Category: design

Nightclub fires and evacuations

Mainstream press around the world reported on the fire in a Russian nightclub over the weekend in which 100 people were killed.  One report says the nightclub owner has been arrested quotes the Russian President Dmitry Medvedev as saying

“All that has happened can only be described as a crime….I think this is absolutely clear….You have noted that a criminal investigation has been launched.  This is not a premeditated crime, but that does not reduce the gravity of the consequences. A huge number of people were killed.”

The fire reportedly started when stage pyrotechnics set fire to the ceiling.

Some readers, particularly in the United States would see distinct similarities with the  February 20 2003 in which 100 people were killed and over 200 injured.  A fire, also started by stage pyrotechnics, occurred in the Station nightclub on Rhode Island.  That whole event was captured on video.  The band’s tour manager who started the pyrotechnics, Daniel Biechele, was charged with 100 counts of involuntary manslaughter, pleaded guilty and served 4 years of a 15 year jail sentence.

The nightclub owners did not contest their charges and received similar sentences to Biechele.  Civil penalties added up to around $US175 million.

Given that the Station fire was six years ago, it is hard to understand why any nightclub would even consider using such stage pyrotechnics.

Other nightclub fires should not be forgotten although they received less coverage in the Western media.  Those with which SafetyAtWorkBlog is familiar include the 2002 fires in the Caracas nightclub, La Guajira where 47 people died, mainly from smoke inhalation.  Rumours had it that the nightclub had exceeded its allowable client limit.  Investigations showed that fire exits were not clear and the fire extinguishers were inoperative.

Although there are several incidents going back to the 1970s one that received a huge amount of attention was the December  30 2004 fire in the Republica Cromagnon nightclub in Buenos Aires. (The Wikipedia entry for this incident has a very good list of similar incidents)

The Republica Cromagnon nightclub had several of its doors shut with wire or padlocks.  The nightclub had 4,000 patrons in a premises licensed for 1,100.  Initial reports said that 715 people were injured and over 190 died from a fire that was started by a flare.

The incident generate three days of rioting and street protests of thousands of people, many were relatives of the dead.

In this case, not only were the club’s owners jailed on murder charges but city building inspectors and police officers were charged with manslaughter and corruption.  The inspectors allowed the nightclub to operate with inadequate safety standards.  The police accepted bribes from the owners and did not report the overcrowding or use of flares.

In November 2005, the mayor Buenos Aires, Anibal Ibarra, was suspended from office after the legislature voted to impeach him over issues related to the Republica Cromagnon fire.

Managing safety in nightclubs is a complex business as the industry overlaps many jurisdictional areas from workplace safety to building design to security to emergency response.  As the world moves towards the main season of celebrations with Christmas, New Year and others it is worth considering some of the more useful OHS guidelines for nightclub operation, even though such measures should have been considered well before now.

Going from the violations related to the Rhode Island fire by OSHA it would be expected for a nightclub owner to

  • Remove any highly flammable materials from the interior of the structure
  • Make sure that exit doors are visible at all times
  • have a written emergency action plan
  • have a written fire prevention plan
  • nominate and train staff to assist in a safe and orderly evacuation of other employees
  • review fire hazards with employees.

Seattle has a nightclub patron safety handout.

One guide from Virginia specifically references the Station nightclub fire.

The Health and Safety Executive has a guide to assessing risks in nightclubs as well as general OHS advice for the hospitality and leisure industries.

WorkSafe Victoria has a guide on crowd control which may also be useful

Many local jurisdictions have guidelines, or the industry itself has developed guidelines, to assist in the management of nightclub crowds.  SafetyAtWorkBlog urges owners and staff to undertake reviews prior to peak times.

Kevin Jones

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.

PCBUs have begun appearing

A reader has drawn SafetyAtWorkBlog’s attention to one State regulator in Australia who has already begun to apply the broader definition for “employer” in their OHS guidance material.

In September 2009, the ACT Safety Commissioner published a Guidance on “Safe Structures, Systems and Workplaces“.  In that guidance, the Commissioner refers to

…”New general duties to ensure work safety by managing risk apply to a person:

…carrying on a business or undertaking;…”

This anticipates the definition put forward in Australia’s OHS model Act in relation to PCBUs (Peek-A-Boos).

The matter of a “business or undertaker” was also used in the ACT’s Work Safety Act 2008 (effective from 1 October 2009) throughout the document but with slight variation.  Of most interest here are the definitions of employer, worker and “business or undertaking”:

“employer, of a worker, includes a person who engages the worker to carry out work in the person’s business or undertaking.”

“worker means an individual who carries out work in relation to a business or undertaking, whether for reward or otherwise, under an arrangement with the person conducting the business or undertaking.”

“business or undertaking includes—

(a) a not-for-profit business; and

(b) an activity conducted by a local, state or territory government.”

The logic of such an inclusive term is understandable but needs greater clarity which is likely to some from regulations or supportive documents.

Having a Peek-A-Boo is one thing, let’s just hope that the jargon does not develop to start referring to “undertakers”.

Kevin Jones

WorkSafe Victoria Awards winners

On 29 October 2009, WorkSafe Victoria held its WorkSafe Awards event at  the Palladium Room at Melbourne’s Crown Casino.  SafetyAtWorkBlog attended as a guest.  All the winners were deserved and there are short profiles of some of the winners below.

WorkSafe Awards 2009 004The first award was for the Health & Safety Representative of the Year, won by Phyl Hilton.  Hilton was clearly honoured by the award and in his acceptance speech acknowledged that good OHS laws are “socially progressive” – a position that is rarely heard outside of the union movement or from non-blue-collar workers.  It is an element missing from many of the submission currently being received by Australian Government in its OHS law review.

Hilton presented as genuine and his commitment to the safety of his colleagues was undeniable.  Significantly, he thanked several WorkSafe inspectors for their support and assistance.  WorkSafe would have been chuffed but the comment which reinforced safety as a partnership.

WorkSafe Awards 2009 001The Best Solution to a Health and Safety Risk was given to Bendigo TAFE for a machine guarding solution.  Guards have become an unfashionable hazard control solution and often now seem to rely on new technology.  The chuck key guard was as hi-tech as an interlock device but one that the users of the lathes, almost all young workers, would not need any involvement with.  If chuck key remains in the place, the guard is out of position and the machine cannot start.  Simple is always the best.

The combination of beer and safety is a heady mix for Australians so the keg handler had a cultural edge on the other award finalists in the  category, Best Solution to Prevent Musculoskeletal Injuries.  The keg mover and the keg stacker seemed to be two different devices WorkSafe Awards 2009 002and it would have been great to have a single device but the stacking option was particularly interesting.  Many pub cellars are cramped and being able to stack beer kegs in a  stable fashion is attractive, and sensible.  The cross-support that is placed on top of each keg was, perhaps, the standout feature.  One can almost see the staring at the top of the keg by the designers and the creative cogs turning.  The best solutions always seem to be those where one asks “why didn’t I think of that?”

WorkSafe has placed a lot of attention on safety in the horse racing industry, particularly, as injuries received by jockeys and the killing of injured racehorses are in public view and therefore are highly newsworthy.

WorkSafe Awards 2009 003The attraction of this winner of Best Design for Workplace Safety is that the inventor has looked beyond PPE for jockeys to what a jockey is likely to hit when falling of a racehorse at speed.

The OHS law drafters should take note that this innovation has come from looking at “eliminating a hazard, at the source”, an important terminology omitted from the last Australia OHS law draft.  Would there have been the same level of innovation if the racing industry had done what was “reasonably practicable”?  It is very doubtful.

This post has focussed on individual achievement and physical solutions to hazards.  The awards for OHS committee and safety management systems are not detailed here as they are more difficult to quantify but for completeness, the Safety Committee of the Year went to RMIT – School of Aerospace, Mechanical and Manufacturing Engineering, Bundoora East, the Best Strategy for Health and Safety Management went to the Youth Justice Custodial Services – Department of Human Services, Parkville for its program in Clinical Group Supervision.

Some of these solutions need to be viewed to fully understand their merit and it is hoped that SafetyAtWorkBlog will be able to post the videos of the winners and, more importantly, the other finalists, shortly.  Certainly the other finalists in the solutions categories deserve almost as much recognition.

Kevin Jones

WorkSafe Awards 2009 005

Health and Safety Representative of the Year

Recipient: Phyl Hilton – Toyota Motor Corporation, Altona

Phyl, who works as a toolmaker at Toyota’s Altona Plant, has been a health and safety representative for 10 years. Representing 27 members in the trades department within the Press shop, he takes a leading role in identifying opportunities for safety improvements in his workplace. Using a practical and collaborative approach, Phyl has played an integral part in many initiatives, including the design and construction of weld bay facilities, the procurement of portable fume extractors and the development of press plant policies in English and Japanese. Phyl was also part of the Traffic Management Control Working Party and the Working at Heights and Trades Hazard Mapping projects. He is committed to developing and driving safety knowledge among Toyota apprentices and actively mentors and coaches fellow health and safety representatives.

Best Design for Workplace Safety

Recipient: Bendigo Regional Institute of TAFE, Bendigo

Initiative: Lathe Chuck Guard

Bendigo Regional Institute of TAFE works with students and apprentices to prepare them for the workforce. An incident highlighted the risk of an operator forgetting to remove a key from the chuck on a lathe before turning it on. Working on lathes is a normal part of work in many businesses within the manufacturing industry. The chuck can spin at 1000rpm or more and this could cause the key to fly out from the machine with high force, creating a projectile that could result in serious injury to the operator or others close to the lathe. The Lathe Chuck Guard protects the operator by refusing to close if the key is left in the chuck. The guard is interlocked to ensure the lathe can only be started with the guard closed. Having a guard assists with providing a safe work environment within the TAFE workshop. The Lathe Chuck Guard is a simple, cheap, yet effective, way of reducing the risk of projectile keys. It is adaptable for a range of lathes across industries and will benefit other educational facilities and the wider manufacturing industry.

Best Solution for Preventing Musculoskeletal Injuries

Recipient: Cherry Constructions and Workright Safety Solutions, Seaford

Initiative: Keg Handling System

The Keg Handling System is a mechanical aid system to assist the hospitality industry. It consists of a keg lifter, trolley, ramp and stack safe crosses and is used for handling beer kegs. Keg handling has been a major issue in hospitality for several decades and is traditionally done by hand without the use of mechanical aids. The Keg Handling System seeks to improve the way kegs, which can weigh up to 67kg, are handled and reduce the risk of injury. The keg lifter can lift a keg, manoeuvre it into position and lower it to the floor or on top of another keg with minimal effort from the operator. The trolley can pick up a keg from any position so that it doesn’t have to be moved to meet the trolley. It has a locking device so the keg is fixed to the trolley. The stack safe crosses allow the kegs to ’nest‘ into each other, stopping them from toppling. The major risks associated with handling beer kegs are musculoskeletal injuries to the back, shoulders and arms, and crushing injuries. The automated and easy-to-manoeuvre system is readily used in small spaces and by a range of staff. This design can also be adapted for other industries to aid in lifting and transporting many items including gas bottles, oil drums and even large pot plants in nurseries.

Best Design for Workplace Safety

Recipient: Racing Victoria (Flemington), Dan Mawby and Delta-V Experts (North Fitzroy)

Initiative: Running Rails

Running rails have been a safety issue in the racing industry for many years, causing serious injuries to jockeys and horses involved in collisions. Track staff have also been hurt due to the manual handling required to set up and move rails. Designed and invented by Dan Mawby, tested by Delta-V Experts and used by Racing Victoria, this new lightweight durable UV-rated plastic running rail is a welcome replacement for the solid aluminium rails currently in use. The major improvement is that the horizontal rail doesn’t break from the impact of weight-bearing objects – instead, it elevates, springs and bends on impact. The design and flexibility of this rail system also has the ability to steer a horse back on track should light contact be made, therefore avoiding injury. The new Running Rail is in place at Flemington and Caulfield Racecourse and some training facilities.

Australian Standards and OHS harmonisation

This morning in Melbourne, WorkSafe Victoria conducted a three-hour seminar on the harmonisation of Australia’s OHS laws.  The speakers and panelists were John Merritt of WorkSafe, Tracey Browne of the Australian Industry Group and Cathy Butcher of the Victorian Trades Hall.  Tripartism at its best.

The large auditorium was filled with hundreds of attendees, very few were the familiar faces of the OHS professionals who can often dominate such events.

A question was asked to the panel about the application of the Australian Standard for Plant.  The question was, basically, will the Australian Standards be referred to within the upcoming OHS regulations?  The panel unanimously said no.

This was the clearest indication yet that the rumour about Australian Standards not being given legislative legitimacy through legislation is correct.  Tracey Browne however provided the rationale.  She said

“The important thing is that as soon as we incorporate an Australian Standard in a regulation, we create a whole different legislative status of something that was never designed to be a safety regulation….

This doesn’t change the fact, though, that it is the “state of knowledge” and when you look at what you are doing in relation to what is reasonably practicable, you need to take into account all the things you know or ought to know.  So if you are [for instance] bringing plant into Australia, and that is your business, then you need to know what the Australian Standards are and make sure that’s part of your consideration.”

Standards Australia is undergoing a considerable rethink due to a big loss of funds and in response to the changing regulatory structure in all sorts of industry and financial sectors.  The challenge is acknowledged by the CEO of Standards Australia, John Tucker ,when he discusses a “new way of operating“.

Kevin Jones

Handedness is not considered when investigating a workplace incident

Ha01-012Robyn Parkin has completed her small survey of handedness in safety management.  Initial results are below:

  • “92% of respondents stated that their companies do not ask whether a person is left- or right-handed on their accident report form, and 77% do not consider handedness as a possible root cause of accidents.
  • 13 companies stated that they may consider handedness where ergonomics is a possible issue, eg with poor access to equipment controls.”

More details will be available in an upcoming edition of New Zealand’s Safeguard magazine.  Robyn Parkin can be contacted about her research at robyn@impac.co.nz

Kevin Jones

What Trevor Keltz gets right

Madonna has just released another greatest hits CD.  Trevor Kletz has done similar in releasing the fifth edition of “What Went Wrong?” He admits that almost all of the content has appeared elsewhere.  It’s been almost 20 years since I had to read Kletz’s books and articles as part of working in a Major Hazards Branch of an OHS regulator in Australia.  Not being an engineer, the books informed me but were a chore.  This is not the case with the last edition.

Kletz has two parts to the book.  The first is a collection of short case notes recording as he says

“…the immediate technical causes of the accidents and the changes in design and methods of working needed to prevent them from happening again”.

The second discusses the weaknesses of management systems.  In short, the book reflects the expanding nature of safety management over the last forty years.  Kletz may be from the Olde School of safety engineers (he is 87 years old) but often one needs a fresh perspective on a profession and coming from a person with such extensive experience, Kletz is worth listening to.  Thankfully, he does not sound like a grumpy old man.

Kletz notes that process industry lessons seem to fade after a few years.  In my opinion this may be an effect of the transience of modern careers where corporate memory is often fragmented.  It may also be due to the shipping of manufacturing and process industries off-shore and the establishment of large complexes in countries with different (lax) safety requirements.  It may also be due to a corporate performance regime where maintenance is not valued or understood as that supports long term thinking rather than quite returns on investment.

Regardless of the cause, the short-term memory makes the need for such books as this as more important than never.

In anticipation of his look at management systems he notes in his preface, that management systems need maintaining and, more importantly, reading.  In some circumstances, too much faith is placed in the system (I would refer to the Esso Longford explosion as an example).  Kletz says all systems have limitations.

“All they can do is make the most of people’s knowledge and experience by applying them in a systematic way.  If people lack knowledge and experience, the systems are empty shells.”

What Kletz does not write about is human error because, as he says, “all accidents are due to human error”.  He avoids making the weak logic jump that the behaviouralists make where, “if all accidents are due to human error then fix the human and you fix the hazard”.  Kletz devotes a whole chapter to his classification of human errors as

  • Mistakes;
  • Violations or noncompliance;
  • Mismatches;
  • Slips and lapses of attention.

This edition of “What Went Wrong?” provides a baseline for the safety concepts we have come to accept but also a critical eye on safety and manufacturing management shortcomings.  The style is very easy to read although occasionally repetitive.  Thankfully the process technicalities are avoided unless they relate to the technical point Kletz is making.  I found part B hugely useful but it is recommended for all safety professionals.

Kevin Jones

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