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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.

Professor Michael Quinlan, Beaconsfield and Safety Cases

I have spoken elsewhere of the non-release of Professor Michael Quinlan’s OHS report into the Beaconsfield mine. On 4 August 2008, he spoke at the coronial inquest into the death of Larry Knight. According to media reports, Professor Quinlan said about the rockfall that killed Larry Knight:

“I can’t say the event wouldn’t have occurred – I can say that the chances of it occurring would have been reduced… They are steps that should have been taken, in my view.”

He has also been very hot on the validity of risk assessment processes at workplace. As part of Melick report into the disaster, Melick used Quinlan’s report when writing

“As far as can be determined, the risk ranking of ground control was not reassessed or revised in the light of these (earlier rockfall) events…. The evidence indicates that the possibility of further significant seismic events in the mine in 915 and 925 metre levels was foreseeable.”

In December 2007, I interviewed Professor Quinlan about a range of OHS issues including major hazards. In the SafetyAtWork podcast, he said that some mines in Western Australia have begun to apply a safety case regime to safety because of the high-hazard nature of the workplace. At that time he supported such a move.

Quinlan pointed out, though, that safety case regulation is very resource-intensive and, therefore, only relative to large organisations and well-resourced regulators.

It is unlikely that such a combination could have been applied to the mine in Beaconsfield as Quinlan is reported as saying at the inquest that

“Workplace Standards Tasmania was under-resourced and [he] recommended the development of mine-specific safety laws and trade-union mine inspectors.”

Many submissions to the National OHS Law Review have mentioned the relevance of a safety case approach to OHS but only one of the currently available submissions mentions that the safety case approach could be applied to mines.

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

Stress and job mobility

In The Age newspaper for 31 July 2008, James Adonis wrote the article “Eight signs your workplace is crook”. One of those signs was stressed workers. He quoted a report by Watson Wyatt where employees listed stress as a major reason for leaving a job. Stress did not rank in the employers’ top five reasons for people leaving.

This disconnect illustrates a major misunderstanding about workplace stress by employers and, maybe, employees. The ultimate control measure for workplace stress is to leave a job and I recommend this to colleagues who do not see it as a viable hazard control option.

The challenge is to make sure that the next job is not, or does not become, a similarly stressful job.

The executive summary of the report says

“Forty-eight percent of organizations say that job-related stress — created by long hours and doing more with less — affects business performance. Although only 5 percent are taking strong action to address it…”

The focus on business performance may reflect the perspective of the report writers but as it is only available for purchase for $US49, I would ask for the report (2007/2008 Staying@Work Report: Building an Effective Health & Productivity Framework) at a library.

Bank influence on Beaconsfield Mine

It is all too easy to misread the headline on page 7 of today’s Australian newspaper:

MacBank ‘had input’ into goldmine

This seems to confirm the recent statements by miners to the coronial inquest into Larry Knight’s death at Beaconsfield Mine, and accusations by unions. The headline is based on the statements made by Michael Ryan who was the administrator to Allstate Explorations. Ryan said that the Macquarie Bank had representatives on the joint venture committee and those bank representatives asked questions about the mine. However Ryan could not recall if questions were raised by them about production levels.

Ryan said that Matthew Gill, the mine manager, had made several unsuccessful attempts to have government safety inspectors visit the mine. The article does not specify the reason for Gill’s attempts.

Michael Ryan said that he would approve any expenditure on safety at the mine.

The article says that in the month prior to the April 2006 rockfall, Ryan asked about safety in the mine.

“He said he asked Mr Gill on a number of occasions if the mine was safe, including in March 2006, after observing an unusual number of rocks caught in support mesh. “(Gill’s) answers were to the effect that it was (safe).”

Matthew Gill has spoken publicly several times about his experiences following the rockfall and is now on the professional speakers’ circuit. He was appointed the Managing Director of Monarch Gold Mining Company.

Crandall Canyon Mine Investigation Report

On 24 July 2008 the U.S. Department of Labor’s Mine Safety and Health Administration (MSHA) announced that it has fined the operator of the Crandall Canyon Mine in Emery County, Utah, $1,340,000 for violations that directly contributed to the deaths of six miners in 2007.

According to MSHA’s media release, Agapito Associates Inc., a mining engineering consultant, was fined $220,000 for faulty analysis of the mine’s design. MSHA cited the mine operator for 11 additional, non-contributory violations issued as the result of the investigation. The proposed penalty for these violations is $296,664, bringing the total proposed penalties against the mine operator to $1,636,664. Crandall Canyon Mine is operated by Genwal Resources Inc., whose parent company is Murray Energy Corp.

Safety At Work magazine covered the incident extensively as it provided a stained mirror to the lucky rescue of the miners from Tasmania’s Beaconsfield mine. I reported elsewhere on the fresh seismology findings.

The MSHA report states that

“Three separate methods of analysis employed as part of MSHA’s investigation confirmed that the mining plan was destined to fail.” (my emphasis)

To a non-US observer the fine seems remarkably light given that the mining plan was critically deficient, 6 people died in the first incident and 3 died ten days later.

Not everyone is happy with how the investigation has been conducted.

MSHA accident investigators have cited Genwal Resources Inc. and Agapito Associates Inc. for the following violations:

The mine operator did not immediately contact MSHA after coal outbursts threw coal into the mine openings and disrupted regular mining activities for more than one hour on three separate occasions prior to the August 6 outburst.
The mine operator failed to propose revisions to the roof control plan when conditions (coal outbursts) clearly indicated that the plan was inadequate and miners were being exposed to dangerous conditions.
The operator violated the approved roof control plan by removing coal that was required to support the roof.
The operator’s outside engineering firm failed to recommend safe mining methods and pillar/barrier dimensions, and the operator failed to maintain pillar dimensions that would effectively control coal outbursts.

The complete accident investigation report (16 megabyte) is available at as is MSHA’s response and additional content.

The earlier investigation report by the Utah Mine Safety Commission is available HERE

Imperial Sugar explosion update

Last month America’s 60 Minutes broadcast an article on the explosion at the Imperial Sugar plant (pictured below) in Port Wentworth which killed 13 workers and hospitalised 40. On 25 July 2008, the Occupational Safety and Health Administration (OSHA) issued citations proposing penalties totalling $8,777,500 against the Imperial Sugar Co. and its two affiliates alleging violations at their plants in Port Wentworth and Gramercy.

The US Chemical Safety Board (CSB) has released some details about its appearance at the US Subcommittee on Employment and Workplace Safety, Senate Committee on Health, Education, Labor, and Pensions, on 29 July 2008. (Transcripts and video are available HERE)

CSB Chairman John Bresland said the tragedy demonstrates the need for a new OSHA standard that would cover a range of industries exposed to this hazard, such as food, chemicals, plastics, automotive parts, pharmaceuticals, electrical power (where generated by coal) and others.
According to the CSB, Chairman Bresland told the subcommittee, chaired by Sen. Patty Murray of Washington,

‘After witnessing the terrible human and physical toll from the Imperial explosion, I believe the urgency of a new combustible dust standard is greater than ever. A new standard, combined with enforcement and education, will save workers’ lives.’
‘We obtained documents indicating that certain parts of Imperial’s milling process were releasing tens of thousands of pounds of sugar per month into the work area. Based on our evidence, Imperial did not have a written dust control program or a program for using safe dust removal methods. And the company lacked a formal training program to educate its workers about combustible dust hazards.’

Bresland emphasised the need for a uniform Federal standard:

‘Instead of the present patchwork of miscellaneous federal, state, and local requirements, the Chemical Safety Board has recommended that OSHA develop a single, comprehensive, uniform standard – based on the sound, consensus-based technical principles and practices that are embodied in NFPA standards,’ Chairman Bresland said. ‘Ambiguities in the NFPA standards need to be resolved in clear, enforceable regulations developed by a thorough, public rulemaking process.’

Category: safety

Foster’s unforgiveable fatality

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Professor Michael Quinlan, Beaconsfield and Safety Cases

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Why are many of China’s coalmines closed?

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Stress and job mobility

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Bank influence on Beaconsfield Mine

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Crandall Canyon Mine Investigation Report

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Imperial Sugar explosion update

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