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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

Quad Bikes – industry response

On 30 November 2009, the CEO of The Federal Chamber of Automotive Industries, Andrew McKellar, responded to some of the issues raised in recent SafetyAtWorkBlog articles concerning the safety of quad bikes.

McKellar emphasised that a balanced approach to ATV safety discussions is required.  He said:

“In terms of a statistical outcome, the results show that, on balance, [ROPS] does not result in a safer outcome, in some situations people are going to be killed where otherwise they would have been fine.  In other circumstances, they will survive an accident or a rollover accident where they might have been seriously injured if they hadn’t had it…….There is no clear safety benefit from putting such structures on those vehicles.”

As has been shown in previous articles many Australian and New Zealand OHS regulators have not recommended ROPS for quad bikes.  This indicates that there must be some convincing evidence that ROPS are inappropriate.  But that leaves the same problem with quad bikes in 2009 that existed decades ago, people are becoming injured or are dying from the (mis)use of these vehicles.

In most other vehicle and manufacturing circumstances consistent misuse would indicate that the vehicle itself and the interaction between driver and vehicle requires considerable investigation and/or redesign.  The investigation by Ralph Nader was referred to in an earlier article as an example of unsafe design being engineered out.

Equipment designers in a range of industries strive to make their equipment foolproof but there does not seem to be same motivation in the quad bike manufacturing industry which still advocates helmets as the best hazard control option.  This option is supported by calls for safe driving courses and keeping within the manufacturers’ specifications.

Helmets may be best practice at the moment but it is hard to believe that that is where the situation should stay.  By not progressing beyond this control option, manufacturers and safety regulators are focusing on rider awareness in a sector, agriculture, that is renowned for taking (inventive) shortcuts and whose principal workforce are men who have a macho dismissive attitude to safety.  A new approach is required.

Kevin Jones

Australian research figures into quad-bike deaths and injuries

A SafetyAtWorkBlog reader drew our attention to a research report on quad bike safety by one of Australia’s most well-known researchers into agricultural safety, Lyn Fragar.

The report entitled “ATV Injury on Australian Farms – The Facts – 2006” details a compilation of police, hospital and injury data from many years concerning ATVs or quad bikes.  Recommendations and observations are made but curiously the design of the vehicles is not considered as a contributory factor in rollovers and rollover protection structures are not mentioned.

Kevin Jones

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.

Safety photos

Many online safety professionals get the occasional email asking whether there is a repository of safety photos that can be used in support of safety programs.  The enquiries come from all over the world and the easy answer is there isn’t one.

There are many reasons for this.  One is that almost all of the photos taken by OHS regulators are produced for legal purposes and have legal restrictions.  Similarly photos taken of incident sites by companies are usually for evidence.

The best  safety photos are those photos that are not taken for safety purposes but standard work photos that show safe work practices.  Yet few companies take photos of their workplaces purely to record how work is undertaken.

Recently the European Agency for Safety & Health At Work ran a contest for the best safety photo in Europe.  The winner has been announced for a photo entitled “Beekeeper” by Christopher Azzopardi.

Copyright - EU-OSHA, www.osha-photocompetition.eu

The Agency also has a gallery of the top 100 images received for the competition which are recommended for viewing.

The reuse of images are subject to legal restrictions so please check with EU-OSHA.

In SafetyAtWorkBlog’s experience, safety professionals should have a camera with them during inspections or walkrounds, not to catch out workers doing the wrong thing but as a record of how the workplace operates.  Just as audits can provide snapshots of processes so images are snapshots of the “way things are done”.

Kevin Jones

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