Fatigue is the biggest threat to a person’s safety

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Not so long ago, it was considered a legitimate criticism to blame the individual for “doing the wrong thing” at work.  Depending on the type of worksite, this was considered “human error” or “bloody stupid”.

Fatigue is an interesting illustration of how occupational health and safety must cope with new perspectives on established hazards.  Australian OHS legislation operates on a responsibility to manage the systems of work in a workplace, of which only one element is the worker.

A good incident investigation goes beyond the incident to see what led up to a worker acting the way they did, the reasons behind the decision.  Instead of “tell me about your childhood”, OHS practitioners can legitimately ask “tell me about your sleep patterns”, or “tell me about your second job”, or “tell me about your relationship with your partner”, as these can be contributory factors to the decision made on the day or the work environment at the time of the incident.

Some recent AAP articles provide interesting examples of the different contexts in which fatigue as a workplace issue can manifest:

Ambulance Employees Australia (AEA) said weary paramedics had fallen asleep at the wheel and administered wrong drugs because they did not have enough time off between shifts.

They have called for a minimum 10-hour break between shifts, compared with eight hours under the current award.

But Ambulance Victoria has said the fatigue issue was one of 175 union claims, which it said sought $800 million from pay talks.”

Investigators examining the near-catastrophe at Melbourne Airport last month are exploring whether fatigue was a factor after being told the pilot had barely slept the day before the flight.

Emirates pilots are permitted to fly a maximum of 100 hours each 28 days and the pilot was also almost at the legal threshold of the number of hours he was able to fly.

Emirates has issued a statement saying safety was a top priority for the airline.”

A higher priority than a good night’s sleep apparently!  Clearly it is the spread of hours that is the issue not the total over a fixed period.

Both these examples relate to workers’ interactions with the public and reflect the complexity of OHS’s spread to public safety.  

It seems that every investigation now automatically assesses the fatigue level, or impairment, of the participants in incidents in the same way mobile phone records are checked in car accidents and blood-alcohol levels or drug testing in some industrial events.

If your OHS professional does not consider psychosocial issues in developing safety management plans or incident investigation, seek a second opinion, or better yet, make sure the first opinion is comprehensive.

Kevin Jones

Role of OHS Inspectors

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There have been several incidents recently that illustrate the unenviable pressures on inspectors and Australian OHS regulators.

The Tasmanian Coroner found that the mining inspectorate of Workplace Standards Tasmania was “inadequate” and incapable of  “of carrying out its core function of inspecting and enforcing best safety practices within the mining industry.”  Two inspectors for that State’s mining sector- a sector that in 2007/08 was 621 mining leases strong, according to the Annual Report of Mineral Resources Tasmania.

The construction union (CFMEU) in Victoria was highly critical of WorkSafe Victoria following a scaffolding collapse in a main street of the suburb, Prahran.  A similar event occurred in Sydney a couple of days later.

However, OHS legislation clearly states the employer is responsible for safety in workplaces, as WorkSafe reiterated in a press statement.  TV an press reports did not quote the construction union official criticising the construction company or project manager for having the scaffold collapse on their worksite.

(The CFMEU provides a scaffolding checklist on its website.)

In the scaffolding situation a union criticising the OHS regulator is a peculiar distraction from the obvious failure of the organisation that has control of the worksite, the employer.  In the Beaconsfield case, the distraction is just as effective and allows the employer to feel that less attention, less criticism, equates to the incident or the fatality being considered of a lesser significance.

The days of government certification for scaffolding, boilers & Pressure vessels, and a raft of other work items disappeared almost twenty years ago in many Australian States.  One of the reasons this occurred was that regulators realised that by certifying something, by granting official approval, the regulator took on some of the responsibility for the work item.  Most regulators, with government support, realised that it was in their interest to re-emphasise the employers’ legislative obligations that had existed in law for some time.

One does not need to physically visit worksites to encourage “best practice”.  No inspectorate would expect every workplace to be visited by inspectors but high-risk workplaces, such as mines, may have this expectation.  

It seems increasingly popular for the OHS inspectorate to be called in early on high hazard organisations (HHO) projects. (HHO is a concept most recently discussed by Jan Hayes and discussed elsewhere in the works of  Professor Andrew Hopkins)  This enables projects to meet high safety standards in the planning stage.

OHS regulators have a delicate balancing act between consultation and enforcement.  This is a balance that is constantly being tweaked as political, economic and social pressures fluctuate.  The process is not helped b y fingers being pointed in the wrong directions.

Kevin Jones

[NOTE:Professor Michael Quinlan  of  UNSW, Middlesex University and University of Sydney) will be a keynote speaker at the upcoming   Safety in Action 2009 Conference on 2 April 2009 concerning the results of a five-year research report into what OHS Inspectors do and the implications for employers and safety professionals.]

Is technology the solution to everything?

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Today, I received a media statement by the Acting Chairman of the National Transportation Safety Board (NTSB), Mark V. Rosenker.  He said that new technologies have the potential to substantially reduce rail incidents.  Rosenker is quoted as saying

“Just think how far computer and GPS technology has developed in the past 10 years.”

He urged the delegates at the International Railroad Safety Conference in Denver, Colorado on 6 October 2008 to

“… be forward thinking.  Work closely with the highway industry to develop useful, intelligent transportation safety systems that can prevent accidents at grade crossings.” 

In mid-September 2008, the a Metrolink commuter train and a Union Pacific freight train collided in Chatsworth, California, killing 25 people.  The engineer of the Metrolink train was using new technology – he was texting on his mobile phone instead of paying attention.

I can’t see how the new technologies that Mark Rosenker discusses:

electronically controlled pneumatic (ECP) braking, acoustic bearing detectors, wheel impact detectors, … truck performance detectors [and] intelligent transportation systems (ITS)…”

would have stopped the deaths of 25 people in Chatsworth?

I realise that the NTSB investigation into the Chatsworth collision has a way to go but I will be listening for some non-technological control measures to be proposed as well.  The NTSB is going to need to keep up its “qualification, training and oversight of employees” that it has implemented in the last decade or so becasue clearly in the case of the Metrolink engineer, Robert Sanchez, these techniques failed.