transport – Page 47 – SafetyAtWorkBlog

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.

Hole in Qantas aircraft

Qantas Airways has a reputation for safety. It’s aircraft have not fallen from the sky for over 50 years. This fact was brought to wide public attention in the movie RainMan and is a fact that most Australians take pride in.

Airlines do not promote themselves on the basis of their safety record principally because it is a high-risk strategy that can be ruined by just one crash.

In late-July 2008 Qantas Airways had a very lucky escape when, according to current reports, an oxygen cylinder exploded and tore a hole in the fuselage of a plan flying over South East Asia. Ben Sandilands in the Sunday Age rightly points out that lives were saved because the pilot was able to undertake an emergency landing at the nearby Manila airport.

In The Sunday Age 27 July 2008 (not available online), Sandilands pointed out that Qantas often flies on long routes over the sea such as Melbourne to Los Angeles, or over Antarctica on its Argentinean route. Had the fuselage damage occurred on one of these routes:

“The pilots would have been forced to choose between risking a potentially catastrophic mid-air break-up versus a crash landing or ditching.”

Qantas does not advertise on its safety record but its continuing success is partly attributed to that record. The avoidance of disaster from this recent episode is a combination of luck and good management. Qantas executives can do little about luck but it does need to maintain its good management and be seen to do so.

Relocating maintenance tasks to Malaysia may make sound economic sense, perhaps moreso in times of extremely high fuel prices, but national pride in a national airline should not be underestimated.

UPDATE

An exploding oxygen bottle is firming as the cause of the hole in the fuselage. However other issues are being raised as another Qantas plane had problems overnight. An undercarriage door would not close complete and Qantas flight needed to return to Adelaide. Passengers were understandable a little more concerned than usual.

Several of the articles referenced in this blog include complaints by passengers that oxygen masks failed to work or could not be fitted. Qantas has said that inspections of masks are included in maintenance schedules and it may be a significant factor that it seems to be an oxygen bottle that exploded however the Australian Transport Safety Bureau has asked for passengers to contact it if they had such problems.

Editorials are appearing in which the importance of safety to the longevity of an airline (as well as the passengers) is being emphasised. The Age newspaper on 29 July 2008 said that

An airline’s future is its good name. Qantas has for decades thrived on its reputation. Alan Joyce has the challenge before him to continue that tradition.

(Alan Joyce is the incoming chief executive officer.)

Australian Level Crossings – Part 2

The Victorian Government’s investigation into level crossing safety is continuing. Yesterday the Parliamentary Committee on Road Safety ran a seminar on technological issues related to level crossings. Today (22 July 2008 ) I attended the morning session of a seminar on Fail-Safe technologies. The meat of today’s seminar was to be an open and frank…

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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.

Australia military and safety culture – update

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.

Australia military and safety culture

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.

Category: transport

Inquiry into health impacts of maintaining jet-fighter fuel tanks

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Hole in Qantas aircraft

UPDATE

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Australian Level Crossings – Part 2

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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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Australia military and safety culture – update

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Australia military and safety culture

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UPDATE

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