first item on the agenda). Or that most managers are reluctant to burden their boards with H&S detail.
c) that H&S and training departments struggle for credibility next to the relentless drive for profit, (“The safety and training department at Pike appears to have been marginalised”, “Generally, his department [H&S training] struggled for credibility alongside the more production focused departments”, “Comments made …..in November 2010 by some of the second intake of trainees indicated that the safety approach taught in the classroom was not always evident underground” (RC)).
d) that growing number of H&S problems are regularly ignored.
e) that a convenient abdication by top management and board members to ‘more OHS-competent people’ is regular. Such experts then generate 398 ‘how to’ documents that explain in great detail all the ins and outs of a duck’s bum but aren’t properly implemented for daily improvements.
f) that frequently former high flyers (in various organisations) on the way down that slippery pole, perhaps as a result of dramatic political or corporate changes, are offered responsibility for H&S, or given a safety ‘research’ project, even if they know little about it and have zero interest in it. For most this ‘pick me up as I come down’ becomes the equivalent of the depressing Japanese window desk that looks out onto everything and nothing at the same time.
All of these are warning signs about an entrenched practice of OHS and its values. Not everyone is an eyewitness to all of these, but most of us are ear witnesses, and we ain’t all that naive. We do know.
The system is buggered
Somewhere in that event space between that worker’s arm being ripped off and what so many post-disaster reports repeatedly conclude (also see Penrose, 2007, Losing the Lesson of the Past) convenient distortions of information occur. These result from an uncomplicated corruption of simple facts. This, in turn, nurtures and sustains the current approach to OHS and its implicit values, and spawns damaging ‘theorems’ (e.g. “H&S is a joint effort”, “We’re a team”, “It’s to do with safety culture”), and an invalid ‘how to think about it all’ (e.g. “A risk assessment-based Management System”). The notions of a research or a social paradigm (Kuhn, 1962) are premature here.
This is an insidious two-stage corruption. First, of reasonably accurate workplace information, and secondly, knowingly responding to that as a fair representation. I believe the worst of it is the second stage, with people knowing that this information is inaccurate and misleading, but choosing to pretend that it isn’t; philosophers used to call this bad faith. But this culpability is not shared equally. Some are just brought up on and/or are educated in this OHS discourse with its thin concepts and accepted ‘wisdoms’ and then refuse to be seduced by the obvious.
“Nah, Mate” a worker once corrected me on the 10th day of a long and bitter strike triggered by regular exposure to a carcinogen. The strike involved hundreds of workers. “It’s the system that’s buggered!” and then, along with over a thousand others ‘waved’ his hand meaningfully at the company HR executive who had provocatively stuck a video camera out of a window at the sea of angry workers’ outside the gate.
I tend to agree. It’s ‘the system’, as he said, not….. “the systemic problems lying behind the tragedy” (RC). This is a serious difference. But what does that mean? In simple terms, the way this society has come to talk, think and act about daily health and safety conditions for its children at work, (pick your preferred age, 18? 25? 35? 55?). How can it be otherwise if its laws, regulations, codes of practice and the entire aspirational paraphernalia of limiting and standard-enabling documents specify and allude to (approximately) one kind of world view (e.g. responsible care and effective concern), and the very opposite happens daily in hundreds of thousands of workplaces? The stark truth is that currently H&S programs (if there are any) in most small to medium workplaces – where most workers work – do not have any relationship to productivity. But a competent and decent manager will have an eye to both. And it’s that decent manager who’ll make it appear as if good H&S standards and productivity are causally related. As he/she gains respect, trust and loyalty improvements generally will increase. Minister Shorten’s Centre for Workplace Leadership is a good move. But it will only work if Decency&Dignity 101 is fundamental.
Chameleon-statistics vs. reality
Work-related fatalities, whilst obviously tragic, are not the main daily problem for the vast majority of workers, (more that 11 million who work about 50 million hours per day – think of how many separate tasks that spawns!). Nor do they usually indicate these problems, despite what politicians and bureaucrats use them for in chameleon-statistics to make silly points. The vast majority of H&S problems are to do with the constant, ever pressing crowd of hazards that workers work with every hour – one at a time – where, mostly, no injury (of the recorded kind) occurs. Workers know 28 things that are going wrong every day, whereas the boss and H&S officer choose to know only 2 and 5 respectively. For example: working in eye ‘burning’ caustic soda or menthol mists and fumes for 20 years; or in frequent breath-stopping SO2; or with asphalt-related daily nose bleeds; or suffering regular workplace asthma; or with permanently roar-ringing factory ears; or skin that had absorbed chemical mists, fumes, aerosols and smokes which then sweats out every night in unnerving multi-coloured body silhouettes on the sheets; or not sleeping well for years on end, humiliated, stressed, bullied, and frightened to lose their job. By being orchestrated to shut up (or use bullshit terminology) they have essentially been banished from themselves. Of course not everyone, but too bloody many!
This aggregate of one-at-a-time familiar hazards, with the one-at-a-time pattern of response behaviour is the process of normalised tolerance of such strings of daily events that creates the nursery for most OHS incidents. This includes both personal and process safety. Rigid personal intolerance of these daily hazards would have a profound influence on the career path of very serious hazards including growing process risks that have the potential for huge catastrophic consequences. This is a different point of view about the personal vs. process safety discourse. I do not believe that H&S incidents (personal or process) are unique, localised storms in a sea of tranquillity. Rather, they are fomenting events in a sea of endemic tolerance of risk and regular near misses.
Since both politics and industry have not matured to a civilised stage where most workplaces and all machinery design are decently safer, and OHS matters are demonstrably paramount, one way to maintain practical attention on them is by strong and genuine encouragement of workers to practice a vigorous and open intolerance of all local, well-known hazards, including the destructive psychosocial ones. This manner of defence would then tightly couple with the entire approach and turn it on its head. It would become the gate keeper manner for all matters to do with H&S, including design. Proper consultation was supposed to achieve that, but that method itself was corrupted beyond recognition.
Two main things would happen: first, workers would develop and practice an open, almost reflexive mental ‘posture’ about local, daily hazards, (“Not on your life, mate, not here!”). This would have to be powerfully and loudly endorsed and welcomed by their managers.
Secondly, managers would become well aware of that approach and would never tolerate 21warnings about explosive volumes of methane in a coal mine, or be allowed to by their workers. All managers would need to take some specialised (very solid) OHS training relevant to their industry (including some history) so their understanding of due diligence requirements would be sharpened, and they couldn’t just leave it to their workers. But, this bottoms up approach is not enough on its own.
The IR monster has over reached
The current (legalistic) approach of industrial relations (IR) as the main tool kit to deal with work life, with its focus on employment and pay, generates the basis for treating OHS as a second order activity, despite the common rhetoric, (“It’s our top priority”).
A counter argument could go: when managers employ people, or unions recruit members the essential condition is ‘to be employed’. Since you can’t be safe at work unless you are ‘at work’ (employed) doesn’t that suggest that employment and wage conditions are primary?
No. Consider if you’d like to be employed in a well-paid, unsafe, unhealthy and evil job, (e.g. cruel to animals; in a seismic, asbestos-containing mine)? The majority of those who have a genuine choice would not. What kind of job it is does matter. But in a forced choice between being seriously unemployed or getting work in a workplace with low levels of, say, asbestos, or benzene fumes, or unguarded dangerous machinery I suspect the H&S issues would get only secondary consideration from too many people. And that’s consistent with what the man said, “It’s the system that’s buggered”.
Tests of this tension (employment/safety) seem impractical and uninformative: “Would you rather be unemployed for 10 years or dead for 10 seconds?!”, “Would you rather put food on the table for your family (and pay worrying bills), or keep looking for a safer and safer workplace?!” These are indicators of the problem, not relevant tests of practical choices and correct messages. When the CFMEU banned work across industry after any workplace death (in construction) that sent a firm message about H&S. So do bans of dangerous/ poor/ injurious equipment (Australian Nursing Federation), toxic chemicals (Australian Workers Union), or shameful structures (Maritime Union of Australia). But all of that is not nearly enough.
So, should employment and pay issues be secondary to H&S? No; I am arguing that they are just another aspect of working conditions, but these conditions should begin by providing a safe, healthy and sustainably decent place to work; nothing else should be acceptable. IR, as I see it, is a part of H&S conditions, not the other way around.
The point is to elevate the matter of workers’ daily H&S conditions to a primary status, to discourage treating workers as precariously employed pockets-in-waiting who also (in passing) need some attention to H&S standards. Maybe it’s a good time to be doing OHS, there is so much fresh stuff to be re-discovered, rehabilitated and implemented by leaders with decent values.
The Pike River commission of inquiry was the 12th of its kind in NZ. One of the comments made is that “….as a country we fail to learn from the past”, and it offers the suggestion that, “Government, industry and workers need to work together” (RC). But does not identify what exactly should be learnt from the past or how working together will really make a difference. Nor does it note the power of language to distort, (“Learn from past’, “Work together”), its persistence across the history of disasters, or its deep freezing of non-communications in the form of’ fashionable wisdoms’ (‘consult’, ‘jointly’, ‘learnings’). The creation of yet another shopping list of recommendations on its own will not be enough, even if it’s a good one, in the scheme of things, in a difficult task. The devil is in the daily detail at 2.32 pm of an ordinary day.