Peanut allergy fatality saga to continue

Safety management in the education sector seems to be one of the hardest management challenges.  There are overlapping safety obligations through OHS legislation, education department guidelines, public health matters and meeting the demands of parents and students.

700 Peanuts - Federal Court coverA decision in the Federal Court of Australia on 30 June 2009 illustrates the challenges.

A 13 year old boy from Scotch College, in Melbourne, Nathan Francis, died after eating from a ration pack of beef satay on a Defence Forces camp.  The school, which was supervising the camp, were aware of the boy’s severe allergy to peanuts.

The Australian Department of Defence was fined over $A200,000.

The full judgement of the court raises several  issues that are relevant to the management of safety of people in one’s care.  The judge has recommended a State coronial inquest to determine the roles and responsibilities of Scotch College in Nathan’s death.

Justice for Nathan and his family is likely to have many more months to go. [ SafetyAtWorkBlog will follow the issue.]

A fantastic audio report on the decision is available at the ABC website. The payment of the fine back to the government is not dealt with in this blog.

The first section of the judgement (below) indicates what the judge believes are the failures that need to be addressed through an appropriate safety process:

  • Communication;
  • Instruction;
  • Provision of appropriate supplies;
  • The importance of labelling; and
  • Following procedures and guidelines

Some readers may find that this prosecution could make an interesting case study for safety management.

Kevin Jones

Justice North found that the Federal OHS Act was breached by the Commonwealth government through the Chief of Army.  The respondent

(a) supplied Cadet Nathan Fazal Francis, Cadet Nivae Anandaganeshan and Cadet Gene van den Broek with one-man combat ration packs (CRP’s) containing a satay beef food pouch which contained peanuts or peanut protein for their consumption despite having been informed that the said cadets were allergic to peanuts;
and, in so doing, it failed to:

(b) warn parents of the [Australian Army Cadets] AAC cadets about the contents of the CRP’s;

(c) warn AAC cadets about the contents of CRP’s;

(d) warn AAC cadets with pre-existing food allergies of the contents of CRP’s;

(e) make appropriate use of information provided by AAC cadets and parents of AAC cadets regarding pre-existing or known allergic conditions and correlate that information with the potential risk of being exposed to allergies through the supply of food contained in CRP’s;

(f) ensure that the contents of CRP’s allocated to AAC cadets did not include food products or allergens that may have triggered allergic responses by removing or requiring the removal of peanut-based food products from CRP’s;

(g) prevent distribution or provision of peanut-based food products to AAC cadets with pre-existing allergic reactions by:

i. inspecting the contents of CRP’s to be allocated to those individual AAC cadets who had given notice of allergic conditions;

ii. isolating cadets with pre-existing medical conditions and/or notified food allergies at the time of distribution of CRP’s and issuing them with CRP’s that did not contain peanut products or other food allergens;

iii. removing all CRP’s known to contain peanut protein or other food allergens from circulation amongst AAC cadets;

iv. requiring all AAC cadets with notified allergic conditions to provide their own food supplies;

(h) issue any or any adequate instructions or provide adequate supervision regarding distribution of CRP’s;

(i) issue any adequate instructions or provide adequate supervision regarding consumption of contents of CRP’s;

(j) prevent the consumption of CRP’s containing food allergens by AAC cadets with food allergies;

(k) distribute CRP’s after consulting or considering pre-existing medical conditions; and

(l) take into consideration the findings of a report dated 22 November 1996 by the Australian National Audit Office entitled ‘Management of Food Provisioning in the Australian Defence Force’.

Safety culture improvements in Spain

The improved safety status in workplaces that have an active union presence has been verified through research, but what of the efforts on safety management from outside the union research efforts.

Below is the abstract of an article that was published online late-2008 (and is available for purchase).  The research was conducted in a country with a negative safety culture so the improvements may be more marked than from outside Spain.  However, the full study (not accessed by SafetyAtWorkBlog) may provide an interesting before-and-after story.

“Occupational accidents severely deteriorate human capital, and hence negatively affect the productivity and competitiveness of countries. But despite this, we still observe a scarcity of preventive practices, an unsatisfactory management commitment and an absence of safety culture among Spanish firms. The result is evident in firms’ high accident rates.  This situation is a consequence of the general belief among firms that investing in safety is a cost, and hence has negative repercussions for their competitiveness.  The current work aims to identify good practices in safety management, and analyse the effect of these practices on a set of indicators of organisational performance.  For this, we first carry out an exhaustive literature review, and then formulate a series of hypotheses.  We then test the proposed model on a sample of 455 Spanish firms.  Our findings show that safety management has a positive influence on safety performance, competitiveness performance, and economic-financial performance.  Hence they provide evidence of the compatibility between worker protection and corporate competitiveness.”

The full article is available in Safety Science (Volume 47, Issue 7, August 2009, Pages 980-991).

Kevin Jones

B Fernández-Muñiz, J Montes-Peón and C Vázquez-Ordás, ‘Relation between occupational safety management and firm performance’ (2009) Safety Science 47: 980-991.

Latest guidance on working alone

Western Australia’s WorkSafe has just released its latest guidance on working alone and it is the most practical look at the hazard from any OHS regulator in Australia.Working_alone cover

Importantly, it differentiates between “alone” and “remote”.  In 1995, when the Victorian First Aid Code of Practice raised the issue of isolation, there was considerable confusion.  How can someone in the metropolitan area be isolated or remote?

  • Undertaking an assessment of first aid needs of a multi-storey building which has cleaners or nightshift working at 2am.
  • Working alone in a petrol station in an outer suburb.
  • (Sadly) showing a potential client a new property in a new real estate development on the fringes of the city.
  • Security guard walking the perimeter of an industrial site
  • Delivering pizzas at 3am
  • Home visits from medical specialists

The WA definition of “alone” is very useful and needs to be kept front-of-mind in OHS policy and procedure production.  It could be used in the review process of existing policies and prores to ensure their applicability.

“A person is alone at work when they are on their own, when they cannot be seen or heard by another person, and when they cannot expect a visit from another worker or member of the public for some time.”

The working alone guidance identifies four industry types that require special support for working alone:

  • Agriculture
  • Pastoral
  • Forestry
  • Mining

Although SafetyAtWorkBlog advocates low-tech control options as much as possible (usually because of increased reliability) thankfully this guidance discusses mobile phones, satellite communications, GPS locators and other communications devices.

Kevin Jones

When employees are their worst enemy.

A recent article in a rehabilitation newsletter reminded me of a client from several years ago.

Several employees in a small item packaging line were reporting wrist and forearm soreness toward the end of their shift.  They believed that the line speed was too fast for them to comfortably work their full shift.

In consultation with the workers and the operations manager we went through various possible control options – line speed, automation, seating, posture, warm-up exercise, footwear, length of shift…..

A couple of days later, I was at the workplace at the end of the shift.  The employees said they were sore but they did not go home.  They stayed on for several hours of overtime.  When I asked them about this they said they always do the overtime.

So the assessment of working environment had incomplete data.

My advice was that if the employees were putting themselves at harm of the potential for harm, undertaking overtime while not fit-for-work contravenes their own OHS obligations.  If the employer offered these employees overtime knowing the employees were in pain, the employer is breaching the OHS obligation.

That is the straight OHS position.  But life is more complex than OHS.  The right OHS decision deprives the employees of additional income.  The right OHS decision could encourage employees to not report their pain or discomfort, for if they do, the offer of overtime would be withdrawn.  Non-reporting of injuries is a common short-term decision that many employees make.

It is in this context that consultation is required between employees, production manager, supervisor, human resources officer, and the health & safety rep, if one is on site.  This consultative group can then make a decision that everyone understands the justification for, even if some participants do not like it.

A question to ponder from the scenario above – if one of the workers developed pain during the normal work shift, undertook overtime without the employer being informed of the pain and put in a worker’s compensation claim for the pain, would the employer feel justified in contesting the claim?

Kevin Jones

Evidence, subjectivity and myth

There is a big push for occupational safety and health decisions to be made on evidence.  OHS academics in Australia are particularly big on this and there is considerable validity in the lobbying but as academics can have a vested interest in research, the calls are often dismissed.

There is also, around the world, a questioning of the value and validity of the risk assessment process related to workplace safety.  In Europe, in particular, the business groups see risk assessment as a major unnecessary business cost (but then again, how many businesses even perform OHS risk assessments?).  Risk assessment has often been criticised because of its subjectivity.  In some circumstances, risk assessment may perpetuate workplace and safety myths.

In the absence of evidence, myths fill the gap.  Sometimes assessments, investigations, estimates and FOAFs (friend of a friend) add to the tenuous credibility of those myths.

Peter Sandman has talked about dispelling myths through risk communication.  One myth he discusses, the risks of flu vaccinations, is also touched on in an interview with Dr Aaron E. Carroll of the Indiana University School of Medicine on the ABC’s Life Matters program.

OHS professionals must seek evidence on workplace hazards so that their advice is sound but equally, myths must be countered.  The links in the paragraph above, along with the excellent website, www.snopes.com, can provide some assistance in how we can reduce the transmission of myths.

I am a big advocate of the “contrary”.  Only by asking questions about established beliefs and tenets can the flaws in our decision-making be illustrated.  Sometimes this is dismissed as being a “Devil’s Advocate” but the process does not advocate bad behaviours, it questions the basis for established behaviours – a process that many people, organisations AND business find enormously threatening.

As we get older or become socialised, we tend to forget the tale most of us heard as a child, The Emperor’s New Clothes.  This tale should be read regularly to remind us of how the contrary position, the quizzical, can be constructive and sometimes, revolutionary (even though in the tale the Emperor ignores the child’s spoken truth) but still provide evidence.

Kevin Jones

Root Cause and Camels

In tertiary risk management courses, one is urged to look for “contributory factors” to an event.  An event can be a specific action or failure but a good investigation looks at the factors that led, or conspired, to the failure – “contributory factors” – as well as the failure itself.

For example, a common phrase is “the straw that broke the camel’s back” meaning a specific event that caused damage.  The common application of this phrase focuses on a single event in an already overburdened situation.

However occupational health and safety (OHS) expands this single event over time and work to analyse the cumulative effects on the camel of carrying innumerable straws.  It just so happened that one particular straw broke the camel’s back.

OHS is also about the cumulative effect of hazards on a company’s health.  There are a multitude of camels and a multitude of straws but the focus remains the same – investigate the combination of issues or hazards that culminated in an injury, event or disaster.

Decades ago investigators would look for a “root cause”, a phrase rarely applied in the technical discipline now but one that remains in common parlance.  However, root cause is not something that OHS professionals should forget or ignore.  A root cause can be an aim of an investigation but not one that dismisses other possibilities.  This may be why the term is out of vogue because it implies a fixation, an “Ahab”, which is a perspective that leads to very poor decision-making in all of the areas of work, business and life.

Kevin Jones

Flawed first aid information

First Aid Complaince CodeSome time ago WorkSafe Victoria issued Compliance Codes on a number of workplace safety issues.  One was concerning First Aid.  The Compliance Codes were intended to replace Codes of Practice which had been around for decades.

The previous major change to workplace first aid was in 1995 when the First Aid Code of Practice was reviewed in Victoria.  Other Australian States vary between prescriptive and non-prescriptive first aid guidelines.

On 31 May 2009, WorkSafe released a factsheet on first aid for low risk micro businesses.  A low risk micro business is explained in the factsheet as those that

  • employ fewer than 10 people
  • are located where medical assistance or ambulance services are readily available
  • are businesses that don’t expose employees to hazards that could result in serious injuries (eg serious head injury, de-gloving, scalping, electric shock, spinal injury) or illnesses that may require immediate medical treatment.

First Aid for Low Risk Micro BusinessesSome examples of low risk micro businesses were included in the factsheet –  “retail shops and outlets, offices, libraries and art galleries” Why a one page information sheet for this sector was deemed to be needed is a mystery?  I asked WorkSafe several questions about this factsheet

  • What was the rationale for the production of this guidance for this sector? Given that the Compliance Code is specifically referenced.
  • Is retail really a low-risk micro-business?
    • What about the use of ladders?
    • Young workers?
    • Working alone or unsupervised?
    • Occupational (customer) violence?
    • Petrol stations?
    • Convenience stores?
    • Night shift security needs?
    • Knife cuts from removing stock from boxes?
    • Manual handling?
  • First aid kits are required but not first aid training. In the case of respiratory failure a first aid kit is next to useless for CPR.
  • Why is only St John Ambulance referenced on the guidance?

The factsheet misunderstands first aid by placing low risk microbusineses into the “paper-cut” sector.  This is doing micro-businesses a dreadful disservice.

TRAINED FIRST AIDER

Shortly after the First Aid Compliance Code was released St John Ambulance broadcast an email about workplace first aid compliance.  In that email St John wrote:

Low risk organisations (office, libraries, retail etc) should have at least one qualified First Aider for 10 to 50 employees…

The May 2009 fact sheet makes no mention of the need for a trained first aider but WorkSafe’s own Compliance Code states this as a compliance element.

A low-risk micro-business may not generate the potential hazards that WorkSafe lists in its definition above but employees in these businesses do have to respond to the injury needs of their customers.  In these times of public liability and the expansion of OHS obligations to include customers, neighbours, and others who are affected by work processes.

WorkSafe itself describes an employee’s duty of care:

“All workers have a duty of care to ensure that they work in a manner that is not harmful to their own health and safety and the health and safety of others.”

The omission of a trained first aider is unforgivable.  What would an employee do if a client collapses in the foyer of a convenience store with a heart attack or chokes on the food that they have just purchased?  What would one do if a stab victim stumbles into the only open retail outlet, perhaps a petrol station, at 2.00am? How would that petrol station attendant  treat someone who has had petrol accidentally splashed in their face?

These matters cannot be treated by a person who is untrained in basic first aid who only has a first aid kit available.  Training for all workers who work alone or in isolation in micro-businesses is a basic element of compliance, one that WorkSafe fails to list in its latest workplace first aid factsheet.

EMERGENCY NUMBER

Almost as unforgivable is that the factsheet makes no reference to the Australian emergency number of 000.  One of the first actions to be performed in a workplace where someone is seriously injured is to call for an emergency ambulance.  While waiting for the medical authorities, and if safe to do so, first aid should be rendered. WorkSafe needs to remember that CPR requires training and that a first aid kit is next to useless in this type of situation.

ST JOHN AMBULANCE

It is curious that only St John Ambulance is listed on the factsheet for further information.  There are many first aid equipment and training providers in Victoria.  It would have been fairer to either recommend all providers or none at all.

[UPDATE: WorkSafe has advised SafetyAtWorkBlog that they will be addressing the St John Ambulance and 000 issues raised.]

COMPLIANCE CODES

On 18 September 2008, the WorkSafe website described the First Aid Compliance Code as covering

“…first aid arrangements including first aid needs assessment, first aid training, first aid kits and first aid facilities.”

In a media statement at the time on compliance codes generally WorkSafe Executive Director, John Merritt was quoted:

“The codes were developed after extensive consultation with industry, employers, employees, governmental agencies and the community to provide greater certainty about what constitutes compliance under the OHS Act.”

“The codes include practical guidance, tools and checklists to make it easier for duty-holders to fulfil their legal obligations.”

Mr Merritt added that: “These codes will provide Victorian employers, workers and Health and Safety Representatives with certainty and assistance in meeting their responsibilities.”

The Compliance Codes are aimed at the many dutyholders yet one of the rationales for the new single sheet guidance is that dutyholders (employers) do not read Compliance Codes.  It seems that the Codes are now principally read by OHS professionals and advisers.

(This position may be one of the reasons WorkSafe is pushing so hard for a truly professional OHS structure through its HaSPA program – the establishment of an OHS middleman between the rules and their application in the real world.)

It is a considerable change to the readership the Compliance Codes were aimed at and is a substantial change from the Codes of Practice which, in the case of First Aid, were handed out to all first aid trainees, included in information kits for health & safety reps, and were read by dutyholders and integrated into their OHS management practices.

The significance of Compliance Codes and Codes of Practice at the moment is that these documents are to be part of the Federal Government’s move to harmonisation of OHS laws.  (Some eastern States have already begun joint publication of guidances). Variations in these documents, often the most referred-to OHS documents in workplaces across the country, will undercut the aim of harmonisation – the reduction of business compliance costs through harmonised OHS requirements.  If the practical application of laws are not harmonised, the aims will never be met and the process could be seen as seriously flawed.

Kevin Jones

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