Eliminate the hazards

The first control measure on the “hierarchy of controls” is to eliminate the hazard.  OHS consultants and professionals should always consider ways to achieve this.  It may prove to be impractical, or politically unpopular, but it should always be discussed or recommended.  Reports and submissions that do not consider this control measure can be considered invalid.

In late-January 2009, the organic farmers in Australia reminded the media that its farming members are developing a safer industry for the customer and the producer.  This industry has boomed in Australia since the 1970’s in as a result of a desire and commitment to “eliminate the hazard”.

Interviews conducted by Biological Farmers of Australia (BFA) to help  discover why producers ‘go organic’ reveal a high number of farmers consider the switch for the health of themselves and their families.

Rob Bauer (Bauers Organic Farm, Qld), one of Australia’s largest organic horticultural growers, says he turned to organic farming 27 ago after farmers in his area became ill with cancer.

He says he wanted to decrease health risks associated with synthetic farm chemicals.

“I started thinking about farming differently after growing up in the Lockyer Valley (Qld) where friends and family passed away in their fifties after years of intensive agrichemical production.”

He says neurological problems, tumours, and cancer were among the chronic diseases he watched take their toll on his local farming community.

“I wasn’t comfortable with producing food using harsh farm chemicals for consumers,” he says.

Steve Skopilianos, commercial lettuce producer from Ladybird Organics in Keilor (Vic) looked into organics when he started a family.

“We had been applying pesticide blends with no understanding of their effect on people and employees.  There were times prior to organic conversion where I would not take my own produce home for my family to eat.”

Biodynamic producers of macadamias are happy to avoid high levels of agrichemicals typically used on the nuts.

“Working without a high exposure to synthetic chemical farm products is a weight off your mind,” says Marco Bobbert, from Wodonga Park Fruit and Nuts macadamia plantation (Qld), certified biodynamic since 1987.

He says direct chemical exposure could easily occur on conventional farms from accidents in production. “All it takes is a broken spray pipe.”

He says it is not just organic farmers who are concerned – “All farmers try to minimise their contact with chemicals on-farm. But organic production actively works toward negating that risk”.

Research has shown there is good reason for producers’ concern – a high exposure to some farm chemicals can lead to major health problems.

Particularly problematic substances include organophosphate insecticides and pesticides, which have been connected to several types of cancer, sterility and cognitive deficits (1).

The agrichemical endosulfan is one example of a highly toxic  organochlorine cyclodiene) insecticide still in use in Australia.

1. (1) Ciesielski, S, Loomis, D, Rupp Mims, S, Auer, A, Pesticide Exposures, Cholinesterase Depression, and Symptoms among North Carolina Migrant Farmworkers; American Journal of Public Health, 1994.

Indonesian Mines & Depleted Uranium

As in most professions during time in occupational health and safety, one meets amazing people.  One that SafetyAtWorkBlog  cherishes is Melody Kemp.  

Melody is an ex-pat Australia who currently resides in Laos. As well as working on OHS matters throughout the Asian region she is also the author of the excellent OHS publication Working for Life: Sourcebook on Occupational Health for Women, a free download.

In 19 December 2008 Melody had an article printed in Asia Times Online concerning the social impacts of a proposed mine on the small Indonesian island of Lembata.  In this era of corporate social responsibility, safety professionals have a broad brief which covers many industrial, corporate and environmental responsibilities and it is often company behaviour in far-flung outposts of the corporate structure or the world that indicates a clearer picture of corporate and safety culture.  

Melody’s article is highly recommended for those with a social conscience, for those in the mining sectors and for those whose companies have Asian operations.

In 2003, Melody wrote an article on the health risks of the use of depleted uranium for Safety At Work magazine (pictured below).  That article can be accessed HERE.

Kevin Jones

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Management failures and a rape of a five-month-old baby

Earlier this year, SafetyAtWorkBlog reported on the attack on a nurse in the Torres Strait Islands north of Australia, the investigation of the issue by Queensland Health and the mechanisms introduced to get the working conditions and accommodation up to a safe level.  In this case there was a clear link between occupational health and safety and the security of a worker.

OHS law in Australia obliges workers and those in control of a workplace to ensure the safety of people on their premises.  Last week the Northern Territory government received a report (081128vol1-f9c6d46d-75d5-4a5e-95e7-7c040ae6600c1) into the security measures at the Royal Darwin Hospital.  This hospital has undertaken fantastic medical work in the past, most noticeably, on a large scale following the bombings in Bali in October 2002.

However it failed to prevent the rape of a five month old female infant on 30th March 2006, while the indigenous baby was an inpatient.

Carolyn Richards, the Health & Community Services Complaints Commissioner, said in her report

As a result of a complaint reported to the Health & Community Services Complaints Commission an investigation was undertaken by the Director of Investigations, Mrs Julie Carlsen, who is employed as the Director of Investigations (DI) Health &  Community Services Complaints Commission.

This report highlights that the Department of Health & Community Services (DHCS) needs to implement effective risk control mechanisms to minimise the risk of an assault on a vulnerable inpatient in the Royal Darwin Hospital (RDH). The investigation has led to the conclusion that DHCS (DHF) and RDH have not complied with the applicable Australian Standard. It has also revealed that crucial information has been withheld from an expert engaged by RDH to review security arrangements and from the DHCS (DHF) Security Manager based at RDH. This report also details inadequacies and failings by those responsible for managing RDH who have failed for over two years to implement and maintain better security for patients in the Paediatric Ward. It is published with the hope that it will cause DHCS (DHF) and RDH to give higher priority to improving its risk management and security procedures.

The Commissioner’s conclusions are worth including here so that OHS professionals and security officers can establish appropriate procedures for their workplaces.pages-from-081128vol1-f9c6d46d-75d5-4a5e-95e7-7c040ae6600c1

1. On 30th March 2006:

  • There were no arrangements in place on the Paediatric Ward to ensure the safety and inviolability of vulnerable patients.
  • No risk assessment had been conducted.
  • The arrangements in place did not comply in any aspect with the Australian Standard which sets the benchmark for proper security.
  • There was no control on access to the Ward or to the patients.
  • The staff had not received adequate training, and possibly none at all, about the risks arising from lack of security arrangements.
  • In 2002 RDH had commissioned and received an expert consultant’s assessment and report on security arrangements at RDH. The Terms of Reference did not require 5B to be assessed. By 30 March 2006 the recommendations in the report had not been implemented in Ward 5B. This failure can only be described as shameful.
  • Following the rape of the infant police were not notified for about 2 hours.

2. Action taken by RDH after the rape to improve security was: (a) slow (b) inadequate, and (c) has not been adequately evaluated or reviewed to determine its effectiveness

3. RDH has a Security Manager on site as well as an NT Police member stationed at the hospital. Neither has been asked to evaluate the security on the Paediatric Ward either before or after the rape of the infant.

4. Staff working on the Paediatric Ward have not been trained at their induction on the elements of security arrangements to reduce the risk to vulnerable patients nor has there been adequate ongoing training of staff before or after the 30th March 2006 incident.

5. In 2007 the same expert safety and security consultant, as in 2002, was engaged to assess security arrangements at RDH. He was not informed of the rape of the infant in March 2006 nor was he asked to report specifically on arrangements in the Paediatric Ward.

6. On 21 November 2007 two investigation officers from the Health and Community Services Complaints Commission visited the Paediatric Ward by prior arrangement. They were able to enter the Ward and wander around, have entry to every part of it and stand at the nurse’s station, for about 25 minutes without anyone asking who they were and why they were there.

7. Management’s lack of commitment to the proactive identification of risks and to taking appropriate action has not created a culture where each member of staff takes responsibility for identifying and reporting risks and developing safe practices.

8. A security review of RDH was carried out by an expert hospital safety and security consultant who issued a report in 2007. The Security Manager of DHCS (DHF) was not given a copy even though he requested it. HCSCC enquired of RDH management why he was not given a copy and RDH have offered no explanation. On 31 October after this report was published to RDH and DHF the CEO of DHF advised this Commission that he had finally been given a copy and that he had seen a draft copy.

9. RDH Maternal and Child Health Clinical Risk Management Committee considered security in the Paediatric Ward following the incident. The Committee met on 16th May 2006, 2.5 months after the rape of the infant. It met a further 4 times. It submitted an action plan to the General Manager of RDH in July 2006. At its last recorded meeting on 5 September 2006 there had been no response from the General Manager on the recommendations, particularly with respect to installing CCTV cameras with recording facilities on the Paediatric Ward. There were still no recording cameras on the Paediatric Ward as at June 2008 although a CCTV system had been installed in the kitchen area to deter the pilfering of food. Dr David Ashbridge on 31 October 2008 advised, when responding to a draft of this report, that CCTV cameras were installed in Paediatrics on 25 August 2008.

10. The surveyors from the Australian Council of Health Standards which accredits RDH probably did not receive all relevant information about the incident of 30 March 2006 and what action RDH were taking. Those surveyors on 13 October 2006 were informed by RDH that the patient information pamphlet and admission interview are being reworded to reflect the changes to ward access. There was no verification throughout the investigation that any action had been taken by RDH to implement the recommendations of the review. Neither the report of ACHS nor records of information given to ACHS have been provided to the HCSCC. DHCS (DHF) was invited to provide me with those relevant documents in response to this draft. No response was received on this issue from DHF or RDH. According to the published information of ACHS the accreditation survey commences with a self assessment by the hospital concerned. This Commission specifically requested details and copies of the information provided to the ACHS surveyors but no response was received from either the CEO of the Department or the General Manager of RDH.

11. The governance arrangements at RDH do not promote adequate transparent accountability of the General Manager and the Department of Health and Families for the operation of the hospital. Control of all aspects of the day to day management of RDH rests in the hands of three individuals. This includes staff recruiting, training, security, nursing and medical services, procurement, record keeping, financial accountability and risk management. Such specialist management groups as exist are subordinate to the General Manager’s authority. The General Manager reports to the Director of Acute Services who reports to the CEO of the Department. I have been unable to find out what role the Royal Darwin Hospital Board has since its last annual report to 30 June 2006. 

It is well worth obtaining the complete report to understand how such an individual tragedy occurred.  As one media commentator has posited

“One wonders what the reaction would have been if a non-indigenous infant was raped.”

Mining fatalities and accountability

The 11 November 2008 edition of The Australian includes a page 2 story where the previous manager of the Beaconsfield Mine has been called on to be held responsible for the management failures that led to the death of Larry Knight in 2006.  The call was made by counsel for Larry Knight’s family and the Australian Workers’ Union in a submission to the Tasmanian inquest into the fatality.

According to the media report, the wrong decision was made in trying to stabilise the working area of the mine and that the risk assessment process was inadequate.  The latter comment should be of considerable interest to OHS regulators and safety professionals.

The importance of the Tasmanian Coroner’s findings are illustrated by comments in the submission by the counsel for the mine.  The media report says that 

“…Dr Neal tells the Coroner the mine had done all it reasonably could to guard against the risk of rockfall and to manage the mine’s notorious seismicity.” [emphasis added]

This is particularly important when considering the introduction of “reasonably practicable” into the OHS legislation throughout the Australian States being considered by the National OHS Law Review.

It is regrettable that the to-ing and fro-ing in the inquest is not getting as much media attention in the non-mining states, as there have been many risk management and accountability issues raised.  The media is likely to wait until the findings of the Coroner, Rod Chandler, and focus on the result rather than the journey.

There was a similar experience in New South Wales with the inquiry that followed the drowning of four mine workers at the Gretley mine in November 1996.  The information did not resonate to the rest of Australia except through the mining sector, yet there were important lessons from the inquiry.  Most OHS professionals, if at all, would recollect the prosecution of Gretley mine managers on matters of culpability, rather than the death of the four workers.

When the Tasmanian Coroner hands down his findings in the near future, it will be very useful to consider them in the light of the earlier reports, assessments and papers, among many others, listed below. 

SafetyAtWorkBlog is a strong advocate of learning new OHS management practices by looking beyond one’s field of expertise.  OHS professionals, safety managers and risk managers need to watch the action in Tasmania and other jurisdictions for themselves and not rely on a small group of OHS lawyers to bring matters to their attention and advise them how to avoid their responsibilities.  Accountability is a moral and legal responsibility.

Holding Corporate Leaders Responsible by Andrew Hopkins

The Impact of the Gretley Prosecutions by Andrew Hopkins

Mine Safety – Law, Regulation, Policy by Neil Gunningham

A submission by the Tasmanian Minerals Council on CRIMINAL LIABILITY OF ORGANISATIONS – ISSUES PAPER NO 9, JUNE 2005 to the Tasmanian Law Reform Institute

N Gunningham, ‘Prosecution for OHS offences: deterrent or disincentive?’ (2007) Sydney Law Review, 29 (3), pp 359-390.

R Guthrie and E Waldeck, ‘The liability of corporations, company directors and officers for OSH breaches: a review of the Australian landscape’ (2008) Policy and Practice in Health and Safety 6(1),
pp 31-54. 

N Foster, ‘Mining, maps and mindfulness: the Gretley appeal to the Full Bench of the Industrial Court of NSW’ (2008) Journal of Occupational Health and Safety – Australia and New Zealand 24(2),
pp 113-129.

Longford explosion anniversary, Andrew Hopkins and a new book

October 2008 was the tenth anniversary of the explosion at Longford gas plant in Australia that resulted in many injuries, two fatalities and almost two weeks of severely interrupted gas supply to the State of Victoria.

The Longford explosion at an Exxon-Mobil site resulted in a Royal Commission, an OHS prosecution and a record fine.  Recently it was often invoked in comparison to the Varanus Island pipeline explosion in Western Australia.

Professor Andrew Hopkins, sociologist with the Australian National University, was studying safety management systems well before the Esso Longford explosion but it was that major disaster that added international prominence, and a substantial extra workload, to Andrew.  Other than domestic acclaim, in July 2008, the European Process Safety Centre declared Andrew winner of the EPSC Award for 2008.  He is the first person outside of Europe to win this award.  It is believed that Andrew was formally presented with the award at the EPSC conference earlier this month.

Andrew has a refreshing perspective on safety management systems, partly because he has brought a sociologist’s eye to management decisions; his vision is not clouded by the OHS baggage through which many other analysts struggle.

Andrew’s next book due out this month through CCH Australia is Failure to Learn The BP Texas City refinery disaster and could have him travelling frequently the United States to offer his wisdom.

SafetyAtWorkBlog is working on a new interview with Andrew when he returns to Australia but in the meantime, a 2000 interview with Andrew is available as a page on this blog.  The interview was conducted at a book launch in September 2000 for Lessons From Longford.

Professor Andrew Hopkins (right) receiving the award from Christian Jochum, Director of the European Process Safety Centre
Professor Andrew Hopkins (right) receiving the award from Christian Jochum, Director of the European Process Safety Centre

Corporate accountability – Lessons from Lehmans

Yesterday,the CEO of Lehman Brothers, Richard Fuld Jr, faced an inquisition at the House Oversight and Government Reform Committee.  It was uncomfortable to watch but fascinating.

Video of the hearings shows the questions focused on Fuld’s accumulation of wealth in the good times and the retention of wealth in the bad times. There are parallels with the non-financial accountability of corporate leaders on matters such as workplace safety and corporate social responsibility.

The chair of the committee, Henry Waxman, spoke of company documents that 

“portray a company in which there was no accountability for failure”.

Waxman said he was troubled by the attitude of Fuld where Fuld would not acknowledge any wrongdoing. Fuld did accept responsibility for the failure of the company but would not accept that his behaviour or the behaviour of the company he lead, contributed to the failure.  In other words, Fuld would not accept that his company had a culture that may have contributed to the bankruptcy.

There will be more of this type of inquiry and in many countries other than the United States.  OHS managers should not sit back and watch the chief financial officer squirm with discomfit and anxiety for the way that the financiers handle this crisis, as there are important lessons about their own accountability, responsibility and disaster planning.

Australian CEOs and workplace safety

One of the tasks I have in my consultancy is assisting the Safety Institute of Australia to promote their Safety In Action conferences.  As part of this I have been able to provide some videos from the May 2008 conference.  The videos are excerpts from the presentations of four of the chief executive officers and company directors who spoke of day one of the conference about their experiences with workplace safety issues at board level.

Dr Ziggy Switkowski
Dr Ziggy Switkowski

One speaker is Dr Ziggy Switkowski, current  chairman of the Australian Nuclear Science and Technology Organisation and former CEO of Telstra Corporation.  Dr Switkowski’s video is the longest and possibly the most interesting.  His manner is relaxed and chatty as he builds on some of the comments of the former speaker, Jerry Ellis.

 

  

Peter McMorrow
Peter McMorrow

Peter McMorrow, managing director of Leighton Contractors, was perhaps the most instructional in terms of safety management. I have written briefly about his full presentation before. In this video, he talks about his early engineering days, how he went clay pigeon shooting with a shotgun and hard hats and how he was too close to an explosive charge.  These tales contrasted well with his presentation of contemporary safety standards.

Glenn Henson of ExxonMobil speaks about accountability and the human role in safety, and Colin Blair, deputy CEO of Standards Australia, discusses how experienced a near miss in his early days as a young engineer.

Each of these speakers were asked about what motivated their interest in workplace safety.  These casual introductions to their main presentations reminded us in the audience that early work experiences, intense or humourous, do provide a structure or shadow to how senior managers in major corporations approach safety.

Until the end of August 2008, the videos will only be accessible at www.siaconference.com.au to those who sign up for a regular conference newsletter.

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