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…
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 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.
Following repeated questions about the release date for the inquiry into the 2006 Blackhawk helicopter crash on HMAS Kanimbla and the publishing of some of the, supposed, recommendations in the Sydney Morning Herald, it is believed that the findings will be released around the middle of July 2008.
Earlier this year, the Charlotte Observer began researching avian influenza but ended up with an expose about occupational health and safety in the US poultry industry, called “The Cruelest Cuts”. A recent podcast, and vodcast (I recommend the vodcast), highlights many safety management issues that are relevant to other industries and other jurisdictions
The arguments generated by the Charlotte Observer’s articles continue. A recent article reports on the House Education and Labor Committee hearings and the issues summarised in the above vodcast.
Some of the issues raised may bring “Fast Food Nation” to mind but Eric Schlosser had a broader agenda in his book than in the Charlotte Observer reports.
The articles and the video remind us to question and to ask and to prod and probe when any government department report on OHS management is released. They also illustrate how easy it is to make a company look like it is safe.
In Australia at the moment there is debate about migrant workers and soem employers have recently been prosecuted on OHS matters related to these workers. In fact, today (2 July 2008 ) according to WorkSafe Victoria, a Victorian Magistrate will sentence Lakeside Packaging over OHS issues.
The case involves injuries to two Chinese guest workers on s 457 visas. One man was hurt on two occasions – both arms broken. Lakeside Packaging Pty Ltd pleaded guilty to 7 charges.
The incidents:
• Guoping Cai (35) was hurt on 16 March 2006 at the company’s Dennis St, Campbellfield premises, when his arm was crushed in an unguarded printing machine as he cleared a paper blockage. Both bones in his right forearm were broken and he was in hospital for 2 weeks Plates and bolts were put in his arm and he required a skin graft.
• Zhi Hong Fu (52) fell from a ladder which had been placed on top of a steel working platform on 5 April 2006 at the Rex Road, Campbellfield premises. He was doing electrical work for which he was not qualified. He broke his right wrist and suffered other injuries He returned to work four days later with his arm in plaster. On 30 June, with his dominant right arm now in a brace, he suffered a second injury while using a drill with his left arm and steadying it with his chin. The drill kicked and his other (left) arm was broken. The company pleaded guilty to 5 charges in relation to these incidents.
Australia does not have a Mexico on its border, and the governments have heavily regulated the migrant intake but, as the court action has shown, the safety management approaches of some employers are the same the world over.
Australia is accumulating a considerable body of knowledge about safety cultures in workplaces. Sadly most of the information comes from inquiries into disasters that involve multiple fatalities. The UK has its body of knowledge from oil-rig explosions and train crashes. Australia’s is predominantly from mining disasters, gas plant explosions and, also, train crashes.
Now according to the Sydney Morning Herald, the Australian Defence Force also has a deficient safety culture. In some ways this is of greater concern than such criticisms of private sector disasters as one would expect the military to have greater control over issues such as equipment maintenance, and staff conduct due to its regimented command structure.
ABC’s AM program reported that the board of inquiry findings into the crash of a BlackHawk helicopter on the deck of a navy ship in 2006, identifies
“.. a culture of risk taking and sloppy safety standards in the army’s elite helicopter squadron.”
According to media reports
“The inquiry’s final report found senior pilots in the Sydney-based 171 Squadron had a culture of aggressive flying, safety procedures were slack and the reporting of incidents involving engine failures and other safety breaches was haphazard,..”
A video report on the board of inquiry which includes film of the crash is available online.
Bill Calcutt makes some excellent points about the consultative strategy used by the Australian government in its recent 2020 summit. The summit showed that this government had differentiated itself from the previous conservative one through “transparent evidence-based decision making” and a wide consultative base, even though the guests were selected. Sadly, I am not sure…