Tag: death

The personal cost of surviving a major hazard explosion

As one gets older, the “where are they now?” columns in the newspapers or the summer magazine supplements become more interesting.  The articles of faded pop stars and political one-time wonders are diverting but every so often one makes you stop and think.

OHS is not renowned for “where are they nows?”.  The discipline and the profession has few celebrities but there are important people.  One such person is Jim Ward.  Jim’s story is long and involved but he came to the public’s attention as a survivor of the 1998 gas explosion at the Esso gas plant in Longford Victoria.  The blast, which killed 2 workers, crippled the State’s gas supply for almost 2 weeks.  A Royal Commission was held into the disaster.

Usually a worker’s evidence may be reported on for a day or two in such an investigation but Jim Ward became more than that primarily due to the attempt, according to some, by Esso Australia (a subsidiary of ExxonMobil) to scapegoat Jim.  This attempt was roundly condemned in the Royal Commission.

Pages from AMS_Post_Traumatic_StressIn the Australasian Mine Safety Journal, Jim Ward has written a short personal account of what happened that day but, more importantly, how that day has changed his life.

After the failure of steel exchanger and before the fatal explosion, Ward writes:

“I raced to a doorway and looked out into the gas plant where I saw a thick white fog rolling down the walkway. This white fog was a cloud of vaporised hydrocarbon. Gas – highly flammable gas.

Out of the fog stumbled two zombie-like creatures. Two men – blackened from head to toe. They were covered in soot which had been blown from the inside of the huge steel exchanger when it violently ruptured. They had their arms out in front of them trying to feel their way through the fog, blinking as if trying to catch some daylight to help guide them to safety.

Over the roar of the jet–engine–like sound of gas spewing into the atmosphere I yelled – I yelled at them to get into the control room. Into the control room and to relative safety. Ninety seconds later the gas found a source of ignition and a second, much louder explosion shook the control room building again.

What followed from that moment on was sheer unadulterated terror.”

In his article he goes on to explain the psychological impact of that day and the diagnosis of his post-traumatic stress syndrome.  Ward rightly points out that mental health is poorly understood in the workplace.

Many employers are satisfied if they get through a single day without a problem or complaint but silence is not compliance and there may be mental health issues that require attending to even though they are difficult to identify.

Ward’s article is a timely reminder that the measurement of a successful OHS management system or a more personal “safe system of work” has changed and that business needs to scrutinise OHS auditors on the mental health assessment criteria.

Perhaps, most particularly to Australia, it is necessary to gauge OHS laws through contemporary hazards, such as mental health.  The law will exist for decades and need to be able to adapt to emerging hazards, many of them not coming from the physical.

His article also means that workers need to consider colleagues as more than just colleagues and look to their humanity.  In the past many of us are inclusive and dismissive when we refer to someone as a work mate.  People are more than that.

It may be, as this article is written on 9 November 2009, that Jim Ward’s message has already been learnt by the survivors and emergency workers of the World Trade Center from 2001.  But for many outside the United States it is also two days before Armistice Day, the end of the World War which really brought  shell-shock or combat stress reaction and post traumatic stress disorder to the public mind.

When remembering the fallen in war and work we should also ask “where are they now?”

Kevin Jones

New coronial approach should lead to greater safety information

The Australian State of Victoria has been in a fortuitous position with a Coroner, Graeme Johnstone, who was a staunch advocate of safety in the public and workplace spheres.  Johnstone was a strong and physical presence at many conferences and in the media.  Indeed, it would be difficult to find a more obvious and influential safety advocate in Australia over the last twenty years.

Johnstone retired recently due to ill-health.  From 4 November 2009, his successor, Jennifer Coate, will be sitting in an official Coroners Court and the supportive legislation should provide even greater support to safety advocates.

According to a media release issued in support of the Court, there are several important legislative changes.

  • The power of the court to make recommendations to any Minister, public statutory body or entity relating to public health and safety and the administration of justice. Previously recommendations could only be made to Ministers.
  • Importantly, any Minister, public statutory body or entity either receiving or  [sic] the [sic]of a recommendation must now respond in writing within three months stating what action will be taken (if any) as a result of the recommendations. This has never been required before and is an Australian first.
  • All inquest findings, coronial recommendations and responses to recommendations will be published on the internet, unless otherwise ordered by a coroner. This is the first time in Victorian coronial history that a requirement to publish inquest findings has been enshrined in legislation.
  • A new power for coroners to compel witnesses to testify without the risk of self incrimination. The court will now be able to issue a certificate excusing evidence heard by the court from being used to incriminate witnesses in other court proceedings.”

On the first point, how much different would have been the approach to level crossing safety with this authority?  Would the faulty design of some level crossings have been changed more quickly?  Of course, recommendations are still only recommendations but by referring to statutory authorities and others, there is likely to be less direct political spin and, perhaps, greater accountability.

This leads to the second point, timelines.  Any meeting, action item, control measure or even correspondence, should have a timeline for response.  This will allow the families of victims a hook on which they can hang their dissatisfaction with government inaction.  Of course, there is usually no guarantee that correspondence is publicly accessible but to bullet point three.

Not only will inquest findings now be easily accessible to the public, the government responses mentioned above will be made available on the Coroner’s website.

Around ten years ago I was writing a book on occupational health and safety in the sex industry in Australia.  I requested details form the Coroner’s office of deaths in this industry.  I received many pages of decisions which helped considerably in determining whether deaths occurred at work or in relation to work.

Several years later, I put in a similar request for information on dairy-related deaths in support of a WorkSafe Victoria guidance with which I was assisting.  The level of detail provided then was a line or two on each incident.  It was enough to prepare a rough data table but was woefully unhelpful in the preparation of case studies of work-related fatalities.  The accessibility allowed under the new laws will allow for a greater, and more public, understanding of the contributing factors to death which should lead to greater options for elimination or control.

The Coroner is clearly enthusiastic about her new powers.  In the media release Coates says

“This new legislation will better enable the court to thoroughly examine and investigate the different types of deaths reported to us so we can help prevent similar deaths from occurring.  Of real significance is the requirement that any body or entity receiving a recommendation must respond to us. This will be a real mechanism for change to public safety and we expect enormous benefits for the Victorian community to follow,” she said.

Judge Coate said publishing inquest findings, recommendations and responses on the internet would make public statutory authorities and entities more aware of their responsibility to respond to coronial findings.

“The new response requirement means the recommendations of a coroner cannot be selectively pursued or ignored. This is an important gain for the public safety and administration of justice for our community”

She said the publication of inquest findings, recommendations and responses on the internet would also make the coronial process more accessible to families who experience the death of a loved one investigated by the court.

“We have gone to great lengths to ensure our new practices under the Act recognise and have regard for the families and friends of a loved one who has died.  That includes acknowledging the distress of families and their need for support and a recognition that different cultures have different beliefs and practices surrounding death.”

SafetyAtWorkBlog wishes Coroner Coates all the best and will be keenly watching the progress.

Kevin Jones

Management – the importance of what comes before

A special guest for the Safe Work Australia events in Queensland was Matthew Gill, former Beaconsfield Gold mine manager.  According to a media statement from the Government

“Matthew Gill who was the public face of the Beaconsfield mine rescue will speak about how he immediately took control of the emergency and then implemented rescue operations for the three missing miners,” [Workplace Health and Safety Queensland Executive Director, Dr Simon Blackwood] said.  “Mr Gill maintained an unwavering commitment to the safety of the people conducting the rescue and to the trapped miners.

“He oversaw the rescue teams which battled 24 hours a day for 14 days to release the two miners trapped almost 1km underground. Mr Gill will relive the emotional story of finding Larry Knight’s body and having to talk to his family afterwards.

“Previously he has been involved with mine rescue at rock falls at Mt Lyell in Tasmania and in Papua New Guinea, but Beaconsfield was the first time that he had such ‘hands on’ involvement.”

Matthew Gill has a lot of skills to share on disaster management and media handling but a lot of that skill seems to come about after the rockfall in 2006 that killed Larry Knight.

Cover KNIGHT,_Larry_Paul_-_2009_TASCD_25Prior to that time, in 1995 to 1997, Matthew Gill was the Responsible Officer for the mine.  From 1997, Gill appointed other people to undertake the role that is required by legislation.  Sometimes there were three people in the role at the same time.  Professor Michael Quinlan was quoted in the Coroner’s report saying that

“……….the very notion of appointing a Responsible Officer would have little meaning unless that person so appointed exercised overall control of the workplace and could therefore make critical decisions in relation to OHS not simply recommend them, be part of them, or make decisions but not others than might affect safety. For example, as Responsible Officer Mr Ball was a participant in decisions on mine design and mining methods – decisions that have a critical effect on the safety of underground workings – but he was not the only or final decision maker.”

The Tasmanian coroner Rod Chandler,agreed that there should be only one Responsible Officer and that the legislation be amended to reflect this.

Media reports of the inquest into Larry Knight’s death reported that after rockfalls in October 2005 and various risk consultants’ reports Matthew Gill undertook some remedial work on the mine and in February 2006, Gill declared the mine safe to restart mining.  The decisions made on the basis of those consultants’ reports came under close scrutiny in the coronial inquest.

On 10 November 2008, AAP’s Paul Carter reported the following:

Lawyer Kamal Faroque [representing the Knight family and the Australian Workers’ Union] told Coroner Rod Chandler in Launceston that Allstate’s management failures contributed to Mr Knight’s death…. Mr Faroque said mine manager Matthew Gill was ultimately responsible for deficiencies in the mine’s ground supports.  “It is submitted that deficiencies in ground support contributed to the Anzac Day rockfall which killed Mr Knight,” he said.

He also said there was no reasonable basis for Allstate to conclude that it was safe for workers to return to the area after two earlier rockfalls.

“Mr Gill accepted responsibility for the decision to recommence stoping in the western zone following the October (2005) rockfalls,” Mr Faroque said.  Stoping is a mining method in which underground chambers are opened up deep beneath the surface.

Mr Faroque said the risk management process conducted following the October 2005 rockfalls was inadequate.  “It is submitted that these failures are a sound foundation for a finding that Allstate contributed to the death of Larry Knight,” Mr Faroque told the court.

There is no doubt that Matthew Gill was integral to the successful rescue of Brant Webb and Todd Russell but Gill had been employed at the mine for over a decade before the fatal rockfall and therefore was also involved with the decision-making leading up to the rockfall.  The decisions made by the company over many years should be analysed to see the combination of bad, poor, or short-term decisions that ultimately led to Larry Knight’s death and the entrapment of his colleagues.

The rescue of Webb and Russell is an exciting tale with a happy ending and at least one book and several long articles (even a school lesson plan) have been written about this.  The most lasting lessons for safety professionals, mine managers and business operators would be what contributed to the bad decisions leading to Larry Knight, Brant Webb and Todd Russell being in an unsafe working environment during a rockfall.

This is a more complex story that requires knowledge of geology, the stock markets, corporate accountability, OHS and mine safety regulations.  If this story had been Matthew Gill’s presentation during Safe Work Australia Week, it would have been worth travelling to Queensland to hear.

Kevin Jones

Gov’t responds to insulation installer’s death

Recently SafetyAtWorkBlog reported of the death of a worker installing insulation in a domestic home.  A staple for the foil insulation apparently pierced an electrical cable and electrocuted the worker.

The Queensland Government has introduced mandatory provisions to avoid the hazard in the future.  In a media release on 1 November 2009, the Industrial Relation Minister, Cameron Dick,

“… issued a ministerial notice under the Electrical Safety Act 2002 to prohibit the use of metal fastenings for ceiling insulation.”

The ban is effective from 1 November 2009.

It may already be the case, elsewhere in the world, that non-conductive fasteners are used for installing metallic insulation.  If not, the rules introduced by the government should prove useful references.

“The ministerial notice means that installers will have to use nylon or plastic fasteners (which are already in use within the industry), glue or tape to fix foil insulation in ceilings.

As well as banning metal fasteners, the notice also:

  • forces insulation installers to comply with the Wiring Rules with respect to the placement of any type of insulation near recessed downlights
  • makes electrical safety risk assessment training mandatory for all installers
  • forces installers to document their on-site electrical safety risk assessments and keep a record f or five years.”

Such a mandatory rule is clearly a necessary short-term fix but it does little to address the concerns of the Master Electricians Association.  Training and enforcement are the long-term solutions but policymakers must also anticipate the applications of their policies more closely.  New policies should not be announced in an industry that does not have the resources to meet the policy’s aims.

Kevin Jones

New approaches on OHS fines and penalties

At the moment Australian OHS professionals, lawyers and businesses are preparing submissions to the Government on the harmonisation of OHS laws.  One of the areas that the Government is seeking advice on is penalties.  The Discussion Paper asks the following

Q17. Are the range and levels of penalties proposed above appropriate, taking account of the levels set for breaches of duties of care by the WRMC?

Q18. What should the maximum penalty be for a contravention of the model regulations?

Q19. The intention is that all contraventions of the model Act be criminal offences. Is this appropriate or should some non-duty of care offences be subject to civil sanctions e.g. failure to display a list of HSRs at the workplace, offences relating to right of entry?

The amount of  any fixed financial penalty is not a big issue in my opinion.  There is an assumption that the threat of a large financial penalty imposed on one company will encourage other companies to improve safety.  Is anyone seriously saying that all of the financial penalties imposed over the decades are in some way responsible for an improving level of safety in workplaces?  The motivation to improve safety comes from elsewhere.

The threat of large financial penalties send companies to seek ways of insuring against having to pay a fine.  Often it is cheaper to pay an insurance premium on the slim chance of being prosecuted and fined.  I acknowledge that this has been a corporate and risk management approach primarily but there are cases where such options are being offered to small business.

Large financial penalties, such as the then record fine to Esso over its Longford gas explosion, are easily paid with little OHS improvement resulting from the fine.  It can be argued that the negative corporate exposure from the resulting Royal Commission, a reulting class action and the media coverage resulting from its unforgivable treatment of Jim Ward were stronger motivators for improvement.

In most Australian States, there is not a crime of industrial manslaughter.  This issue has faded from the political agenda but it remains very much alive in England.  On 27 October 2009, the Sentencing Guidelines Council wrote the following:

“Companies and organisations that cause death through gross breaches of care should face punitive and significant fines, a consultation guideline published by the Sentencing Guidelines Council proposes today.

Fines for organisations found guilty of the new offence of corporate manslaughter may be measured in millions of pounds and should seldom be below £500,000.

The new sanction of Publicity Orders forcing companies and organisations to make a statement about their conviction and fine introduced under the Corporate Manslaughter and Corporate Homicide Act should be imposed in virtually all cases.

The consultation guideline proposes that the publicity should be designed to ensure that the conviction becomes known to shareholders and customers in the case of companies and to local people in the case of public bodies, such as local authorities, hospital trusts and police forces.  Organisations may be made to put a statement on their websites.”

The Council recommends a minimum financial penalty and a publicity order that has teeth. More on the publicity order is below.

Council member Lord Justice Anthony Hughes clearly states the purpose of financial penalties and it is not preventative.  He said in a media statement

“Fines cannot and do not attempt to value a human life – compensation will be payable separately in these cases.  The fine is designed to punish and these are serious offences so the fines imposed should be punitive and significant to reflect that.”

Penalties as a Percentage of Turnover

Hughes says that the Council rejected a Sentencing Advisory Panel proposal that I believe should be floated in the current debate on penalties in Australia, even though it is likely to be similarly rejected.

The Panel recommended the following

“In order to achieve an equal economic impact on offending organisations of different sizes, the proposed starting points and ranges for offences of corporate manslaughter are expressed as percentages of the offending organisation’s average annual turnover during the three years prior to sentencing.  The relevant turnover is that of the company convicted of the offence or, where the offending organisation is a holding company, the consolidated turnover of the group of companies of which it is the holding company.”

Here is the penalty table

Manslaughter table

Lawyers argue extensively about the use of manslaughter in relation to deaths in workplace but the public jumps across the legalese by repeatedly asking how the death of their loved one is not manslaughter when the actions of a director or company led directly to the death?  No level of legal explanation is going to counter this need for accountability, some would say revenge.

Similarly the penalty rate listed in the table above is easier for the public to understand conceptually compared to a judge’s or lawyer’s explanation of why a financial penalty for a workplace death was less than the maximum.

Sentencing options are complex and SafetyAtWorkBlog has no legal contributors but on 30 October 2009 within a public discussion period on national OHS laws and at the end of Safe Work Australia Week, it seem thats penalties imposed from a percentage of turnover may be an attractive concept to many safety advocates and one that needs to be considered in the Australian context.

Publicity Orders

On the issue of publicity orders, many Australian jurisdictions have had this option for a while.  Indeed, the issue of enforceable undertakings is getting a broader hearing after some of the recent actions by Comcare against John  Holland Group and others.

It is always important to look at the most recent actions and decisions in OHS law and regulation from outside one’s own jurisdiction so that innovations are not overlooked.  It seems that the Sentencing Advisory Panel has looked at lots of  jurisdictions in making the following requirements.

The Sentencing Advisory Panel listed specific requirements of a publicity order to be applied within a specified timeframe:

  • a quarter-page advertisement in a local or regional newspaper, in the case of an organisation operating in one area; or
  • an eighth-page advertisement in three specified national daily newspapers, in the case of an organisation operating nationally; and
  • an eighth-page notice in a relevant trade publication; and
  • a prominent notice in the organisation’s annual report (also in electronic format where applicable); and
  • where applicable, a notice on the homepage of the organisation’s website for a minimum period of three months.

The panel also closed a possible (out) for offending companies.

” The making of a publicity order does not justify a reduction in the level of fine imposed on an organisation for an offence of corporate manslaughter.”

The ads on home pages, local newspapers and trade publications (if there are any) seems very reasonable but the media option that may be most influential is the inclusion in the company’s annual report.  Acknowledging a workplace death and expressing regret in an annual report is admirable but “a prominent notice in the organisation’s annual report” goes straight to the shareholders who often have the ear of the corporation.  Just look at the influence being applied by them at the moment on executive salaries.

Now is the right time for Australia to consider alternative OHS penalty options.

Kevin Jones

Australian AGMs mention workplace deaths

Australia’s corporations are busy releasing their annual reports in October 2009.  The outgoing managing director and CEO of Boral Limited, Rod Pearse, provided his comments on the company’s safety performance to shareholders on 28 October 2009.

“Since demerger [January 2000], Boral’s safety outcomes have delivered steady year-on-year improvements and compare well with both ASX100 and industry benchmarks. Employee lost time injury frequency rate of 1.8 and percent hours lost of 0.06 have both improved by 80% since 2000 and are better than those of our competitors in like industries and in the top quartile of companies in the ASX100.”

Boral is, according to the executive statements, “a resource based manufacturing company with low cost manufacturing operations.” Continue reading “Australian AGMs mention workplace deaths”

The OHS obligations of global corporations

BHP Billiton has issued a media statement concerning the death of a miner, Gregory Goslett, at its coalmine in Khutala in South Africa.  Due to the number of deaths the company has had over the last two years, attention on any safety issue at BHP is intense.  BHP’s short statement reads:

“It is with deep regret and sadness that BHP Billiton announces a fatal incident at its Khutala Colliery opencast operations in South Africa. At approximately 05:02 am on Tuesday, 20 October 2009 Gregory Goslett (27), Mining Operations Supervisor, was fatally injured whilst driving a light vehicle at the mine.

An initial investigation indicates that Gregory was travelling in a light vehicle when a piece of coal fell from a loaded 25 ton haul truck travelling in the opposite direction. The piece of coal went through the windscreen of the light vehicle and struck Gregory causing fatal injuries to him.

The company is offering all comfort, assistance and support to Gregory’s fiancée Tarryn, his parents and those affected at the operations. Our thoughts are with Gregory’s family, friends and colleagues at this difficult time.

Mining at the opencast area has been suspended and investigations are underway.”

The Age newspaper points out that

“The accident was of the type that BHP has previously moved to eliminate from its Pilbara iron ore mines in Western Australia after several deaths last year…..”

“A key safety change made by BHP in the Pilbara in response to last year’s run of fatal accidents was the improved management of the interaction of light vehicles with heavy vehicles.”

The circumstances of Goslett’s death illustrates the obligations, some would say challenges, that multi-jurisdictional corporations need to ensure that safety improvements are consistently applied across their workplaces, regardless of location or remoteness.

BHP Billiton has been tragically reminded of this but BHP is only one corporation in the global mining industry.  Safety solutions and initiatives must extend beyond jurisdictions, countries and commercial entities to each workplace where similar hazards exist.  (The oil refinery industry was reminded of this with the Texas City Refinery explosion) The communication and sharing of solutions is a crucial element of the safety profession around the world.

Kevin Jones

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