disaster – Page 12 – SafetyAtWorkBlog

Compensation denied because police officers only saw the aftermath of fatal incident

In 2003, emergency responders attended a major rail incident at Waterfall in New South Wales, in which multiple passengers were injured and seven died. According to a 14 April 2010 article in The Australian (page 7, not yet(?) available online):

“The officers [David Wicks and Philip Sheehan] were among the first at the scene of the crash that killed seven people, including the driver, who lost control of the train after he had a heart attack”.

Those officers have been denied compensation under the NSW Civil Liability Act because

“they did not witness the crash, only its aftermath.”

Both police officers had been diagnosed with post-traumatic stress disorder (PTSD) and been medically discharged.

Their claim for compensation has now reached the High Court of Australia Continue reading “Compensation denied because police officers only saw the aftermath of fatal incident”

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

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

Gas leaks at Esso’s Longford plant

WorkSafe Victoria is investigating two gas leaks that occurred on 6 November 2009 at the Longford gas plant owned by Esso. This plant was subject to a fatal explosion in 1998 and was recently written about on SafetyAtWorkBlog.

According to an ABC news report on 11 November 2009, repairing one leak led to a consequent leak and a “plant operator suffered minor injuries when he fell during the incident.”

A WorkSafe Victoria spokesperson told SafetyAtWorkBlog that inspectors have been on site for several days, the area of the incident is still not operational and that any restitution work in the area will need WorkSafe’s approval.

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.

In 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

CFMEU, IPA, Gretley Mine – political lessons

Readers outside of New South Wales may vaguely remember that in 1996 four miners died in a coalmine in the Hunter Valley 0f New South Wales. They may also remember that the was some press about the prosecution of some directors of the mining company. It was one of those incidents and court cases that should have gained broader attention that it did.

As OHS stakeholders in Australia ponder the ramifications of the Government’s proposed Safe Work Bill, it is important to also ponder the legal legacy of the Gretley mine disasater. It may provide non-NSW and non-mining readers with a better understanding of the resistance to the new harmonised laws from the mining industry in both New South Wales and Western Australia.

On 15 October 2009, Andrew Vickers of the Construction Forestry Mining & Energy Union used the Gretley saga as a justification to call for the harmoinised legislation and support systems to allow for variations to meet the special needs of the mining sector.

cover PHILLIPS 5.04925E-210RETLEY On the other side of political fence, Ken Phillips of the Institute of Public Affairs, a conservative thinktank, produced a document about the politics of the Gretley saga. The publication was supported by a video, available below. Phillips’ paper is a useful illustration of business’ opinions of the unions and New South Wales’ OHS legislation. This legislation is a centrepiece to the ACTU and union movement’s concerns and opposition to many elements of the current draft Safe Work Bill.

Prominent sociologist, Andrew Hopkins, has written about the OHS management issues raised by the disaster and its aftermath.

SafetyAtWorkBlog believes that these political and safety resources can provide a primer to many of the issues being discussed in the current debate on OHS laws.

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

Category: disaster

Compensation denied because police officers only saw the aftermath of fatal incident

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Nightclub fires and evacuations

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Big fine for Queensland Rail – big risks in rail

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Gas leaks at Esso’s Longford plant

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The personal cost of surviving a major hazard explosion

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CFMEU, IPA, Gretley Mine – political lessons

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What Trevor Keltz gets right

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