Big fine for Queensland Rail – big risks in rail

Almost two years ago, two rail workers died in Queensland. According to the official report into the incident:

“At approximately 1056 on Friday 7 December 2007, two QR [Queensland Rail] Infrastructure Services Group (ISG) track workers were fatally injured as a consequence of being struck by a track machine (train) at Mindi, approximately 130 kilometres south-west of Mackay.

The collision occurred when Track Machine MMA59, in the process of conducting track resurfacing work on the Down line at Mindi, commenced a routine reversing movement.

During the process, two QR Systems Maintenance personnel, working on the same track and behind the track machine, were struck and fatally injured by this track machine.

Analysis of evidence and conditions surrounding the accident revealed:

An overall lack of compliance with elements of the QR SMS at the Mindi site; and

Inadequate communication and coordination between workgroups at the Mindi site.”

On 26 November 2009, Queensland Rail was fined $A650,000 over the deaths. The fine is only $A100,000 below the maximum fine applicable. According to a media release about the fine:

“The Workplace Health and Safety Queensland investigation found that QR’s safety management systems were inadequate for managing the separation of workers and plant, particularly when both were within the same section of track between signals.

It also found that QR knew the systems were inadequate and not working because it had been highlighted to management in a series of audits.”

Not only were Queensland Rail’s safety management systems inadequate, Queensland Rail knew they were inadequate because a series of audits had told it so.

Railway in Australia and elsewhere is one of the most regulated industries. It is also one of the industries with the most prescriptive set of rules. It is a complicated business but one where hazards are known and systems are in place to control these hazards.

The extent of QR’s failure to operate safely can be illustrated by some of the many recommendations made in 2008 by Queensland Transport:

The necessity for consistent and effective Worksite Safety Briefings by ISG personnel;

Preconditions to the reversal of vehicles in accordance with QR safeworking requirements;

Responsibilities and training syllabi for ISG Resurfacing personnel;

The necessity for pre-departure safety checks on ISG trains;

Provision of safe separation and segregation between ISG track workers and trains;

ISG SMS compliance monitoring, at the local level;

Fatigue management within QR, and in particular ISG rostering;

Management of the perceived relationship between ISG and Network Control;

Awareness of the priority of safety over commercial pressures by remote ISG staff;

Distribution of safety communications and documents within QR;

Representation for relevant stakeholders in operational change management processes;

Risk and change management training for ISG operational personnel;

Safety risks presented to ISG through the permanent coupling of track machines;

The safety value to QR of an enhanced and transparent reporting system;

The management of ISG district staff relationship issues; and

ISG and Network Access radio protocol compliance monitoring.

Many elements are familiar to other investigations in rail and other industries – fatigue, on-site communication, training, segregation, document control and distribution, local compliance enforcement, transparency in reporting…..

On 10 September 2008, the QR CEO Lance Hockridge said:

“When I arrived in November 2007, I found an organisation with a safety record that was improving but not what it should be. Only three weeks later we had a very tragic reminder of this when work colleagues Jamie Adams and Gary Watkins were killed at Mindi.

“Organisations hoping to achieve meaningful change must firstly be honest with themselves – we need to confront this reality and make the changes required.”

Queensland Rail did not face the reality of problems identified by safety auditors and two workers died.

The news of the record fine came at a time when the ownership of Victoria’s metropolitan rail network has changed from Connex to Metro. Victoria has a stressed rail service but has managed to avoid the controversy of Queensland Rail and RailCorp in New South Wales but this has been through luck rather than good management. The Victorian Government, and particularly the Transport Minister, Lynne Kosky, needs to read the Waterfall Inquiry report and the Queensland Mindi report to understand the personal, economic and political cost of not having a tightly managed, functional rail safety regime. Having been in power for just over 10 years, this government now owns all the Victorian problems and must account to the electorate for not fixing them.

The political risk was summarized in an editorial in The Age on 30 November 2009

“In September, a Senate report into federal funding of public transport found Melbourne’s network was badly managed in comparison with Perth’s government-operated system. A key problem was lack of accountability: it was unclear who was in charge. The consequences of the lack of an overarching transit authority to oversee the whole system are clear…..

New operators of trains and trams in new livery will struggle to deliver acceptable service unless the Government makes good its past neglect of infrastructure.”

The fact that the Victorian rail system is being privately operated will not be an acceptable shield when the first passenger train crashes with a jam-packed peak hour cargo.

Kevin Jones

Crushed finger leads to claim and Court

Regularly in OHS submissions to the government and on OHS discussion forums, safety professionals state that industrial relations should be kept separate from workplace safety issues. In a perfect world ? Possibly, but there was a court decision on 13 November 2009 in Australia that shows that this separation is not possible in the modern world.

According to a media statement from WorkSafe Victoria:

Concrete panel supplier, The Precast Company, pleaded guilty in the Dandenong Magistrates Court on Friday 13 November to failing to provide an injured worker with suitable employment as required under Victoria’s workers compensation legislation.

The Court heard that the injured worker was employed as a crane operator when he suffered a crush injury to his finger. He attended Dandenong hospital and 5 days later was certified as being fit for alternative duties.

Two weeks later, he left work early on a Friday to attend his doctor. When he returned to work the following Monday he was informed that he had abandoned his employment and had no right to be there.

At the time, the company defended its action stating the worker had not been dismissed, but instead had walked out of the workplace half way through the day without reason.

As the injured worker had an accepted workers compensation claim, The Precast Company, in dismissing the injured worker, had failed to provide suitable employment despite the worker being certified as fit for alternative duties. Under the State’s workers compensation laws, an employer is required to provide employment to an injured worker who has a capacity for work.

The company pleaded guilty to one charge of failing to provide suitable employment and was fined $2,500 without conviction and agreed to pay costs of $1,500.

WorkSafe’s own summary of court action provides more details:

The defendant company operates in the building and construction industry. It has declared annual remuneration of about $2 million and has 45 full-time employees. An employee working as a crane operator suffered a crush injury to his finger on 1 April 2008 and was issued with a certificate of capacity certifying him ‘unfit for all duties’ from 2-4 April and fit for alternative duties from 5-16 April. The worker returned to work on 7 April on light duties. He left work early to attend a doctor’s appointment and returned to work on 14 April and continued light duties. He saw his doctor on 17 April and was issued a further alternative duties certificate from 17 April -1 May.

On 18 April the worker left work around midday to attend his doctor’s later that afternoon when he was issued with another certificate. At this stage he had still not submitted a claim form. When he arrived for work on 21 April he was told that he had abandoned his employment and had no right to be there. He went home and soon after sought legal advice. He lodged a claim for compensation that day which CGU accepted.

The defendant company’s director wrote to WorkSafe stating that the worker was not dismissed but had abandoned his employment on 18 April 2008. The director was overseas on that date and his explanation is based on what other staff have told him. The foreman provided a statement to a circumstance investigator that on 18 April the worker “just walked out of the workplace half way through the day. He would not provide a reason. As far as I was concerned he was abandoning his employment at this time.”

On 23 June 2008, the date that the worker’s claim was accepted, he was issued with a certificate of capacity certifying him fit for alternative duties until 21 July. By dismissing the worker the defendant company failed to meet its obligation to provide him with suitable employment once his claim had been accepted.

These are the only public details available at the moment but clearly effective communication was not occurring between the employee and the company. Sometimes circumstances that involve safety become a more complex industrial relations issue which may lead to Court, no matter how hard you try to compartmentalise them.

Coincidence or unique perspective?

Since the end of the end of the public comment phase on Australia’s national model OHS laws, Safe Work Australia has been daily uploading submissions to their website. Within the last lot of uploads was a block of around 100 submissions, all of which are marked confidential and have, apparently, been submitted by individuals.

One confidential submitter shares his name with a person who has been associated with some peculiar industrial relations behaviour. In August 2009, during a heated industrial dispute concerning work on the West Gate Bridge, a trade unionist pleaded guilty to dangerous driving and to carrying a piece of pipe without lawful excuse, according to one media report.

A person with the same name is also listed in an order issued by the Federal Court of Australia in March 2009 that places restrictions on several people in relation to the West Gate Bridge project and the premises of contractor John Holland.

It is not possible to determine if this is a coincidence because the submission is confidential and submissions do not include contact details. But if it is the same person, it is a shame that the OHS submission is not publicly available because a person who may have been involved in an intense industrial dispute and who may have been legally restrained would surely provide an interesting perspective on the relationship between OHS and industrial relations.

It is relatively easy to determine the politics of organisations that make submissions but when lodged by individuals political perspectives or professional connections cannot be determined, even when the submission is not confidential. That such a large number of confidential submissions have been lodged is curious but due to due process, it is likely to remain so.

Kevin Jones

Where is the evidence of OHS misuse for IR purposes?

The mainstream press has dipped into some of the submissions to the Australian Government on its harmonisation of OHS laws. Kirsty Needham reports on the submissions in the Sydney Morning Herald.

Needham reports on basically the submissions of the Australian Chamber of Commerce & Industry and the Australian Council of Trade Unions – the ideological opposites on safety regulation. She quotes ACCI’s David Gregory:

“There is no doubt that health and safety has been used as an industrial relations issue on plenty of occasions … we want to put reasonable boundaries around those entitlements.”

This position is always attached as a myth by the unions but it is an accepted fact in the minds of employers, OHS professionals and many workers. The Royal Commission into the Building and Construction Industry in 2003 found that

“in the building and construction industry throughout Australia, there is…..widespread use of occupational health and safety as an industrial tool.”

“The types of inappropriate conduct which exist throughout the building and construction industry include….the use by a union of occupational, health and safety (OH&S) issues as an industrial tool, intermingled with legitimate OH&S issues;”

“Occupational health and safety is often misused by unions as an industrial tool. This trivialises safety, and deflects attention away from real problems. Unions have a legitimate interest in the safety of their members. This should not be altered. However, the scope for misuse of safety must be reduced and if possible eliminated.”

“Misuse of non-existent occupational health and safety issues for industrial purposes is rife in the building and construction industry. Genuine occupational health and safety hazards are also rife.”

A major source of evidence for the repeated statement of fact is mentioned in the final report from February 2003 was an “OH&S case study (Tas).”. SafetyAtWorkBlog is trying to obtain more details on this.

One example of the evidence that is readily available relates again to the Royal Commission. The Commission undertook an investigation into industrial disputes a the construction site of The Age newspaper in Tullamarine. The Commission reports

“the evidence from Mr Judson [Wayne Judson is a Director of Probuild] will be that during the negotiation of the project agreement (which was a period where any industrial action between Probuild and the unions would have been unprotected) there were many occasions when safety walks and OH&S issues were used as a device by the unions to pressure Probuild and Fairfax to agree to the project agreement and nominated shop stewards.

The potential misuse of OH&S raised, not of course for the first time in this Commission, is a very serious matter. To misuse OH&S debases the currency of safety. ‘Crying Wolf’ often enough on enough sites creates the risk that no one knows whether a safety claim is about something real and important or whether it is simply a means of supporting the latest industrial demand.”

Some of Commissioner Cole’s comments on the debasement of safety are sound but the “evidence” is from the builder and may not constitute the reality, only opinion in a submission to an investigative body. The Commissioner carefully labels the issue “a potential misuse”.

SafetyAtWorkBlog would say that the fact of misuse of OHS issues for industrial purposes may be an example of the establishment of a fact through “crying wolf”, to use the Commissioner’s term. The frequent statement of a belief does not establish a fact.

Also, to some extent, the construction industry hogs the OHS limelight in much of the tripartite consultation. This is because of the industrially charged nature of construction in Australia and the fact that construction sites are usually highly visible to public. The construction industry is an important economic driver but perhaps this prominence is masking some of the other OHS issues that the Government needs to consider.

As the Australian Government proceeds in its harmonisation of OHS laws and as it reads the hundreds of public submissions, there should be a red flag on each mention of the misuse of OHS for industrial purposes so that assertions are not misread as facts.

Kevin Jones

Behavioural-based safety put into context

Yesterday Associate Professor Tony LaMontagne spoke at the monthly networking meeting of the Central Safety Group in Australia. His presentation was based around his research into job stress and its relationship with mental health.

LaMontagne was talking about the dominant position in personnel management where negative thoughts generate a negative working environment, one of stress, dissatisfaction and lower productivity. SafetyAtWorkBlog asked whether this was the basis for many of the positive attitudinal programs, or behaviour-based safety programs, that are frequently spruiked to the modern corporations.

He said that this was the case and that such programs can have a positive affect on people’s attitudes to work. But LaMontagne then expressed one of those ideas that can only come from outside an audience’s general field of expertise. He said that the limitations of such programs are that they focus on the individual in isolation from their work. He wondered how successful such a program will be in the long-term if a worker returns from a “happiness class” to a persistently large workload or excessive hours. The benefits of the positive training are likely to be short-lived.

This presented the suggestion that positive training programs, those professing resilience, leadership, coping skills and a range of other psychological synonyms, may be the modern equivalent of “blaming the worker”. The big risk of this approach to safety is that it ignores the relationship of the worker with the surrounding work environment and management resources and policies. Even the worker who is furthest from head office does not work in isolation.

It is unclear what the positive training programs aim to achieve. Teaching coping skills provides the worker with ways of coping with work pressures, but what if those pressures are unfair or unreasonable? What if those pressures included bullying, harassment, excessive workloads? Will the employer be meeting their OHS obligations for a safe and healthy working environment by having workers who can cope with these hazards rather than addressing those hazards themselves?

Professor LaMontagne reminded the OHS professionals in attendance yesterday that the aim of OHS is to eliminate the hazards and not to accommodate them. He asked whether an OHS professional would be doing their job properly if they only handed out earplugs and headphones rather than try to make the workplace quieter?

Recently SafetyAtWorkBlog received an email about a new stress management program that involves “performance enhancement, changing the way people view corporate team dynamics”. Evidence was requested on the measurable success of the program. No evidence on the program was available but one selling point was that the company had lots of clients. This type of stress management sales approach came to mind when listening to Professor Montagne.

When preparing to improve the safety performance of one’s company consider the whole of the company’s operations and see what OHS achievements may be possible. Think long-term for structural and organisational change and resist the solutions that have the advantage of being visible to one’s senior executives but short on long-term benefits.

And be cautious of the type of approaches one may receive along the lines of programs that can change

“…high performance habits so employees can operate at 100% engagement and take their achievement to the next level while achieving a healthier culture in the workplace”.

Kevin Jones

Note: Kevin Jones is a life member of the Central Safety Group. The CSG is just finalising its website (http://www.centralsafetygroup.com/)where information of forthcoming meetings will be available.

Summer heat, fatigue and UV – a speculative solution

Let’s pull together several workplace hazards and suggest one control measure that may address all of them at once. Of course, the control may generate other work hazards or management challenges.

In Summer, work occurs throughout daylight hours. The long days, and possibly daylight savings, maximise the window of productivity for workers, particularly those who work outside – building construction, housing, rail maintenance, roadworks….. Such work can lead to the workplace hazards of excessive exposure to ultraviolet radiation (UV), fatigue, and heat stress.

Each of these hazards has its own separate advocates for safe practices, as well as the OHS regulator that provides guidance on all hazards. This complicates the management of OHS because sometimes there are conflicting control measures or at least measures that are incompatible with the needs and desires of the workforce. If we think of this combination of hazards as a Gordian Knot, we could solve the problem by splitting the working day into two sessions on either side of a sleep break or, as the November 2009 edition of the Harvard Health Letter calls it, a nap.

The Harvard article, “Napping may not be such a no-no”, discusses the good and bad of napping and the tone of the article seems to look at this control measure mainly for office-based or administrative tasks.

“[Robert Stickgold, a Harvard sleep researcher] says his and others’ findings argue for employer policies that actively encourage napping, especially in today’s knowledge-based economy. Some companies have set up nap rooms, and Google has “nap pods” that block out light and sound.”

The article suggest a couple of suggestions

“Keep it short. A 20- to 30-minute nap may be ideal. Even just napping for a few minutes has benefits. Longer naps can lead to grogginess.

Find a dark, quiet, cool place. Reducing light and noise helps most people get to sleep faster. Cool temperatures are helpful, too.

Plan on it. Waiting till sleepiness gets so bad that you have to take a nap can be dangerous if you’re driving. A regular nap time may also help you get to sleep faster and wake up quicker.

Don’t feel guilty! A nap can make you more productive at work and at home.”

But sometimes SafetyAtWorkBlog likes to extend a solution to the bigger picture.

In Australia, the peak period for extreme levels of UV is between the daylight savings hours of 10.00am and 1.00pm, or 3.00pm in some instances. If an outside work site suspended work for three hours, the employees could have lunch and rest, or sleep, in the shade. Depending on the location of the work site, some could even go home for that period.

The work day could still be as productive by starting early and finishing late, basically inserting a rest break of several hours into the middle of the daytime shift. There is evidence in the Harvard article that productivity could be increased as a result of the rest break.

iStock_000004187454 construction siestal

On quick reflection, this scenario is a fantasy because the ramifications of such a change are huge, and OHS is unlikely to achieve any structural cultural change of this magnitude, but it remains an attractive fantasy. The attraction is the logical simplicity but, of course, logic is often bashed around by reality and below are some of those realities:

Expanded work hours for a construction adjacent to a residential area working on the 9 to 5
Deliveries of supplies to be rescheduled to the two work periods
Would the split shift continue on cloudy and cool days or during Winter?
Would the portable/temporary lunch sheds now need to include a bunk room for all employees on a work site?
In a bunk room, would one person’s snoring becoming an occupational hazard for everyone?
Can plant be “paused” for the lunch break?
Can a concrete pour be interrupted for a lunch?

Lists of other problems or challenges are welcome through the blog’s comments field below.

Such a structural or societal control option (or fantasy) should be discussed, debated or workshopped as what may not work in the grand scheme may allow for changes, or tweaks, on a smaller scale. Often the best OHS solutions come from speculation which can lead to the epiphany of “why do we do it that way?”

Of course, some countries are way ahead of the rest of the world in managing these workplace hazards by already having a culture that embraces the “siesta“.

Kevin Jones

ng may not be such a no-no

Amputations, shocks and burns – court cases

In late October 2009, there were several OHS court cases in Australia that raise issues that need to be kept at the forefront of the thoughts of safety managers, safety professionals, workers and business owners.

Amputation

One case in South Australia identified the need to have sufficient detail in policies and procedures for workers to be safe. The comment of Industrial Magistrate Michael Ardlie is particularly important.

Beerenberg Pty Ltd was fined $A9,000 dollars for breaching OHS law

“The incident happened in May 2007 at the company’s Hahndorf premises. A female employee was operating a mincer as part of the process of producing green tomato chutney.

The court was told that at the conclusion of the task, the employee switched off the machine but noticed a piece of tomato hanging from the mincer plate. She went to flick the piece off, but in doing so lost the tip of her index finger.

SafeWork SA’s investigation concluded that the woman’s finger had gone through one of the holes in the mincer plate and come into contact with the cutting blade behind, which was still winding down after the machine was switched off.

The fingertip could not be reattached, but the woman returned to work with the business after five weeks. Aside from the cosmetic appearance, there remains some numbness in the finger.

In his penalty decision today, Industrial Magistrate Michael Ardlie acknowledged that while there was a safe operating procedure written and a warning sign in place, these measures alone were insufficient.

“(The measures) did not specifically warn employees of the dangers presented by the moving parts of the mincer after the mincer had been turned off… the procedures in place did not go far enough.”

Since the incident, the company has fitted a purpose-built distance guard as well as an interlock that shuts the machine down once the guard is removed.”

Magistrate Ardlie fined the defendant $9,000 this being its first offence.

Crushed Fingers and Guarding

The same Industrial Magistrate as above, McArdlie, had to deal with a very different case. Whereas Beerenberg was facing its first offence, OE & DR Pope are on their fifth.

“SafeWork SA prosecuted OE & DR Pope Pty Ltd after investigating an incident at its Wingfield printing plant in March 2007.

A 34-year-old male employed as a machine operator, suffered crush injuries to three fingers of his right hand, which were caught between moving rollers. While he returned to work after three weeks, he suffered residual sensitivity problems, and left the business in December 2007 for unrelated reasons.

The court was told that the operator had attempted to clean dry spots from a roller without stopping the machine, and was able to gain access to the moving parts through a 70mm gap in the guarding. Furthermore, the employee’s usual assistant was not available leaving him to perform two roles on the machine. The supervisor who also should have been present was elsewhere on the premises at the time.

In his decision on penalty handed down today, Industrial Magistrate Michael Ardlie noted that the machine involved had replaced another involved in a previous injury, but that a risk assessment failed to identify the problem which ultimately occurred:

“Whilst the defendant prior to the incident did assess the machine, installed a guard and introduced a Standard Operating Procedure, the steps it took were inadequate.”

The court was told that this was the company’s fifth offence dating back to 1998, and all previous incidents resulted in similar injuries from similar circumstances.

Therefore, being a subsequent offence under the Occupational Health Safety and Welfare Act 1986, the defendant faced a maximum fine of $A200,000. Magistrate Ardlie fined the company $A40,000.”

Fifth incident in just over ten years – “similar injuries from similar circumstances”. The reduced fine of $A40,000 seems a little odd in this context.

There are several elements that are disturbing in this case – ineffective guarding, excessive or conflicting workload and absent work supervisor.

Overhead Hazards

Just as falling in some workplaces is as “easy as falling of a log”, so it is that many people forget to look up. A court case in Western Australia has fined Shrigley Drilling Contractors $A40,000 after one worker was shocked and another burnt when their drilling rig tilted into high-voltage overhead powerlines in 2006.

“Laurence Victor Shrigley – trading as Shrigley Drilling Contractors – pleaded guilty to failing to ensure that the workplace was safe and, by that failure, causing serious harm to another person and was fined in the Perth Magistrates Court this week.

In May 2006, Western Power had contracted Outback Power Services to perform works and construct a voltage regulator at Eneabba. Outback Power had contracted Mr Shrigley to perform drilling works.

On May 17, Mr Shrigley and an electrical contractor were engaged in drilling holes with a drilling rig underneath power lines. The position in which the drilling contractor chose to place the rig required him to raise the mast very close to the power lines.

In repositioning the rig, the left-hand outrigger was raised and the mast tilted towards the power lines. The mast touched the power lines and Mr Shrigley received an electric shock and was thrown backwards from the drilling rig.

Another man, who was driving the truck that carried the drilling rig and was working with Mr Shrigley on a voluntary basis, also received an electric shock serious enough to set his clothing on fire. He sustained burns to around 60 per cent of his body.

The court heard that no formal pre-start meeting had been held before the work commenced, and no directions were given for the work, with the exception of where the holes were required to be placed.

Mr Shrigley had not checked whether the power lines were live, or attempted to make any arrangements for the power in the area to be isolated.”

The features in this case include contractor management, using a volunteer, inadequate preparation, and inadequate number of workers (apparently, no spotter).

It is understandable that cynicism is rampant in the safety profession when the same work practices lead to injuries in the 21st century just as they did in the 20th and sometimes in the 19th.

Kevin Jones

Category: construction

Big fine for Queensland Rail – big risks in rail

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Crushed finger leads to claim and Court

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Coincidence or unique perspective?

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Where is the evidence of OHS misuse for IR purposes?

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Behavioural-based safety put into context

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Summer heat, fatigue and UV – a speculative solution

ng may not be such a no-no

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Amputations, shocks and burns – court cases

Amputation

Overhead Hazards

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ng may not be such a no-no

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Amputation

Overhead Hazards

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