Insights into crisis decision-making and communications – Victorian Bushfire Royal Commission

There’s an opportunity to follow the hearings of the Victorian Royal Commission on last summer’s horrendous bushfires via a live web stream. Here is the link to the Commission’s home page: http://www.royalcommission.vic.gov.au/ The “live stream” link on that page takes you to a live broadcast of the hearings underway at the time.

Fortunately, the catastrophe of the summer’s bushfires don’t happen often (unfortunately, the enormity of some people lighting fires does happen too often). What is even more rare is for us to be able to listen to first-hand witness experiences of decision-making in extreme conditions and to gain insights from listening to those experiences.

I often have the Royal Commission’s live stream running in the background while doing other work. I do that because I’d prefer to hear the witnesses reports directly. Of course, there will be a final report, but hearing the tone and context of the questions and answers are the sort of things that can be very difficult to recreate in a written report.

Monitoring the live stream is highly recommended for all safety professionals; doubly so for those people who work in larger businesses or organizations. A rare chance to observe and compare decision-making processes and lines of communication in complex situations to see what did and didn’t work.

Col Finnie
col@finiohs.com
www.finiohs.com

Varanus Island investigations continue

International safety attention was focused on a tiny island of the northwest Australian cost in mid-June 2008 when a pipeline exploded.  Investigation reports have been presented to government and companies have regained operations after the major gas explosion that disrupted supplies across Western Australia.

In early May 2009, the WA Department of Mines & Petroleum announced a further investigation will be undertaken. WA Mines and Petroleum Minister Norman Moore has said that the department would carry out the final stage of investigations into the  explosion.

Kym Bills and David Agostini have been classified officially as inspectors and will undertake the investigation.

Moore said that the October 2008 report by NOPSA needed additional information which has recently become available.

 “…that investigation was limited by its reporting time frame and the absence of critical evidence, such as the results from destructive and non-destructive testing of the pipeline.”

A ministerial media release identifies the investigation’s scope:

  • the pertinent sequence of events on Varanus Island during the incident
  • the likely cause(s) of the incident
  • any actions and omissions by the operator of the Varanus Island facility, or its contractors, leading up to and during the incident that may have contributed to those events.

The final report will be presented to the department in June 2009.

Background on Varanus Island is available in SafetyAtWorkBlog by searching “Varanus” as a keyword.

Kevin Jones

Why won’t the Tasmanian government release the OHS report into the Beaconsfield mine collapse?

Since the 2006 rockfall at Beaconsfield Mine in Tasmania, the public has received limited information.  There have been books about the rescue of two workers and the Coroner’s inquest into the death of Larry Knight.  Greg Mellick undertook an investigation into the rockfall and found that noone was to blame for the rockfall.

Many workplace disasters have generated royal commissions in Australia.  The rockfall did not.  However, industry specialists, OHS professionals and others have established an expectation that investigations and reports into industrial disasters are publicly accessible.

The expectation is not unreasonable given that the OHS profession, legal profession, engineers and others operate within a belief that the analysis of disasters can provide ways of avoiding a recurrence.  Apparently the Tasmanian Government does not understand the significance of information in improving the safety of workers and the public in its State, even though its OHS and mine safety legislation is structured around prevention.

The Tasmanian Coroner released his findings into the death of Larry Knight.  The findings quoted extensively from the 400+ page OHS report from Professor Michael Quinlan that was part of Greg Mellick’s investigation process.  But the report itself is yet to be released.  Nor has the larger report undertaken by Greg Mellick.

The Director of Public Prosecutions has chosen not to lay charges over the rockfall.

The mine is back at full operation.

The survivors of the rockfall are rebuilding their lives.

Only a couple of weeks ago, the Legislative Council Select Committee on Mining Industry Regulation released its report into the State’s mining legislation.  The terms of reference have evolved from the findings of various investigations including Quinlan’s.  The committee was required to investigate

  1. Regulation and workplace standards within the mining and related industries in Tasmania.
  2. Safety performance of the Tasmanian mining industry compared to other primary industries in the State and the mining industry nationally.
  3. The role of Workplace Standards Tasmania in the regulation of the mining and associated industries.
  4. The efficacy and limitations of the co-regulatory model within the mining industry in Tasmania; and
  5. Any other matters incidental thereto.

On 2 April 2009 at the Safety In Action Conference in Melbourne, Professor Michael Quinlan expressed bewilderment at the decision to not release his investigation report.

SafetyAtWorkBlog contacted the OHS regulator in Tasmania asking for the Quinlan report.  We were advised that it was likely that the only way to obtain a copy was through Freedom of Information with the Department of Premier & Cabinet. (DPAC)  A representative of DPAC will contact us about the report’s status.

DPAC has a copy of the Mellick report.  The Australian Workers Union has a copy of the Mellick report.  SafetyAtWorkBlog believes there are leaked copies of the report in existence but for some reason, unknown at this time, the public is not permitted to see the report.

The Queensland government has available four reports into mining disasters in the Moura area with one report going back to 1972!!

In the years after the ESSO-Longford gas explosion, Professor Andrew Hopkins published “Lessons From Longford“.  It was for a long time the publisher’s best-selling book.  It is quoted extensively in the OHS and management professions.  Some of Andrew’s terminologies and concepts of safety culture have become ingrained in the psyche of OHS professionals in Australia.

It is hard to see any reason in April 2009 for the Mellick and Quinlan reports not be be publicly available.  Indeed there are many important professional and community reasons for the reports to be seen.

What is the professional legacy of the Tasmanian government’s investigations into the Beaconsfield Mine rockfall in 2004?

What will the government say when the next rockfall occurs in an underground mine?  What will the Premier or the Minister say to the next generation of widows or to the carers of the crippled miners?  Certainly David Bartlett or David Llewellyn cannot say that they did all they could to make workplaces safe.

Kevin Jones

Two different approaches to risk management and safety in Australia

Australian Standards can have a major role to play in the management of safety in workplaces.  They apply to equipment, documents, decisions and can have legislative credibility if required by specific regulations.  Australian Standards are regularly referred to in guidances issued by OHS regulators adding further credibility.  The highest selling standard for many years has been Risk Management.

Unreasonable safety costs

One of SafetyAtWorkBlog’s long-held peeves needs to be stated here.  The standards are produced by a private company, Standards Australia.  The standards are only available for sale.  Small business, in particular, often baulks at OHS improvements because they see OHS management as a large cost for a small return, in a risk management context.  But the standards they need to satisfy regulatory compliance can only to be purchased.

If the Australian government is serious about easing the cost of regulatory compliance, make any Australian Standard that is mentioned in legislation available for free.

But government’s are only interested in reducing indirect OHS costs through paperwork and “red tape”, and OHS compliance requires some level of documentation.

Risk Management

Two important OHS documents that discuss risk management were released within weeks of each other.  First the Australian government released the second and final report of the Review into National Model OHS Laws (OHS Report).  The other report was the findings of the Tasmanian Coroner into the death of Larry Knight.  

The Coroner’s report was highly critical of the Beaconsfield mine’s (BGM) risk management process.

“BGM submits that there has been adequate documentation of its risk management…… I do not accept BGM’s submission” (pages 68-69)

The Coroner goes on to say

“…., the evidence is unclear upon the steps taken by BGM, prior to this decision, in its evaluation of those risks identified by its own risk analysis process. To illustrate:

  • There is no evidence to explain the decision to resume mining in contradiction of Mr Gill’s memorandum which had stipulated that forward modelling be completed beforehand.
  • Mr Gill had, in his memorandum posed the questions, “Are our current ground support standards sufficient for the seismicity being experienced?, and if they aren’t, “What is required?” However, there is not any evidence of BGM having undertaking an assessment of the sufficiency of its ground support standards so that these questions could be answered nor is there any record evidencing why the decision was taken to resume mining without these questions being addressed.
  • Dr Sharrock had identified an important depth of failure issue which Mr Gill acknowledged was raised by him at his close-out meeting yet there is no evidence to explain the evaluation of this concern by BGM and the basis for its rejection.
  • There does not appear to be any evidence of BMG having considered the reevaluation of its ground support after Mr Basson’s modelling results became available although this had been advised by Mr Turner.”  (pages 66-67, my emphasis)

The coroner’s report is full of this type of comment of an inadequate risk management and assessment process.

Reading the report in full generates a big question of how can a company be so deficient in its safety management system and still not be held responsible for the consequences of its actions?

The company remains belligerent  in its defence of the very risk assessment process that the Coroner slammed.  In a media statement, CEO Bill Colvin states

“…the company is disappointed at the lack of acknowledgement of the extensive risk assessment process undertaken by the Beaconsfield Gold mine following the October 2005 rock fall.

“Contrary to comments made by the Coroner, there was rigorous risk assessment, the mine did vary its ground support system and it changed its mining method. Nevertheless, the Coroner did find that no person contributed to the death of Larry Knight.”

Which report was he reading?

Outside of the coronial process, there seems to be sufficient evidence in the coroner’s report for Workplace Standards Tasmania to have another look at prosecuting BGM for failing to ensure that Larry Knight had a healthy and safe work environment.

Review Panel – Risk Management

The Review Panel decided not to include risk management as an enforceable element of national OHS legislation, even though it is a legislative requirement in Queensland.  The panel has reduced the emphasis on risk management by including it only “as part of an object of the model Act.” (page xviii) 

Placing it as an object of the Act puts risk management out of the public’s eye.  If risk management is not part of the obligations of an employer in law, we should not expect business operators to embrace them.  The BGM risk management process was found to be deficient by the Coroner and may have contributed to the death of Larry Knight but the Review Panel sets risk management as an aim and not an enforceable part of model OHS legislation.  It advocated the concept but would not committed

The panel heard, in a submission by Johnstone, Bluff and Quinlan, that

“The Model OHS Act should explicitly require duty holders to undertake systematic OHS management in order to comply with their general duty obligations, and the Act should outline the approach to be taken in a way that integrates the concept of ‘reasonably practicable’ into the process, and also shows how duty holders should use the provisions in regulations and codes of relevance to the issue being addressed in order to comply with the general duty.”

The Review Panel followed the recommendation of the Law Council of Australia that risk management be included in Regulations and not the Act itself.

But then, the review was not a review of occupational health and safety but of occupational health and safety law.  The management of safety was never its focus.

If it had been such a review, or if the government decides that a “safety management review” is warranted in the next few years, there would have been the opportunity to analyse the cost of managing safety and to show how the legal fraternity and the standards setting processes unnecessarily contribute to high compliance costs and red tape.

Risk management was clearly an important business process at Beaconsfield Gold even if the application of the process was poor.  The Coroner said

“one obvious line of defence is to have in place a systematic, comprehensive, rigorous and properly documented risk assessment process.  It is my opinion that BGM did not abide by such a process in the period between the October ’05 rockfalls and Anzac Day 2006.” (page 71)

Larry Knight died on Anzac day 2006.

The Review Panel believes risk management can sit in Regulations and in legislative aims.  Standards Australia continues to charge for its OHS and risk management standards.  The Australian government remains silent on providing free business management information that has the real possibility of saving lives.  Bring on the safety management review!

Kevin Jones

How to talk safety

Safety advocates often say that safety begins at the top.  Yet few CEO’s will talk overtly and publicly about safety to the extent that Janet Holmes a Court has in Australia.  Janet is a rarity but John Bresland of the United States Chemical Safety Board is making a good attempt through YouTube technology.

In January 2009, Bresland has produced on of CSB’s “safety messages” and, he is not afraid to criticise his political colleagues.

In the latest safety message he criticises those American states who do not allow state employees to be covered by federal OHS legislation and he uses an actual fatality incident to make the point very clear.

For those outside of the US, the video is a good example of a safety advocate putting his face out there and broadcasting about safety to his constituents and interested parties.  Political criticism is seen as valid in this case due to Bresland pointing out an anomaly and showing how an anomaly can kill, injure and maim.

Too many senior executives and professional associations are scared of making political statements even though they support the mission statement of their organisation.  This is an immature position based on insecurity – a quality that should have no place in the coordination of corporations and professional bodies.

Branding is a worthwhile process but it will only succeed if what is being promoted has substance.  The Chemical Safety Bureau has been a solid platform for education and safety improvement for years and deserves support by OHS professionals learning the lessons being shared and displayed.

Kevin Jones

Deaths in isolated work camp from tropical storm

It is relatively easy to manage a workplace in an urban environment.  The buildings stay in one place, the neighbours are almost always the same and the weather bureau provides plenty of warnings.  But in isolated areas, particularly in Australia, it seems the work environment is often more exposed.  Certainly this was the case in mid-March 2007 when Cyclone George hit a railway construction camp killing several workers and injuring twenty.

The camp accommodation of demountable units, called dongas, were supposedly cyclone-proof.  At the time, the Construction Forestry Mining and Energy Union said that administrative staff were evacuated but construction workers were directed to the dongas.

The owner of the worksite, Fortescue Metals Groups said on 11 December 2008 that it will fight 40 charges brought by Worksafe WA under the West Australian Occupational Health and Safety Act.

According to one media report:

“The charges include the failure to provide a safe work environment, failure to design and construct temporary accommodation and other buildings capable of withstanding a cyclone and failure to properly instruct and train workers.”

The installer of the demountable buildings, Sunbrood, had all charges dismissed.

The court case will continue in Western Australia in February and March next year.

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