Category: law

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

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.”

Serious injuries can occur regardless of good OHS intentions

SafeWork South Australia has illustrated a situation that is common in Australian workplaces – no matter how hard one tries to ensure safety, things can still go wrong.  In a court case on 20 November 2009, four farm operators were fined over a foreseeable incident that cost a 20-year-old the sight in one eye as well a fractured skull and paralysis, from falling three metres.  According to a SafeWorkSA media release

“The incident occurred in May 2006 as the farmhand, aged in his early 20’s, was working on a large stock crate prior to mustering sheep for shearing. The crate had been borrowed from a neighbour. The farmhand had to stand on a small platform three metres off the ground and operate a manual winch to lower a ramp within the crate.
During this task, the winch handle forcefully struck the man in the face, after which he fell from the platform to the ground. This resulted in skull fractures and the loss of sight in his right eye, and spinal damage, which left him paralysed.”

The farmers had preventative management measures in place prior to the incident and have made considerable changes to the workplace to enable the worker to return to work.

The comments of Industrial Magistrate Stephen Lieschke in his judgement are worth noting

“While (they) believed they were being comprehensive in their safety improvements, they appear not to have given the same attention to the stock crate as to their own plant and equipment, probably because it was occasionally borrowed to them.”

The defendants were fined $A28,000, a hefty fine compared to some given out in the same jurisdiction.  This figure was after a higher than usual 30% penalty reduction.  Industrial Magistrate Lieschke applied the discount because of an “exceptionally high level of demonstrated contrition”.  The magistrate puts it this way

“General deterrence does require a substantial penalty due to the prevalence of serious injury from the obvious danger of unprotected work at height, and due to the need for employers to take a structured risk assessment and control approach to all work processes and plant.

As first offenders the defendants are each exposed to a maximum fine of $100,000. In my opinion a notional total penalty based on a starting point of a fine of $40,000 is appropriate after taking account of all the above circumstances. After reduction by 30% this results in an aggregate penalty of $28,000. This in turn results in a fine of $7,000 for each defendant.

I also record a conviction against each defendant.”

SafeWorkSA advised SafetyAtWorkBlog that they did prosecute the owner of the stock crate but that, in February 2009 also heard by Industrial Magistrate Lieschke, the charges were dismissed.
Also, the injured worker, Kerrin Rowan, received a worker achievement award from WorkCover in 2008 and clearly the support from the local community is important.

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.

Crushed finger leads to claim and Court

Regularly in OHS  submissions to the government and on OHS discussion forums, safety professionals state that industrial relations should be kept separate from workplace safety issues.  In a perfect world ? Possibly, but there was a court decision on 13 November 2009 in Australia that shows that this separation is not possible in the modern world.

According to a media statement from WorkSafe Victoria:

Concrete panel supplier, The Precast Company, pleaded guilty in the Dandenong Magistrates Court on Friday 13 November to failing to provide an injured worker with suitable employment as required under Victoria’s workers compensation legislation.

The Court heard that the injured worker was employed as a crane operator when he suffered a crush injury to his finger. He attended Dandenong hospital and 5 days later was certified as being fit for alternative duties.

Two weeks later, he left work early on a Friday to attend his doctor. When he returned to work the following Monday he was informed that he had abandoned his employment and had no right to be there.

At the time, the company defended its action stating the worker had not been dismissed, but instead had walked out of the workplace half way through the day without reason.

As the injured worker had an accepted workers compensation claim, The Precast Company, in dismissing the injured worker, had failed to provide suitable employment despite the worker being certified as fit for alternative duties. Under the State’s workers compensation laws, an employer is required to provide employment to an injured worker who has a capacity for work.

The company pleaded guilty to one charge of failing to provide suitable employment and was fined $2,500 without conviction and agreed to pay costs of $1,500.

WorkSafe’s own summary of court action provides more details:

The defendant company operates in the building and construction industry. It has declared annual remuneration of about $2 million and has 45 full-time employees.  An employee working as a crane operator suffered a crush injury to his finger on 1 April 2008 and was issued with a certificate of capacity certifying him ‘unfit for all duties’ from 2-4 April and fit for alternative duties from 5-16 April. The worker returned to work on 7 April on light duties.  He left work early to attend a doctor’s appointment and returned to work on 14 April and continued light duties. He saw his doctor on 17 April and was issued a further alternative duties certificate from 17 April -1 May.

On 18 April the worker left work around midday to attend his doctor’s later that afternoon when he was issued with another certificate. At this stage he had still not submitted a claim form. When he arrived for work on 21 April he was told that he had abandoned his employment and had no right to be there. He went home and soon after sought legal advice. He lodged a claim for compensation that day which CGU accepted.

The defendant company’s director wrote to WorkSafe stating that the worker was not dismissed but had abandoned his employment on 18 April 2008. The director was overseas on that date and his explanation is based on what other staff have told him. The foreman provided a statement to a circumstance investigator that on 18 April the worker “just walked out of the workplace half way through the day. He would not provide a reason. As far as I was concerned he was abandoning his employment at this time.”

On 23 June 2008, the date that the worker’s claim was accepted, he was issued with a certificate of capacity certifying him fit for alternative duties until 21 July. By dismissing the worker the defendant company failed to meet its obligation to provide him with suitable employment once his claim had been accepted.

These are the only public details available at the moment but clearly effective communication was not occurring between the employee and the company.  Sometimes circumstances that involve safety become a more complex industrial relations issue which may lead to Court, no matter how hard you try to compartmentalise them.

Tasmania’s workers compensation changes pass

It is easy to forget that workers compensation is clicking along during this intense period of analysis of OHS laws.  Workers compensation legislation passed through Tasmania’s House of Assembly this week (it still needs to get through the Legislative Council).  The Minister for Workplace relations, Lisa Singh, highlighted the following components of the changes in a media release on 6 November 2009.

“The key reforms will:

  • Improve access to common law damages for compensation by reducing the whole of person impairment threshold from 30% to 20%;
  • Amend the first step-down to 90% of normal weekly earnings rather than 85% of normal weekly earnings;
  • Delay the operation of the first step-down, so that it comes into effect at 26 weeks of incapacity rather than 13 weeks;
  • Streamline the management of injury and illness to deliver better health and return to work outcomes for injured workers and lower costs to employers;
  • Foster and reinforce a return to work culture among employers, workers and other stakeholders;
  • Provide greater income security for injured workers by increasing the duration and reducing the “step-down” of weekly compensation payments for injured workers;
  • Increase lump sum compensation up to $250,000 for permanent impairment or death to levels more comparable to those provided in other states and territories;
  • Provide additional financial incentives for workers and employers to participate in rehabilitation.”

The reforms are based on the Government’s response to the recommendations of Victorian consultant Alan Clayton and the Return to Work and Injury Management Model developed by the WorkCover Tasmania Board.

Alan has been a prominent advisor on workers compensation to governments around Australia for some time.  His Tasmanian review and recommendations were in 2007 and are available online.  The Government’s response is also available.

The Minister has said

“With the range of views that were put forward during consultation I am confident that this legislation strikes the right balance of fairness for workers and their families and support for employers and business.”

Simon Cocker, of Unions Tasmania, said in response to the Bill:

“The Workplace Relations Minister is to be congratulated for pursuing these improvements which will ensure that injured workers are better supported when they return to work and are paid more appropriate rates of compensation while off work.”

“The step-down provisions that currently operate have been shown to be unfair and place injured workers and their families under financial stress at a time when they are often struggling to cope with the impact of a serious injury.”

“Delaying the step down and softening its financial impact is an improvement.”

The Australian Government paid considerable attention to the Victorian OHS Act  because it was the most recent review of that legislation.  If the government continues this trend, the Tasmanian changes may be very significant for the rest of the country.

Kevin Jones

UPDATE: 19 November 2009

Tasmanian workers’ compensation laws passed the Legislative Council on 18 November 2009.

Public Comments vs Petition – modern lobbying required

Recently SafetyAtWorkBlog noted that almost one quarter of the submission to the government on its proposed national model OHS law were from individuals and confidential.  There was a suspicion of bulk proforma submissions.

One example that is available through the publicly accessible submissions is a letter to the Minister, Julia Gillard, from the Dr Sharann Johnson, President of the Australian lnstitute of Occupational Hygienists.  The letter raises concerns over the omission of “suitably qualified” from the legislation.  It concludes

“I strongly implore you to reconsider your decision not to include a requirement for the providers of Occupational Health and Safety advice and services to be “suitably qualified” in the national new model OHS legislation.  lt would be disappointing to see this amalgamation of legislation miss the opportunity to make a significant impact on the standard of OHS advice provided to Australian industry and ultimately improve our health and safety performance at a national level.”

Similar concerns to Dr Johnson’s have been discussed elsewhere in  SafetyAtWorkBlog but on the issue of proforma submissions it is noted that three other submissions, Kevin Hedges, Gavin Irving and a personal submission by Dr Johnson, contain almost exactly the same text.

What these and other proforma submitters are producing is not a response to a draft document or a submission but a petition.  Petitions have existed for centuries and carry considerable political clout but putting in a cut-and-paste submission is unhelpful.  It signifies a united position but is not constructive.  A petition to the Government or specific ministers on a single issue, such as “suitably qualified”, may have had more influence if it included an influential number of signatories and was lodged at the appropriate time, in response to outrage over the particular matter.

There is no criticism of the content of the AIOH letters only of the method of delivery and strategy.  There are many more confidential submissions that have also applied a similar strategy.

SafetyAtWorkBlog contacted Safe Work Australia over the issue  and asked “How many proformas were used and who were they by?”  A spokesperson responded

“Of the 480 submissions received, just over 200 standard form submissions were received from union members, in five different proformas.  Each of the five forms contained similar comments.  In addition, we identified a small number of standard form submissions from one professional association.”

In developing better legislation, the influence on the process from “weight of numbers” is likely to be far less in this circumstance than would be gained through constructive and innovative suggestions.

As Australia is likely to go through similar public comment phases on a raft of OHS regulations and documents over the next 12 months, assuming the Government does not shelve the project.  It is important for the proforma submitters to review their strategies and, perhaps, establish more direct contact through lobbying the relevant Ministers in each State and Federally, on behalf of their large (?) membership. In this way the Government would be familiar with the various organisations, would understand the background to those organisations’ arguments, and would then anticipate the innovative solutions that OHS organisations, professionals and experts, would put forward.

This strategy has worked for the unions and business groups for decades.  It may be time for a new strategy for some groups that combines reliable techniques like petitions with personal contact to be followed up by a knock-out submission at the right time, perhaps supported by a broadly distributed media statement.

Kevin Jones

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