safety culture – Page 63 – SafetyAtWorkBlog

Don’t rely on alarms

The Australian media has been following the investigation into the crash of a light aircraft that was travelling to Benalla on July 28, 2004. There was a report on 5 August about a family who will be suing Queensland Rail over the serious bashing of a relative. Different stories, different states, different modes of transport, but both stories of sadness.

Both stories illustrate an important reminder for the management of safety in workplaces and in public – alarms are there for a reason.

According to media, Barbara Lillicrap, the widow of bashing victim, Scott Lillicrap, said witnesses had pushed the emergency button at the station at least three times, but rail officers believed it to be a prank and ignored it.

A newspaper report says that air traffic controller Stuart Hodge said that an alert was sounded when the plane veered off course before approaching Benalla Airport. Mr Hodge said false alarms were common and there was a culture among air traffic controllers to ignore them.

These two reports also need to remind safety professionals that alarms are simply audible signs to which people need to respond, or at least acknowledge. An ignored sign is a useless control measure and if this is likely to occur, then a higher order of control measure needs to be implemented to control the hazard.

(Don’t get me started on signs at level crossings!)

Foster’s unforgiveable fatality

Foster’s Brewing has received one of the largest fines for a health and safety infringement in Victoria’s history, $1.125 million. In 2006 Cuu Huynh was jammed by the neck between the doors of a de-palletiser and a handrail and died as a consequence. The same circumstances injured another worker in 2002.

A major reason for the large fine is because, as WorkSafe’s John Merritt put it

“The problem had been identified, someone had been hurt previously, the solution was known and it wasn’t fixed until after a man had died. The opportunities to make improvements were repeatedly deferred.”

Foster’s chose to upgrade the de-palletiser involved in the 2002 incident but neglected the other de-palletisers in the same plant. This is where stupidity or laziness enters the equation. The OHS Plant Regulations allow for the risk assessment and findings on one type of machine to be applied to the same machines without revisiting the assessment process. Foster’s chose not to learn from a mistake.

It seems what is “reasonably practicable” for one machine is not so for another.

Readers would be aware that I support companies who choose to keep with the status quo through a risk assessment process, as long as they own up to when that decision may be proven wrong; in the case of Foster’s fatally wrong.

There is no indication that Foster’s will appeal the fine. This is to be applauded as, on top of the fine, the company has had to spend almost $4 million in plant safety upgrades. This is a substantial cost that probably would have been cheaper in 2002, or even earlier, but it remains little comfort to Cuu Huynh’s family.

Below are some of the points that WorkSafe is making in relation to Foster’s handling of safety on their depalletisers.

An employee was hurt in similar circumstances on another machine in 2002. While safety was improved on that machine, improvements were not made to the machine which killed the man in 2006.
Operators were required to enter the operating area of their machines to remove broken bottles and plastic binding tape and ensure sensor lights worked. Workers estimated they would do this up to 20 times per shift.
There was no adequate visual and no audible warning of the opening of the pneumatic doors, unguarded chain sprockets created hazards, while safety devices were easily over-ridden to prevent sudden stoppage of the machine which caused bottles to fall over and break;.
Written standard operating procedures (SOP’s) for operating the depalletisers and cleaning them during breaks in production had been produced, but they did not deal with clearing jams during production. A specific SOP covering this was produced after the workers’ death.
Various operators told WorkSafe they were unfamiliar with the SOP’s and did not have sufficient English to read them. Much training was done ‘on the job’.
Workers were allowed to leave work an hour earlier on the last shift of the week if they had completed cleaning the machine. As a result they would clean the machine while production continued. The man who died was on this position.

This is a litany of poor safety management that any company should be ashamed of. Of particular concern, and should be noted by other companies and OHS regulators, is that written instructions for the machine were inadequate and in a format that could not be easily understood by the machine operators.

One of my safety colleagues has mentioned to me the absurdity that the first of WorkSafe’s new Compliance Codes is expected to be on workplace amenities. This workplace element rarely leads to death or injury and the release of a “minor” code does not auger well for the rest of the codes. It is understandable that Amenities may be one of the easier-to-produce codes but, to my mind, the most neglected guidance material in the last 20 years has been the provision of safety information in languages other than English – a workplace issue that WorkSafe has indicated was directly relevant to the death of Cuu Huynh.

For all of those corporations that say that safety is the first priority and that production will be suspended if a safety hazard is identified, Foster’s did not follow its own policies. According to its own HSE Policy

“We will work towards our goals through a process of continuous improvement and, in particular, fulfil these commitments by:

1. Meeting or exceeding all health, safety and environment regulations in each of our workplaces around the globe.”

Cuu Huynh’s death has shown, as mentioned by WorkSafe above and mentioned in media reports

“…the workplace culture encouraged the machine operators to maintain production by not stopping depalletisers when they were clearing jams or cleaning the machine.”

Production, at Foster’s, was more important than safety.

Why are many of China’s coalmines closed?

Safety At Work magazine has been reporting on the seemingly endless deaths in the Chinese mining industry for many years. Many of the mine fatalities are of multiples that would generate huge investigations in the west. Many deaths are compounded by the attempts of mine managers to minimise the scale of the disasters by delaying reporting the incident, not reporting at all, or disposing of the bodies.

These incidents have occurred mostly in privately-run mines and over the last couple of years the government has had regular crackdowns on the industry.

China is a good example of a country that manages safety in reaction to disasters. Poor safety management is often ignored as long as production is guaranteed. This is evident in its manufacturing sector as much as it is in mining.

John Garnaut in The Age newspaper on August 4 2008 reports on the actions of the Chinese government in the mining sector in the lead up to the Beijing Olympics. Garnaut reports that migrant workers were sent home weeks ago without pay. At one mine he attended, work was stopped by management, ostensibly due to his presence as a journalist.

The closure of these mines has had a heavy impact on the coal supply and coal prices and Garnaut says that the action of the government has come about to

“prevent the Olympic Games from being marred by embarrassing reports of mine disasters.”

China’s decision shows how sensitive it is to criticism from other countries. The mess over internet access is a further example.

China does not only manage safety reactively, it manages through diversion, concealment and censorship.

What Garnaut’s reporting and China’s censorship shows is that safety of workers, and accountability of business owners can be improved through the attention of outsiders. For over seven years, in my experience, China has been experiencing almost monthly fatalities in its coal industry. I have been publishing whatever reports I can obtain (legitimately) from the wire service, however similar reports have not been appearing in the mainstream, or event the trade, press. The community is generally unaware of the cultural negligence that the Chinese system of production and regulation allows.

Perhaps it is a truth that few of us really care but one of the major threats to any management process is hypocrisy. The Chinese government may be comfortable with that but our own governments should not be hypocrites in our trade negotiations with partners like China.

UPDATE

The Associated Press has reported a gas explosion in a coal mine in at the Baijiagou mine in the northeast of Liaoning province on 18 August 2008. Twenty-four workers are trapped but fifty-six other miners escaped without injury. The story came through the Xinhua News Agency in China, so it will be worth seeing, during this Olympics fervour, what attention this disaster receives from the West

Inquiry into health impacts of maintaining jet-fighter fuel tanks

Earlier this century the Australian Defence Force established the F-111 Deseal-Reseal Health Care Scheme to compensate workers who may have been affected through exposure to chemicals while cleaning F111 fighter aircraft between 1977 and the late 1990s.

A parliamentary inquiry has been established to further investigate the issue of compensation. In the 29 July 2008 edition of The Australian newspaper details of the work exposures have been restated.

“More than 800 RAAF personnel were forced to do the work on the fuel tanks, removing old sealant using chemicals.

The work was done because of a basic flaw in the design of the aircraft — their fuel tanks did not include a bladder, and the sealant used on rivets to stop leaking had to be replaced at regular intervals.”

Details of the impact of this work on workers and their families have also been restated. Ian Fraser, Queensland president of the F-111 Deseal-Reseal support group has said that

“former workers now suffer temper swings, drug abuse and broken marriages — and some had committed suicide.

A significant number have died from cancer, which Mr Fraser’s organisation says is directly attributable to them being made to work with the chemicals — particularly one known as SR51.”

Those OHS professionals who have read Professor Andrew Hopkins’ book “Safety, Risk and Culture” should be familiar with the case as Hopkins investigated the issue and devoted a chapter to his book on the F111 Deseal/Reseal process. A review of the Hopkins book is available online as is a useful article by Hopkins on safety culture.

It is worth remembering that exposure to chemicals and inadequate protection is not something from the developing nations or from Western industrial history. These workers faced unacceptable risks within the last twenty years.

Managers doing what they think the boss wants

The walkout from the Tasmanian Coronial inquest of the Beaconsfield Mine legal team has given the issues associated with the death of Larry Knight more media prominence than it would otherwise have received. The withdrawal also allows statements concerning the financial pressures on the mine to continue uncontested. An ABC podcast on the coronial inquest…

OHS in the 1970’s

Matthew Knott’s article in the Australian newspaper (21 July 2008 ) included telling comments from Barry Willis, a 64-year-old former maintenance worker at Amberley air force base. The article says

“workplace health and safety was non-existent: open cans of chemical sealant were stored in the refrigerators where the men kept their lunch.”

I have been critical of the military in the past as they are usually well-sourced on OHS and often speak proudly of their approach to safety. Yet just as with the BlackHawk Inquiry findings criticising the safety culture, Barry Willis saw no safety culture in the 1970s.

At the risk of sounding like an old grump, working in that decade was under a different set of cultural rules. Modern OHS legislation was being considered by most Western jurisdictions and industrial diseases were coming to the fore. In the early 1980’s I worked in industrial relations concerning award restructuring. One of the first elements to be restructured was allowances, many of them accurately described as “danger money” – removing roadkill, working at heights, confined spaces and a range of other hazards.

It can be argued that modern salary levels incorporate allowances for hazardous work but the issue of immediate compensation for a dirty or hazardous job, hopefully, has had its day.

Sadly, for people like Barry Willis, the consequences of a hazard, known or discounted, continue and the struggle for acknowledgement and compensation continues.

The crash of Blackhawk 221 and safety culture

The Australian’s government’s report into the crash of a Blackhawk helicopter on the deck of the HMAS Kanimbla in November 2006, in which two defence personnel were killed, has been released by Air Chief Marshal Angus Houston.

According to media statements

“The principal and overarching finding of the Board of Inquiry was that the cause of the crash of Black Hawk 221 was pilot error by the aircraft captain,” Air Chief Marshal Houston said. “Justice Levine stated that the principal finding, however, could not be viewed in isolation nor blame attributed to a highly experienced and well-respected Black Hawk pilot.

“This accident was the regrettable result of a number of factors coming together which culminated in this tragic incident. There was a gradual adoption of approach profiles which, on occasions, exceeded the limits of the aircraft. Other factors included a ‘can do’ culture in the Squadron, inadequate supervision, the pressures of preparing for operations, the relocation of the Squadron and a high operational tempo.”

Amongst the control measures introduced following the Blackhawk 221crash and an earlier incident, the Army issued a new risk-management policy in October 2007. It provides “commanders with clear instructions on how to conduct risk management on operations and in training.”

Ultimately, good has come from the results of the Blackhawk crashes. The decision to release this report, provide audio of the press conference and considerable inquiry background, is commendable. However, as reflected in the Air Chief Marshal’s comments above, and expanded upon in the must-hear podcast (35Mb MP3), safety management standards had slipped over time. He is keen to emphasise that the crashes need to be seen in a broader organizational context, as any incident investigation should.

But, in my opinion, that broader context remains damning. The Defence Forces should, through their strict hierarchical system and regimented decision-making, be an exemplar of safety and risk management.

It is always the case that we should learn from our mistakes but it seems, as in the private sector, that those organizations with considerable safety resources who are best equipped to avoid problems continue to experience them.

With many workplace investigations the excuse for incidents that is frequently trotted out – poor safety culture – is becoming a term of reduced relevance. The failure of a safety culture is not an “act of God” although the phrase, safety culture, is being used in the same manner. It implies that there was only so much that could be done but it also indicates that prior to any incident not enough was done.

Safety improvements through hindsight have become the mainstay of contemporary management. If there is a stuff-up, acknowledge the fact and promise restitution. Don’t accept responsibility. Don’t admit liability. In fact, don’t mention the incident, only mention what improvements one intends to make.

The depressing part of a no-blame investigation is that it can feel so unsatisfying.

Category: safety culture

Don’t rely on alarms

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Foster’s unforgiveable fatality

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Why are many of China’s coalmines closed?

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Inquiry into health impacts of maintaining jet-fighter fuel tanks

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Managers doing what they think the boss wants

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OHS in the 1970’s

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The crash of Blackhawk 221 and safety culture

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