Don’t rely on alarms

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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!)

New Guidance on Preventing Fatigue

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Australian OHS authorities have been struggling for many years to address issues of fatigue in the workplace.  Partly this has been because the issue of stress and bullying came to dominate the psycho-social agenda.

The transport industry has pushed fatigue into the unavoidable hazard basket.  New South Wales’ experience with this issue has been particularly interesting and continues to do so. France’s experiment with a maximum set of working hours, partly on the grounds of occupational health and safety, has proven to be a brave experiment.  The Australian Trade Unions’ campaign on “reasonable hours” had safety echoes.

But, as with so many long-term OHS initiatives, Australia waited until England’s Health & Safety Executive (HSE) did all the leg work before tailoring fatigue guidelines to its own circumstances. At least this guideline acknowledges the HSE’s work.

On 4 August 2008, WorkSafe Victoria and WorkCover New South Wales published their guidelines on “Fatigue – Prevention in the Workplace”.  As far as it goes, it is a good addition to OHS information and, if its existence is publicised sufficiently, should place fatigue on the radar of OHS professionals.  Prior to this guide, the only fatigue information that WorkSafe produced was concerning fatigue in the forestry industry in March 2004! – hardly something that any other industry would see as relevant to themselves.

It is worth comparing some of the basic concepts that the OHS regulators have put forward.

The differing definitions reflect the perceptions of the OHS regulators, the state of knowledge at the time, the approach taken by the organisation consulted in the development of the guidances, they anticipate the level of resources allocated to the promotion and enforcement of fatigue management.  The contrast between the Victorian “definitions” of 2004 and 2008 are particularly marked.

Guidelines only go so far and then it is up to business to consider the advice and decide what to do.  The success of the new fatigue guideline won’t be in evidence for several years and, of course, that relies on the very dim chance of anyone undertaking an assessment of the guideline at all.

There are several issues that I think should be considered when reading the new guidance:

The role of the second job.

Second jobs, often undertaken by shift workers are assessed, if at all, for potential conflicts of interest.  The impediment in being “fit for work” in the principal employment is never assessed.  This guideline, in a roundabout manner, identifies this risk. 

The need for nightshift.

Often nightshift, or specific shift rosters, are traditional structures.  “This is the way it has always been done”.  The existence of nightshift in every workplace should be reassessed on a regular basis as economic factors change and as knowledge of the extent of harm presented by nightshift accumulates.

Overlap of Human Resources and OHS

I have bleated on for years about the silo mentality of the OHS and HR disciplines.  The demarcations have been eroding for ages in the real world of business and this trend has been increases as more and more psychosocial hazards are placed within the OHS context.  But the HR professional and the OHS professional continue to speak different languages and with competing agenda.

Fatigue cannot be successfully managed without a common understanding between HR and OHS.

Impairment

Impairment has been a concept floating around the trade unions for some time and they have never found the right approach to getting this on the OHS agenda.  Much of the content in the new fatigue guideline is broader than fatigue and deals with interaction with our employees and colleagues.  The guideline clearly identifies issues from outside work that may exacerbate fatigue in the workplace. (That other demarcation between work and non-work hazards does not apply to fatigue)

Fatigue impairs judgement as well as actions.  Mental fatigue is applicable to a broader range of occupations than physical fatigue and reaches into occupations that are not familiar with OHS, such as judges and politicians, whose important decisions must not be impaired.

 

Fatigue should not be one of the workplace hazards that are increasing shuffled off into the miasma that is work/life balance and wellness.  It relates directly to the traditional areas of OHS but can only be controlled by non-traditional approaches.  There lies the challenge.

Foster’s unforgiveable fatality

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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.

Another Australian politician attempts suicide

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Over the last few days Australian media has been covering the hospitalisation of Tasmanian MP, Paula Wriedt.  It has become apparent that Ms Wreidt attempted suicide as a result of a combination of work and family pressures.

Being a politician is a difficult job and, as with any job, pressure can become excessive.  This was seen over the last few years in New South Wales with the reported suicide attempt of John Brogden in August 2005 and his retirement due to ill-health, and the resignation of Andrew Tink in March 2006 due to a stress-related illness.

In 2005, Australian politician Andrew Bartlett wrote about John Brogden, the pressures of stress in politics and how the media reports on politicians.

In 2002 a small sample survey into the role of work factors in suicide was undertaken in

 Melbourne by the Urban Ministry Network.  The authors analysed 109 suicide cases from the coronial database between 1989 and 2000.

The main factors in the suicides were

  • Work Stress (21%)
  • Unspecified work problems (19%)
  • An argument or disagreement with a work colleague or boss (13%)
  • Fear of retrenchment (12%)

According to the report, a work injury or work-related mental illness had an impact on the person’s suicide in 31% of the cases.

These figures indicate that work-related suicide is an issue of genuine concern and one that should demand further research.

The Victorian State Coroner at the time of the report and a strong advocate for preventive safety, Graeme Johnstone, write in the foreword:

As a society we tend to concentrate on the obvious – in terms of the workplace that means traumatic injuries and deaths.  We understand that by identifying factors in traumatic workplace injuries and deaths we will be better able to prevent some of the deaths and reduce the number of injuries. This also may be true in the area of suicide and it is why this study on work factors in suicide has so much potential.

One of the authors of that study, John Bottomley, is looking for research funding for a second analyse of suicides.  He can be contacted through the website HERE   His research outline is listed at the top of this page.

In 2000 an Australian politician succeeded in killing himself.  The ABC spoke to an expert on the treatment of depression.

A book review of the Bottomley study is available HERE

UPDATE

Paula Wriedt has spoken to the press for the first time since being admitted to hospital.  She thanks her estranged husband, medical staff and family for their help.

Professor Michael Quinlan, Beaconsfield and Safety Cases

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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.