Category: death

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

Asbestos Awareness Week calls for action

During Asbestos Awareness Week 2009 in Melbourne Australia the trade union movement pledged to begin a national strategy to control and remove asbestos from Australia.  This would have been a very tall ask any time in the last two decades but Asbestos needs to compete now with Climate Change for the attention of the media, the decision makers and the heartstrings of the community.

It is accepted that in the near future more people will be touched directly and indirectly by asbestos-related diseases but, at the moment, the issue is concentrated in low-income industrial suburbs and, as such, is still dismissed by some (often in suburbs with large trees and no pubs) as a disease that only strikes the blue-collar smokers.  The social inequity of asbestos-related diseases should be studied in some depth as it is likely to shame governments into action on this hazard.

Jim Ward - Australian Workers Union

At a seminar in late November 2009, a small audience in the Victorian Trades Hall was told of the success of the Tasmanian campaign in gaining government support for the removal of all asbestos by 2030.  Jim Ward of the Australian Workers Union spoke of the approaches to Goliath Cement (“The James Hardie of Tasmania”). Ward told how the CEO of Goliath did not blink at the request to remove asbestos.  Ward said this type of response has been repeated throughout Tasmania.

The audience also heard from several who are at the frontlines of dealing with asbestos-related diseases.  Vicki Hamilton and Tim Tolhurst spoke of the frustration of having inadequate disposal facilities in regional areas of Victoria.  The challenge here is immense as the temptation to bury asbestos in the back paddock when no one’s around is strong even though it is selfish and immoral.  Vicki and Tim showed how a structured program across the community is required because one cannot encourage the removal of asbestos until there is a place to safely dispose of it.

Vicki Hamilton of GARDS

Pat Preston, ex-CFMEU and now with the Asbestos Contractors’ Group, spoke of the legislative and operational problems faced by licensed asbestos removal contractors.  The holes and conflicts all complicate the process of asbestos removal and disposal and increase the cost, particularly of asbestos removal.

Several speakers pointed to the anomaly that the removal of asbestos from domestic buildings of less than ten square does not required licensed removal, thereby “encouraging” small volumes of asbestos to be hidden at the bottom of domestic rubbish bins.  The OHS risks to waste collectors are not dissimilar to those who dispose of toxic and trade waste down the toilet next to the workshop when WorkSafe or the union is not around.

Of course the audience and speakers seem to all agree that there is no safe level of asbestos exposure.  There are certain to be those in Australia who are “asbestos-skeptics” and many seem to have the ear of the decision-makers.

One speaker provided a fresh perspective that was very appropriate but surprising for a couple of reasons.  Anthony La Montagne, of the University of Melbourne, has undertaken ongoing research on job stress, cancer clusters and, clearly, asbestos issues.  La Montagne provided the glum news that several promising medical techniques for early detection of asbestos have come to nought.  The only effective risk reduction technique is for those who may have been exposed to asbestos to quit smoking as this smoking appears to exacerbate asbestos-related disease.

Several speakers noted that in the Asbestos Awareness Week 2008, there was a motion to have the Government undertake action on asbestos.  The resulting inaction was embarrassing and motivating with participants committing themselves to continuing to lobby for controls on asbestos.  This is going to be a considerable challenge if they continue through the same lobby process that they have applied for the last few years.

Tom Tolhurst of ADSVIC

The asbestos safety advocates should drop “awareness” from the week’s title because awareness equates to “aspirational targets”, former Prime Minister John Howard’s way of promising much and delivering nothing.  Just as everyone accepts that smoking causes lung cancer and climate change exists, people know that asbestos can kill.  Move away from awareness-raising to action.

Research the social inequity of asbestos in low-income areas.  Many domestic houses have asbestos houses or in their roofs, particularly in low-income areas which are also the areas where asbestos workers live.  If the reality and scope of this situation was proven to a level and in a format that policy-makers accept, the asbestos control option would be much stronger.  Even if the government continued its inaction, a case could be put to the discrimination tribunals and human rights sector to shame the government to represent all citizens equally.

Market the asbestos week.  White, pink and striped ribbons are becoming a fundraising cliché but the marketing of social health issues works.  There must be a coordinated approach to getting sponsors and support into the promotion of asbestos-related diseases on a large scale.  Once there is serious money behind the issue, one can fund research and present data that convinces decision-makers of the reality of the issue.

Pat Preston of Asbestos Contractors' Group

Undertake a public health cost-benefit analysis of asbestos-related disease, as one speaker advocated at the Victorian Trade Hall.  There are many lessons from the compensation issues of James Hardie Industries but one is that compensation creates wealthy (for a short while) families of dead workers and can do little of health benefit to the mesothelioma sufferers.  It is surprising that the fact has not clicked in the government mind that compensation for asbestos-related diseases provides an important but only symptomatic relief.  The government is applying paracetamol to an issue that requires surgery.

The union seminar was heartening in that it showed how many people are actually tackling the issue of asbestos-related diseases.  But it also operated under a cloud of frustration with an occupational and public health risk that is not receiving the government support that other similar matters are.  Trade unions are a vital part of any plan to control asbestos but just as many people in the leafy suburbs are isolated from asbestos risks, so the audience for the asbestos message is limited by the message remaining within the trade union context.

Tony La Montagne of the University of Melbourne

There needs to be a creative approach to generating sufficient community outrage over the unnecessary deaths of workers from asbestos so that the government cannot avoid action.  The James Hardie legal action and the lobbying of Bernie Banton, and others, was about compensation, about making a company accept its social responsibility, about making it pay.  It worked, but James Hardie still cannot afford the compensation bill that is the reality of decades of profits from a toxic substance that kills.

In 2009 several Australian Governments have helped out this company by contributing $A320 million to the company’s compensation fund.  Why?  When did the government decide to cover the costs of a company’s exploitation of workers?  This is on top of having to fund the public hospitals that have to deal with mesothelioma victims.  The government, and the taxpayer, is paying twice!

Let the company fail and allow the class action lawyers to pick over the assets.  Or better yet, keep James Hardie Industries alive and bleed it just enough so that it can fund the removal of its toxic legacy for the next thirty years.

Every shareholder in James Hardie that receives their dividend cheques from whichever country James Hardie moves to next (Zimbabwe cannot be far off) needs to understand that those dividends could be used to ease the pain of the workers who generated the corporate profits rather than contribute to their own bloated share portfolios.

Kevin Jones

NZ quad bike fatality

On 26 November 2009, a contract worker on a New Zealand dairy farm was found seriously injured after his quad bike “flipped over on to him”.  The details of the incident according to the New Zealand Police statement are included below.

A Department of Labour spokesperson said he was unable to provide any information about the incident other than that they are investigating.

Our sympathies go to Mr Wilson’s family and all those involved in the incident

“A dairy farm worker was been killed this morning in what appears to be a tragic quad bike accident.

Police were contacted around 7.35 this morning (Thursday, 26 November) when 40-year-old Rhys Mark Wilson, from Alton who is a sharemilker at a farm in Manutahi, near Hawera, was found in a gully on the farm by a co-worker. The worker had gone looking for Mr Wilson because the cows had not been brought in for milking.

CPR was administered and this continued when emergency services arrived on scene but they were unable to revive him.

OSH and police have carried out an investigation and it is believed that the accident happened around 5am when Mr Wilson was rounding up the cows for milking. He had gone down into a gully, probably to retrieve some stray cows and it appears that as he attempted to traverse a steep slope the quad bike he was riding flipped over on to him.

OSH has recovered the bike as part of its investigation and the Police are investigating on behalf of the Coroner.”

ROPS and Quad Bikes – the failure of ATV manufacturers and OHS regulators

The Hierarchy of Controls has some questionable OHS applications to psychosocial hazards but it applies very well to “traditional” hazards, those involving plant.  The Hierarchy also emphasizes that the first step in any hazard control is to consider whether the hazard can be eliminated.  But what happens when the designers of equipment and plant know that a design can be made safer but do nothing to improve it?

For almost two decades some Australian OHS regulators have provided rebates to farmers to fit roll over protective structures (ROPS) to tractors to prevent deaths and injuries to the drivers from rollover or flips.  In 2009, one would be hard pressed to find a tractor that does not have its safety features emphasised as a sales benefit.  ROPS on tractors have been compulsory since 1998 in most States.

On 17 November 2009, Workplace Standards Tasmania issued a safety alert which, like the New Zealand ATV guidelines, advocates helmets and not ROPS even though OHS legislative principles say that elimination of hazards is the aim. The Tasmanian safety alert outlines the reasons for the safety alert

“Recent information shows there are, on average, 15 fatalities a year associated with using quad bikes in the Australian rural industry sector. Many more people are injured.

A recent coronial inquest into seven fatal incidents involving quad bikes (two in Tasmania and five in Victoria) has sparked a renewed call for improved safety on quad bikes.

As a result, Workplace Standards Tasmania has adopted a policy of zero tolerance of breaches of duty of care responsibilities with quad bikes.”

“Zero tolerance of breaches of duty”?  The Tasmanian OHS Act places this duty on the designers of plant

(1) A person who designs, manufactures, imports or supplies any plant or structure for use at a workplace must so far as is reasonably practicable –

(a) ensure that the design and construction of the plant or structure is such that persons who use the plant or structure properly are not, in doing so, exposed to risks to their health and safety;…..

SafetyAtWorkBlog is awaiting comments from Workplace Standards Tasmania on the elimination of ATV rollover hazards.

As a terminological aside, there is a growing movement to rename All Terrain Vehicles as Quad Bikes because the fatality and injury data clearly shows that the vehicles cannot be driven in “all terrains”.

Five recent fatalities involving quad bikes, mentioned in the safety alert, should spark some investigation into whether the design of the plant contributed in any way to the fatalities.  Yet the safety alert makes no mention of design other than, tenuously, encouraging farmers to make sure

“…your quad bike is properly maintained and used according to the manufacturer’s specifications.”

This is a reasonable statement but if it was possible to make the vehicle safer, to save one’s own life and livelihood, by adding a ROPS, why wouldn’t you?

The manufacturer’s specifications are certain to be suitable to that quad bike but what if the quad bike design is itself not “fit for purpose”?  Plenty of other machines and vehicles are being redesigned to accommodate poor or inappropriate driver behaviour.  What makes quad bike so sacrosanct?

Victoria had a major opportunity for reform in this area through a parliamentary inquiry into farm deaths and injuries in August 2005.  Many farm safety advocates had high hopes for major change on ATV safety but design changes were not recommended.

According to the farm safety report

“Some witnesses suggested that roll over protection structures for ATVs should be made compulsory. Others, particularly representatives on behalf of the ATV industry, argued that fitting of a roll over protective structure to an ATV would adversely affect the handling and utility characteristics of these vehicles.”
Extensive research was undertaken by the Monash University Accident Research Centre which found
“…that, in the event of an ATV accident, “if the occupant is adequately restrained [with a suitable safety harness] within a protective roll over structure, the severity of [injuries caused during] the roll over event is dramatically reduced.”
Contrary evidence on ROPS was presented on behalf of the vehicle manufacturers.  The Parliamentary Committee understandably found
“To the Committee’s knowledge, there is no existing example of a roll over protective structure device that satisfies requirements for driver protection without substantially reducing the handling characteristics of ATVs. This report cannot, based on available evidence, make any recommendations concerning the fitting of roll over protective structures to ATVs.”
The UK’s Health & Safety Executive in 2002 undertook a detailed survey on the issue of ROPS and, among many recommendations said
“The use of the “safe cell” technology offers a number of imaginative approaches as alternatives to traditional structures, particularly for smaller machinery, and should not be overlooked.  Their contribution could be invaluable if relevant techniques were validated and became legally acceptable.”
Farmers, equipment manufacturers and OHS advocates are understandably confused when there is conflicting information (but then uncertainty breeds stagnation which is likely to advantage those who do not want change).
An investigation into ATV safety funded by the New Zealand Department of Labour in 2002 provided the following conclusion

“… it appears that the risk of using ATVs is significant, however there are some possible measures that could be put in place to reduce injuries, particularly those that are more severe and/or fatal. It seems that appropriate training is the most promising factor particularly because of the strong impact human behaviour has on the outcomes of the accidents.

In addition, the high risk for a fatal outcome when ATVs are rolled over, pinning the driver Reducing Fatalities in All-Terrain Vehicle Accidents in New Zealand underneath, suggests that further consideration and research is needed regarding the use of ROPS and/or any other measures that can prevent an ATV from rolling over.”

One Australian manufacturer accepted the challenge and has designed a ROPS for ATVs that shows enormous promise. QB Industries has developed the Quadbar, a passive roll over protection structure.  A demonstration video is available to view online.
It is understood that the Australian distributors of ATVs are not supportive of the safety innovation of QB Industries.  Apparently the distributors believe that the Quadbar increases the risk to the rider and that the safety claims are misleading.  The distributors are also concerned that the Quadbar may jeopardise the manufacturer’s warranty.
These concerns may be valid but surely these need to be independently tested and, if the device saves the lives and limbs of farmers and other riders, incorporated into the design in such a way that the vehicles become safer, regardless of the actions of the individual.  After all, the safer design of motor vehicles has progressed substantial from the days of Ralph Nader’s investigations in the 1960’s to such an extent that safety is a major sales strategy.
One independent test conducted for QB Industries by the University of Southern Queensland reported this about the QuadBar:
  1. The Quad Bar did not impede rider operation of the quad bike during normal operation (based on limited riding by the Chief Investigator).
  2. In low speed sideways roll over, the Quad Bar arrests the roll over and prevents the ATV from resting in a position that could trap and asphyxiate the rider.
  3. In higher speed sideways rollover, the Quad Bar impedes the roll over and prevents the ATV from resting in a position that could trap and asphyxiate the rider. In all tests the Quad Bar provided some clearance between the ground surface and the ATV seat so the rider would be unlikely to be trapped in this space.
  4. In all back flip tests, the Quad Bar arrested the back flip and the quad bike fell to one side.
  5. There were no conditions where the ATV with the Quad Bar fitted rested in a position that was more detrimental to rider safety than the ATV without protection.
If this device did not exist, the advocacy of helmets as the best available safety device  may have been valid but this design has the potential to eliminate the hazard and not just minimise the harm.  Surely it is better to have a farmer walk away from an ATV rollover that to break a neck or have a leg crushed.
The battle that QB industries has had, and continues to have, with quad bike vehicle manufacturers is beginning to reveal tactics by the manufacturers that are reminiscent of those of James Hardie Industries with asbestos and the cigarette manufacturers over lung cancer.
The approach of the OHS regulators to ROPS for ATVs must be reviewed because the dominant position seems to be that helmets are good enough, that no one is striving to eliminate the hazard or and that the Hierarchy of Controls does not apply.
QB Industries has followed the OHS principles and has designed a ROPS that warrants investigation, and the support and encouragement of OHS regulators.  The longer this investigation is ignored, the more people will be killed and injured when using these vehicles.  To not investigate this design would be negligent.

Work-related suicides in Europe

The Irish Times has reported on a speech made by Dr Jukka Takala, Director of EU-OSHA, in Spain in November 2009.

“[Dr Takala] said since the publication of a recent study showing a very high level of work-related suicides by French Telecom workers, there was an urgency about getting this information. “Personally, I favour a system such as they have in Japan where the families are compensated for the suicide of a relative, and the debate has already started in this organisation and in the commission and some of the member states,…”

It is not uncommon in OHS to hear calls for further research and more research on work-related suicide is definitely needed.  (Australia has some very good work in this area.)

Caution has to be voiced on the risk that suicides be seen as the mental health version of workplace fatalities.  Research and OHS statistics often focuses on fatalities for various reasons including that the statistics are easy to quantify.  If a worker dies from being crushed by a machine, its a workplace fatality.  There is a trap in terms of suicides where the cause and effect is not so clear, or mechanical.

Only recently have workplace fatalities begun to be investigated with consideration of the social or non-work contributing factors.  If the machine operator was pulled into the machine because they were inattentive, why were they inattentive?  In terms of suicides, the agency of injury will be fairly obvious but the contributory factors could be far more complex.  And if the suicide victim has not left a note explaining the reasons for their action, it is even harder to determine “cause”.

Looking at suicides runs the risk of  not paying enough attention to the mental health issues that have not reached the suicide level.  The focus should not be researching suicides but researching the combination of issues leading to suicide.  It is a much greater challenge but is likely to have more long term benefits.

Takala’s comments about family compensation and the need to acknowledge the reality of work-related suicides gained the attention of The Irish Times because they meet the imperatives for a newsworthy angle.  Takal’s speeches at the Healthy Workplaces European Summit 2009 covered much greater territory than the Irish Times article and should be read to better understand the comment’s context.

There are hundreds of work risks that require assessment and psychosocial hazards is one of those areas.  A full list of speakers at the conference is available by looking at the program.  Abstracts of most presentations are available for download.

Kevin Jones

The personal cost of surviving a major hazard explosion

As one gets older, the “where are they now?” columns in the newspapers or the summer magazine supplements become more interesting.  The articles of faded pop stars and political one-time wonders are diverting but every so often one makes you stop and think.

OHS is not renowned for “where are they nows?”.  The discipline and the profession has few celebrities but there are important people.  One such person is Jim Ward.  Jim’s story is long and involved but he came to the public’s attention as a survivor of the 1998 gas explosion at the Esso gas plant in Longford Victoria.  The blast, which killed 2 workers, crippled the State’s gas supply for almost 2 weeks.  A Royal Commission was held into the disaster.

Usually a worker’s evidence may be reported on for a day or two in such an investigation but Jim Ward became more than that primarily due to the attempt, according to some, by Esso Australia (a subsidiary of ExxonMobil) to scapegoat Jim.  This attempt was roundly condemned in the Royal Commission.

Pages from AMS_Post_Traumatic_StressIn the Australasian Mine Safety Journal, Jim Ward has written a short personal account of what happened that day but, more importantly, how that day has changed his life.

After the failure of steel exchanger and before the fatal explosion, Ward writes:

“I raced to a doorway and looked out into the gas plant where I saw a thick white fog rolling down the walkway. This white fog was a cloud of vaporised hydrocarbon. Gas – highly flammable gas.

Out of the fog stumbled two zombie-like creatures. Two men – blackened from head to toe. They were covered in soot which had been blown from the inside of the huge steel exchanger when it violently ruptured. They had their arms out in front of them trying to feel their way through the fog, blinking as if trying to catch some daylight to help guide them to safety.

Over the roar of the jet–engine–like sound of gas spewing into the atmosphere I yelled – I yelled at them to get into the control room. Into the control room and to relative safety. Ninety seconds later the gas found a source of ignition and a second, much louder explosion shook the control room building again.

What followed from that moment on was sheer unadulterated terror.”

In his article he goes on to explain the psychological impact of that day and the diagnosis of his post-traumatic stress syndrome.  Ward rightly points out that mental health is poorly understood in the workplace.

Many employers are satisfied if they get through a single day without a problem or complaint but silence is not compliance and there may be mental health issues that require attending to even though they are difficult to identify.

Ward’s article is a timely reminder that the measurement of a successful OHS management system or a more personal “safe system of work” has changed and that business needs to scrutinise OHS auditors on the mental health assessment criteria.

Perhaps, most particularly to Australia, it is necessary to gauge OHS laws through contemporary hazards, such as mental health.  The law will exist for decades and need to be able to adapt to emerging hazards, many of them not coming from the physical.

His article also means that workers need to consider colleagues as more than just colleagues and look to their humanity.  In the past many of us are inclusive and dismissive when we refer to someone as a work mate.  People are more than that.

It may be, as this article is written on 9 November 2009, that Jim Ward’s message has already been learnt by the survivors and emergency workers of the World Trade Center from 2001.  But for many outside the United States it is also two days before Armistice Day, the end of the World War which really brought  shell-shock or combat stress reaction and post traumatic stress disorder to the public mind.

When remembering the fallen in war and work we should also ask “where are they now?”

Kevin Jones

New coronial approach should lead to greater safety information

The Australian State of Victoria has been in a fortuitous position with a Coroner, Graeme Johnstone, who was a staunch advocate of safety in the public and workplace spheres.  Johnstone was a strong and physical presence at many conferences and in the media.  Indeed, it would be difficult to find a more obvious and influential safety advocate in Australia over the last twenty years.

Johnstone retired recently due to ill-health.  From 4 November 2009, his successor, Jennifer Coate, will be sitting in an official Coroners Court and the supportive legislation should provide even greater support to safety advocates.

According to a media release issued in support of the Court, there are several important legislative changes.

  • The power of the court to make recommendations to any Minister, public statutory body or entity relating to public health and safety and the administration of justice. Previously recommendations could only be made to Ministers.
  • Importantly, any Minister, public statutory body or entity either receiving or  [sic] the [sic]of a recommendation must now respond in writing within three months stating what action will be taken (if any) as a result of the recommendations. This has never been required before and is an Australian first.
  • All inquest findings, coronial recommendations and responses to recommendations will be published on the internet, unless otherwise ordered by a coroner. This is the first time in Victorian coronial history that a requirement to publish inquest findings has been enshrined in legislation.
  • A new power for coroners to compel witnesses to testify without the risk of self incrimination. The court will now be able to issue a certificate excusing evidence heard by the court from being used to incriminate witnesses in other court proceedings.”

On the first point, how much different would have been the approach to level crossing safety with this authority?  Would the faulty design of some level crossings have been changed more quickly?  Of course, recommendations are still only recommendations but by referring to statutory authorities and others, there is likely to be less direct political spin and, perhaps, greater accountability.

This leads to the second point, timelines.  Any meeting, action item, control measure or even correspondence, should have a timeline for response.  This will allow the families of victims a hook on which they can hang their dissatisfaction with government inaction.  Of course, there is usually no guarantee that correspondence is publicly accessible but to bullet point three.

Not only will inquest findings now be easily accessible to the public, the government responses mentioned above will be made available on the Coroner’s website.

Around ten years ago I was writing a book on occupational health and safety in the sex industry in Australia.  I requested details form the Coroner’s office of deaths in this industry.  I received many pages of decisions which helped considerably in determining whether deaths occurred at work or in relation to work.

Several years later, I put in a similar request for information on dairy-related deaths in support of a WorkSafe Victoria guidance with which I was assisting.  The level of detail provided then was a line or two on each incident.  It was enough to prepare a rough data table but was woefully unhelpful in the preparation of case studies of work-related fatalities.  The accessibility allowed under the new laws will allow for a greater, and more public, understanding of the contributing factors to death which should lead to greater options for elimination or control.

The Coroner is clearly enthusiastic about her new powers.  In the media release Coates says

“This new legislation will better enable the court to thoroughly examine and investigate the different types of deaths reported to us so we can help prevent similar deaths from occurring.  Of real significance is the requirement that any body or entity receiving a recommendation must respond to us. This will be a real mechanism for change to public safety and we expect enormous benefits for the Victorian community to follow,” she said.

Judge Coate said publishing inquest findings, recommendations and responses on the internet would make public statutory authorities and entities more aware of their responsibility to respond to coronial findings.

“The new response requirement means the recommendations of a coroner cannot be selectively pursued or ignored. This is an important gain for the public safety and administration of justice for our community”

She said the publication of inquest findings, recommendations and responses on the internet would also make the coronial process more accessible to families who experience the death of a loved one investigated by the court.

“We have gone to great lengths to ensure our new practices under the Act recognise and have regard for the families and friends of a loved one who has died.  That includes acknowledging the distress of families and their need for support and a recognition that different cultures have different beliefs and practices surrounding death.”

SafetyAtWorkBlog wishes Coroner Coates all the best and will be keenly watching the progress.

Kevin Jones

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