Category: death

Unique company response to confined space penalty

In 2007, according to the ABC news site,

“42-year-old Geoffrey Johnson [died after he] inhaled toxic fumes from paint stripper when he was cleaning the inside of a large chemical tank”.

On 16 December 2009, his employer, Depot Vic P/L, was fined half a million dollars over this breach of the OHS legislation.

Initial reports say that the company is no longer in business but it

“told the court is had put aside money to pay the fine.”

Wow.  What happened to phoenix companies?  – the business scourge that closes down to avoid paying outstanding debts and, often the costs associated with a worker’s death, and then starts up again under a different structure.

That a company will pay a fine for an OHS breach years after ceasing business seems a remarkable and admirable act.

Hyde Park Tank Depot’s assets were purchased by the Scott Corporation several months after Mr Johnson’s death, according to information SafetyAtWorkBlog obtained from Scott Corporation.  The current business and website listing was not operating at the time of Mr Johnson’s death.

WorkSafe Victoria provided background to Mr Johnson’s death in a prosecution summary in April 2009.  The full summary gives a clear indication why the fine was so high.

“Depot Vic Pty Limited (formerly known as Hyde Park Tank Depot Pty Ltd) undertakes cleaning, repair and maintenance of ISO containers for the chemical industry.  ISO containers are confined spaces, being portable tanks used to transport chemicals.  The tanks are usually cleaned purely by hydro-blasting, but on occasion the tanks were required to be cleaned more thoroughly.

The system of work was such that when this situation occurred, the cleaning of the tank required 2 stages. The first stage involved the application of a cleaning agent, usually a product known as ‘Selleys Renovators Choice’ stripper (which is not a dangerous good).

The second stage then involved the use of hydro-blasting on the internal walls to remove the stripper and clean the wall.  The company’s work instructions required that a confined space permit be issued and that appropriate PPE be worn.

On 16 August 2007, an employee of Depot Vic Pty Limited died whilst attempting to remove latex from the internal walls of a 25,500 litre ISO tank.  The deceased had entered the tank and instead of using the ‘Selleys Renovators Choice’ stripper, had used a product known as ‘Paint Stripper Gel GS 125’ that was suited to clean external components only (and not the inside of the tank).  The label of this product contained safety directions such as “do not breathe vapour” and “use only in a well ventilated area”.  This product is a dangerous good ‘class 6.1 (toxic substance) of packing group 111’.  It is also a hazardous substance according to the criteria of the Australian Safety and Compensation Council.

The deceased was located in the tank in an unconcious (sic) state, and when retrieved from the tank did not regain conciousness. An expert analysis of the atmosphere inside the tank concluded that that (sic) there was a lethal concentration in all or part of the tank (10 litres of the dangerous good was used).  At the time of the incident a confined space permit was not issued, the deceased was not wearing respiratory protection, gloves or a harness, and there was no ‘spotter’ in place to supervise the latex removal works.

Further, there was a lack of training and supervision of employees in relation to the work procedures for confined space entry.”

Kevin Jones

Director accountability for OHS reinforced by NZ penalty

On April 5 2008, a cool store in New Zealand exploded killing one firefighter and injuring 7 others.  Icepak Coolstore Ltd, according to the fire services investigation report

“[had] very large quantities of combustible material contained in the expanded polystyrene construction panels and also in the foodstuffs stored.

“There were no compliant fire detection or protection systems or hydrants, and very limited firefighting water.”

In July 2008, the New Zealand Department of Labour (DoL) issued a media statement and fact sheet concerning the explosive potential of flammable hydrocarbon refrigerants.

Language warning on the video below

On 15 December 2009, a New Zealand Court penalised two companies and a director with fines totalling over $NZ390,000.  The DoL has issued a media statement about the prosecution results.

The many reports and inquiries into the explosion and fire are very informative but one element that the DoL wants to focus on is the penalty applied to the Director of Icepak Coolstore, Wayne Grattan.  He was

“fined $30,000 on one charge that he acquiesced in the failure of the company to take all practicable steps to ensure the safety of its employees while at work.”

The Department of Labour’s Chief Adviser for Workplace Health and Safety, Dr Geraint Emrys said (click HERE for audio):

“The prosecution against the director of Icepak should serve as a reminder to officers, agents and directors of organisations that they can be held personally accountable for the failures of their organisation.

“Mr Grattan was charged with acquiescing in Icepak’s failure in respect of obligations to its employees.  The outcome of the case against Mr Grattan reinforces the requirements of directors to be proactive in health and safety matters.”

As many Commonwealth countries have a strong commonality of law, the Icepak Coolstore case should be an important case study in many jurisdictions.

Kevin Jones

OHS law and safety management

Regular readers will be aware that SafetyAtWorkBlog holds the belief that OHS legislation is not the same as managing workplace safety.  Safety can be managed without recourse to law (this is what many mean when they say that “safety is just common sense”) but legislation provides some parameters in which that management occurs.

The Australian Council of Trade Unions has issued a call for tougher OHS laws and used workplace fatality statistics as the basis.  Tying the two issues together serves a political purpose but avoids the fact that a range of economic, political, social and even environmental issues can affect how workplaces manage safety.

The media statement issued on 11 December 2009 says:

“A sharp rise in work-related fatalities last year shows that proposed new workplace health and safety laws need to be strengthened, not watered down, say unions.

There were 177 fatal injuries in workplaces in 2008-9, according to newly released statistics from the national regulatory body, Safe Work Australia. This is an 18% increase from the previous year…. [hyperlink added]

ACTU Secretary Jeff Lawrence said the increase in fatalities was disturbing at a time when proposed changes to Australian workplace safety laws would result in a weakening of protections and rights.

“A double-digit increase in workplace fatalities in one year is shocking,” Mr Lawrence said. “Each of these victims is someone’s partner, parent, son, daughter or friend.  The Federal, state and territory governments will make significant decisions about new national health and safety laws today.  If any evidence was needed that requirements for employers to provide a safe workplace need to be toughened, this is it. We urge the federal and state governments to make workers’ safety their highest priority.”

The ACTU is doing what it should by serving the needs of its members but the push for union prosecutions of OHS breaches is only one part of its social charter.  The aim of improving safety can be best achieved by motivating union members and establishing a dialogue with the general community, which includes business, small and large.

Is the day far off when we may see joint statements from unions and employer groups on the issue of workplace safety?  Can politics be put aside for the benefit of improving safety?  Comments welcome.

Kevin Jones

Self development course contributes to a workplace suicide

What would you do if a work colleague strips, screams, acts “like a child having a tantrum”, starts to sing and then jumps out of a window to her death?  That is the situation that was faced by staff at the Sydney office of the Royal Australasian College of Physicians in December 2005.

Only days earlier, 34-year-old Rebekah Lawrence, had participated in a self-development course called “The Turning Point” conducted by Zoeros P/L trading as People KnowHow.  The course, according to one media report, the course included a session called “The Inner Child”

“in which those taking part were encouraged to develop a dialogue between their child and adult selves.”

Lawrence’s actions just before her death mirrored some of the course teaching.

PeopleKnowHow’s website has closed down with an announcement that all of its courses are under review.  Other organisations that provide similar courses are running for cover.  Transformational Learning Australia has said it

“…no longer has a professional relationship, affiliation or any other connection with People Knowhow.” [emphasis added]

TLA also says any relationship ended in 2005.  That the company has felt it necessary to make a media statement about the end of the relationship shows the extent of the effect of Rebekah Lawrence’s death on this industry sector.

TLA goes on to say that

Our organisation does not accept participants who have a recent history of chronic mental illness, participants under the care of a treating professional who have not obtained that professional’s consent to participate, or people who demonstrate a propensity towards psychological fragility or a significant lack of cohesion during the introductory sessions of the program.”

The New South Wales Coroner found that in the absence of any history of psychosis in Rebekah Lawrence that,

The evidence is overwhelming that the act of stepping out of a window to her death was the tragic culmination of a developing psychosis that had its origins in a self-development course known as ‘The Turning Point’ conducted by Zoeros Pty. Ltd, trading under the name of ‘People Know-How” on the 14, 16, 17 and 18 December 2005.

The full coronial findings are difficult to read due to the personal details of Lawrence’s life, her relationship with her husband David and the general picture of her personality that comes through.   An upsetting and enlightening interview with David Booth is available online from earlier in the investigation process.

The findings also provide considerable detail to the components of the course that Lawrence undertook.  There is a greater level of detail than would be expected to be known by someone signing up for such a course and this is where the lessons can be learnt for the OHS professional and safety manager.

It has become common in many corporations who are trying to improve or introduce a positive workplace culture, to supplement their own efforts with “self-help” or “self-awareness” courses.  Lawrence’s death has highlighted the lack of regulation or accountability in some sectors of this industry.  This also highlights the need for people managers to thoroughly investigate such courses to ensure that good intentions are not likely to increase the risk of harm or damage to the employees who participate.

An audio report on the Coroner’s findings is available online.

Counselling Services

Many workplaces often provide access to counselling services through schemes such as Employment Assistance Programs.  The Coroner’s recommendations have some direct bearing on the issue of “counsellors”.

“The Executive Director of the Australian Psychological Society, Professor Lynne Littlefield pointed out that there are no legal restrictions in Australia for practising under the title ‘psychotherapist’ or under the title ‘counsellor’ and therefore no public safeguards against untrained or incompetent practitioners in this field.

Professor Littlefield pointed out that although there were many skilled counsellors and psychotherapists, there were also many whose competence is questionable and without any regulating mechanisms to stipulate the required training and levels of competence, there was no way of protecting the public from these poorly trained practitioners.”

Rebekah Lawrence’s death is receiving considerable media coverage in Australia at the moment and the New South Wales Government is carefully considering the Coroner’s recommendations concerning the regulation of some areas of the self-development industry.  Employers and safety professionals are going to have a very different set of criteria shortly from which such workplace-related courses need to be evaluated.

One media report has indicated the start of the ramifications of this unfortunate death:

“The NSW Health Minister, Carmel Tebbutt, said she had asked her department for ”urgent advice” on the case and would consider the coroner’s recommendations. A code of conduct for counsellors and psychologists had already been implemented and the Health Care Complaints Commission now monitored practitioners.

The Royal Australian and New Zealand College of Psychiatrists called for closer monitoring and accountability of self-help and psychotherapeutic courses.”

Kevin Jones

How much does poor safety management cost?

In late November 2009, the Victorian State Emergency Services (SES) was convicted of OHS breaches over the death of one of its volunteers and was fined $A75,000.  The SES has chosen to allocate $A150,000 to a review of its safety management after strong criticism from the Mildura Magistrate, Peter Couzens.

In answer to the title of this article, a minimum of $A225,000 and one person’s life.

In May 2007, a volunteer with the SES a, 54-year-old Ron Hopkins drowned on a training exercise in the Murray River.  WorkSafe Victoria provides the following scenario:

“A boat took the four volunteers doing the [swimming] test out into the river and they got in to the water but Mr. Hopkins soon got into difficulty.

An oar was extended to him from the safety boat but he soon disappeared below the water.

Despite the efforts of the SES personnel to find him, his body was recovered the next morning by NSW police divers.

WorkSafe’s investigation found the safety boat had life jackets for the two assessors who were in the boat, but there were no other buoyancy devices which could be used in an emergency.

Some other participants involved in the swim test also experienced difficulties in the cold water and after swimming to the centre pylon of the George Chaffey Bridge, they held on to bolt heads extending from a rubber buffer attached to the pylons at water level. They were later picked up by the safety boat.

At the time of Mr Hopkins’ death the SES had no rule against carrying out swim tests in water where there was limited visibility or where a rescue could be difficult to carry out if someone got into trouble.

As a result, lakes and rivers were sometimes used as well as local swimming pools.

At the time of this incident there were a number of swimming pools with the facilities to help anyone one (sic) who got into difficulties in the Mildura area that could have been used for the test.”

Hopkins had been a member of the SES for seven years and had participated in searches associated with drownings previously, according to one AAP report.  The SES expressed regret and sympathy at the time of the incident in a media statement.   A short report of Hopkins funeral is available online.

As the Murray River runs on the boundary between Victoria and New South Wales a NSW coronial inquest was planned until the Victorian prosecution was announced.

At the committal hearing in June 2009, the magistrate allowed Hopkins’ widow, Meryl, some input in the Court procedures.  And in the November 2009 hearing, Mrs Hopkins’ victim impact statement is reported to have said that:

“… since the incident Mrs Hopkins had felt her life had lost meaning and she sometimes wished she had drowned with him.  The court heard she had experienced mental and physical health issues, including post traumatic stress, panic attacks, exhaustion and sleep disturbance.”

In 2003/04 Chris Maxwell undertook a review of the Victorian OHS Act and was critical of the special treatment provided to government authorities at that time and advocated that any organisation that breaches OHS law should be treated equally.  Maxwell told the Central Safety Group in 2004:

“I have to address a meeting next week of the Heads of Department to talk to them about the chapter entitled “The Public Sector As An Exemplar”.   They need it explained a little more fully. It is good that the Public Sector wants to grapple with the issue “what does that mean for us?”   It is a theme of the Report that the public sector should be treated exactly the same as the private.  It shouldn’t be otherwise but the history of prosecutions tends to make you wonder about that. I know John Merritt, the Executive Director is absolutely committed to that principle. It is interesting to note that the Education Department has recently received an Improvement Notice.”
In his actual report he advocated that government departments should not only be treated the same but that they should become OHS role models.  When comparing the Victorian situation with a UK review he wrote:
“I would go further, however, and suggest that government (as employer and duty holder, and as policy maker) can, and should, be an exemplar of OHS best practice.  By taking the lead in the systematic management of occupational health and safety, government can influence the behaviour of individuals and firms upon whom duties are imposed by the OHS legislation.”
If this had been embraced by the OHS regulator and government departments agencies imagine the state of OHS compliance on matters of workplace stress and manual handling in health care and other public service hazards.  And maybe, the SES OHS program would have been further advanced than it was in 2007 when Ronald Hopkins died.

Safety awareness ≠ safety (always)

Workplace fatalities have markedly increased in Victoria over the last couple of months.  According to WorkSafe Victoria information nine people have died within the last two months bringing the current total to 27 for 2009.

Victoria has a high awareness of the need for safety in the workplace, principally due to the advertising campaigns of WorkSafe which began, in one form or another, in the 1980s when Andrew Lindberg was WorkSafe’s CEO.  But clearly awareness of the need for safety is not being translated into action.

WorkSafe Victoria has become alarmed at the recent surge in deaths and issued a media release asking for things to settle down.  John Merritt, executive director, has said

“With many industries now reaching their peak activity the risks are extreme as people rush to get work completed and begin to think about what Christmas, holidays and the New Year has to offer.

“The construction and manufacturing sectors are aiming to complete projects before a summer shutdown, while transport, warehousing and retailing are ramping-up to Christmas.

“With just a few weeks before Christmas and the spectre of nine deaths in two months behind us, employers and workers must lift their game and reject the urge to take shortcuts or become complacent.”

But there is nothing unique about this time of year as the same activities, the same work pressures exist each year at this time.  More analysis is required of why this October and November 2009 have been particularly bad.  This analysis needs to be much deeper than the market research and attitudinal studies that OHS regulators frequently undertake.

Dead men tell no tales but survivors do and perhaps it is time to investigate the circumstances of an incident in a way that is outside of the legal/prosecution motivation.  Everyone has a different perspective on a workplace incident and many are less than truthful or honest in order to not incriminate themselves or because a lawyer has advised against unsupervised cooperation.  Could it be possible to offer a special consideration to the witnesses of an incident, prior to the Court experience, so as to encourage accurate data of an incident that can then be issued as a safety alert?

The media releases of OHS regulators often refer to incidents that have occurred months or years ago when the circumstances are only remembered by the Courts, the company and the family of the deceased.  Surely there must be some way of issuing an interim alert that does not jeopardise the prosecution?  The preventative benefit would be so much more if the alert relates to an event that has occurred within the last week, for example, or while the tragedy is still being reported in the media.

In various venues throughout Victoria, John Merritt, has been showing a graph of the number of fatalities in the State in line with the National OHS Strategy leading to 2012.  Earlier this year, the fatality rate was above the benchmark.  Now, WorkSafe must be realising that the 2012 target is likely to be impossible.

Australia is not renowned for its OHS research.  What occurs is way below that of other similar economies and the funding is abominable.  It may be time to pull back on advertising expenditure and start researching the causes of the fatalities for a quick turn around of, at least interim, results.  Until this occurs, regardless of regular pleas from OHS regulators it is likely that we will still be hearing of incidents like these from Victoria:

“…a 42-year-old man fell from a roof and died while installing cables for a television antenna on a house in Tullamarine.”

“…another 42-year-old man is being treated for serious burns at the Alfred Hospital after fuel ignited as he prepared to refill a generator…”

“A man has died at Werribee after being run over by the trailer of a reversing tractor”

“…a farm worker was run over by a tractor on another Werribee South vegetable farm. He suffered serious injuries to his pelvis and was flown to hospital for surgery…”

“A Lower Templestowe man, 47, died from crushing injuries after a tractor he was driving became entangled in a steel wire supporting poles for a canopy over a Wandin North orchard.”

“A 45-year-old dairy farmer died near Portland when he was hit by his tractor and an implement and suffered fatal crushing injuries.”

“A man’s head was crushed between an industrial chipper and a truck at Warrandyte North”

“A man aged in his 50s died at Bannockburn near Geelong while operating a boom lift. He was found crushed between the machine’s bucket and the roof of a building in which he was working”

What we can be sure of is that 27 Victorian families will not be celebrating this Christmas.

Kevin Jones

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

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