Tag: death

Unintended consequences of inadequate preparation

The Australian Government instigated a rebate scheme for ceiling insulation for domestic homes in order to the climatic impacts of heating one’s home.  The rebates effectively make insulation free and, as a result, there is a boom in insulation installation.

As with any boom in any industry, there is an influx of new workers.  The Australian newspaper reports the death of an installer in Brisbane in mid-October 2009 and the shortcomings this death illustrates.

The article says that the rebate scheme has been so popular that fibreglass batts are not available so installers are using foil-based reflective insulation.

“Master Electricians Association president Malcolm Richards said the foil-based products should be banned in established homes because untrained installers were stapling foil on to live electricity wires.  He said the practice was the cause of last week’s tragedy in Brisbane and electricians were being increasingly called on to repair dodgy work.”

Firstly, electricians are always being called on to repair the botched electrical work of others.  Secondly, it’s not the fault of the foil suppliers so it seems unfair to ban a legitimate insulation product.

The Master Electricians Association is facing the problem that others face every day, unqualified workers doing the work normally undertaken by qualified workers.

The political opportunism by some in this article is regrettable.

The Australian Government should have learnt from its computers-in-schools initiative/debacle that there are ancillary costs with any government program and that these costs should be considered in the policy development and/or have relevant organisations consulted so that the necessary support services are prepared for the plan’s launch and operation.

The computers-in-schools program did not consider the software costs to use on the free computer for ever secondary school student.  The LPG conversion rebate did not consider the scale of demand.  The solar panel rebate scheme was cancelled even though the demand was great.  The home insulation scheme has drawn inexperienced installers into the industry.  All good intentions harmed through poor planning and some of that harm can be the death of workers.

Kevin Jones

Two forklift cases in Australia – one death and one fine

On 19 October 2009, SafeWorkSA released details of a court case against Macbar Nominees Pty Ltd trading as Southern Cross Trailers .  The company has been fined over $A15,000 due to the incapacitating injury of a worker from a load falling off a forklift.  The event, described below, occurred in July 2007.

“A man aged 38 at the time had been with the firm just two weeks in his job as a labourer. He and two colleagues had been instructed to clean a work area: a job, which involved lifting several large items by forklift.

In the process of this task, a drum that was part of an unsecured load raised aloft by the forklift, fell about two metres onto the man as he moved a second pallet beneath.

He suffered a head wound, which required stitches and a finger injury that required surgery. In a Victim Impact Statement, the court heard that the worker had been unable to resume his work as a labourer as a result of the finger injury.”

A forklift-related incident occurred in Queensland on 5 October 2009 and details of the incident are being reported in the media.  According to Queensland Emergency Services

“Firefighters and paramedics responded to a business on Riverview Road at Dinmore around 10.50pm after a man became trapped under a forklift.  The 18-year-old suffered from crush injuries to his head, neck and chest and was declared deceased at the scene.”

According to media reports, the man had been working at the abattoir for only two months and was not licenced to operate a forklift.  Clearly the management of the site has some very serious questions to answer to the family and the Government.

It is still too early to make more than basic recommendations from this case as the available information is conflicting or not yet released.

  • Licences for driving forklifts or for operating any specialised plant  must be produced and verified, regardless of the size of the site or the complexity of the task.
  • Whether the man was specifically given the task to drive the forklift or whether he was “skylarking”, still raises the issue of supervision.
  • The matter of communication with the family of workplace victims, whether by the Government or the company, is also very relevant.

Kevin Jones

Changing weather conditions can present unexpected hazards

In the south-east corner of Australia, a drought has existed for over a decade.  This week in Melbourne, it has rained on and off for several days, changing the way the community is feeling.  Farmers are happy, owners of rain water tanks are happy, gardeners are happy, even commuters who have to relearn how to drive in the wet are less complaining.

Some months ago, I spoke to a mother whose two-year-old daughter had never seen a heavy rainstorm, thunder or lightning.  Early last year, a colleague and I looked out of an office building window on a 13th floor and saw smoke swirling round the city.  It turned out to be rain but we had not seen rain for so long that we mis-identified it.

This morning, I was removing money from an automatic teller in the street and I was dripped on from the leaking roof of the bank for the first time ever.  A local chemist had buckets on its floor to catch drips from the ceiling that they had never seen before.

Yesterday, 15 October 2009, a concrete pumper at a housing development site in Coburg sunk in some mud just enough to swing the pump’s hose into a worker, killing him.  Other media reports say that a stand of the pumper may have malfunctioned.

There are always many lessons from workplace deaths but one to be taken from this incident is that external factors to the actual tasks in hand must be considered.  Those factors, in this case weather and soil stability, can change within a work period and this variability of environment must be watched and anticipated.

Mud on a construction site is not a new hazard.  But if a hazard is not always  present or regularly encountered, it is easy to give it less attention.

Kevin Jones

Grappler death in forestry operations – WorkSafeBC Slide Show

Below is the latest safety video from WorkSafeBC.  It is included not only as an important indication of a hazard that can be readily controlled or avoided but as a terrific example of how generic safety alerts can be given currency by using the available technology.

It is one thing for text-based safety alerts to be circulated, or for media releases to be broadcast, but this type of safety alert has more influence and provides a clearer understanding of the hazard than text ever could.

Yes, the video is Canadian and may not reflect the work practices in other countries but the hazard is usually the same.  In this case, it was the location of the spotter, the level of communication between the workers and overall a clearly inadequate system of work.

WorkSafeBC should be applauded for its efforts in communicating safety to a broad audience in an effective manner.

Kevin Jones

A spotter working in blind conditions was struck by a grapple. Confirm spotters are in the clear before throwing a grapple.

[vodpod id=ExternalVideo.882790&w=425&h=350&fv=allowfullscreen%3Dtrue%26quality%3Dhigh%26bgcolor%3D%23ffffff%26]

France Telecome becoming a case study

The managerial turmoil at France Telecome over a spate of work-related suicides is likely to become a case study in failed change management, firstly, and public relations, secondly.

A report in The Guardian on 6 October 2009, points to a (French) video of the company’s chairman and CEO, Didier Lombard, speaking to Telecome’s managers in January 2009.  The paper reports that Lombard says

“those who think they can just stick to their routine and not worry about a thing are sorely mistaken”.

The article goes on to say

“He went on to suggest that staff outside Paris spent their time at the beach, fishing for mussels, adding those days were “over”.”

The last quote sounds like a joke between colleagues but as suicides had already occurred at the time of this speech, it was in poor taste even then.

For those outside of France, Lombard was set on the path of making the company relevant to contemporary ICT needs.  A short article from 2005 says

“France Telecom Chief Executive Didier Lombard is merging telephone, Internet and mobile offerings under the Orange brand as part of a three-year program called NExT, an acronym for New Experience in Telecom services.”

There are similarities with a range of telecommunications companies that needed to change – British Telecom, New Zealand Telecom and Telstra to name a few.  Telstra’s management change earlier this century with Sol Trujillo and Phil Burgess caused considerable shareholder and political turmoil with their change strategies.

Organisational change from administrative agencies to commercial entities can be a life challenge but it can be done with time and careful planning.  The suicides at France Telecome seem to be an extreme example of how this process can be mishandled.  However, just as with cancer clusters, the actual cause is often difficult to identify and sometimes can remain a mystery or coincidence.  The circumstances at France Telecome need to be carefully studied from when the change management process began, well before the first suicide.

At the moment we are in the period of shock and panic responses by the company.  Every suicide heightens this panic.  Hopefully the measures being put in place now by the company will achieve a more considered, and long-lasting, corporate result.

Kevin Jones

What Trevor Keltz gets right

Madonna has just released another greatest hits CD.  Trevor Kletz has done similar in releasing the fifth edition of “What Went Wrong?” He admits that almost all of the content has appeared elsewhere.  It’s been almost 20 years since I had to read Kletz’s books and articles as part of working in a Major Hazards Branch of an OHS regulator in Australia.  Not being an engineer, the books informed me but were a chore.  This is not the case with the last edition.

Kletz has two parts to the book.  The first is a collection of short case notes recording as he says

“…the immediate technical causes of the accidents and the changes in design and methods of working needed to prevent them from happening again”.

The second discusses the weaknesses of management systems.  In short, the book reflects the expanding nature of safety management over the last forty years.  Kletz may be from the Olde School of safety engineers (he is 87 years old) but often one needs a fresh perspective on a profession and coming from a person with such extensive experience, Kletz is worth listening to.  Thankfully, he does not sound like a grumpy old man.

Kletz notes that process industry lessons seem to fade after a few years.  In my opinion this may be an effect of the transience of modern careers where corporate memory is often fragmented.  It may also be due to the shipping of manufacturing and process industries off-shore and the establishment of large complexes in countries with different (lax) safety requirements.  It may also be due to a corporate performance regime where maintenance is not valued or understood as that supports long term thinking rather than quite returns on investment.

Regardless of the cause, the short-term memory makes the need for such books as this as more important than never.

In anticipation of his look at management systems he notes in his preface, that management systems need maintaining and, more importantly, reading.  In some circumstances, too much faith is placed in the system (I would refer to the Esso Longford explosion as an example).  Kletz says all systems have limitations.

“All they can do is make the most of people’s knowledge and experience by applying them in a systematic way.  If people lack knowledge and experience, the systems are empty shells.”

What Kletz does not write about is human error because, as he says, “all accidents are due to human error”.  He avoids making the weak logic jump that the behaviouralists make where, “if all accidents are due to human error then fix the human and you fix the hazard”.  Kletz devotes a whole chapter to his classification of human errors as

  • Mistakes;
  • Violations or noncompliance;
  • Mismatches;
  • Slips and lapses of attention.

This edition of “What Went Wrong?” provides a baseline for the safety concepts we have come to accept but also a critical eye on safety and manufacturing management shortcomings.  The style is very easy to read although occasionally repetitive.  Thankfully the process technicalities are avoided unless they relate to the technical point Kletz is making.  I found part B hugely useful but it is recommended for all safety professionals.

Kevin Jones

23rd suicide at France Telecome in 18 months

Adam Sage has been following the suicides that have occurred in France Telecome for some time.  On 23 September 2009 in the TimesOnline (a week later in The Australian newspaper??), Sage provides a useful summary and cogitation on the “cluster”.

But although this number of suicides in one company should be alarming, it is not really a cluster as the suicide rate for Telecome’s employees was only slightly above the national average of 14.7 per 100,000 people.  Sage reports that France is a country with a high comparative suicide rate.  The relevance to SafetyAtWorkBlog is that Sage goes on to identify work-related factors that contribute to suicides.

He quotes a sociology professor who says the French “define themselves by their professions”.  The risk with this basis for identity is always when the demand for the profession declines, one needs to redefine and this is not easy.

Sage finds a psychoanalyst who says that his patients feel isolated at work and have no support mechanisms.

A suicide prevention expert says that often a problem at home is the suicide trigger with someone who is feeling stressed at work.

Sage provides a potted history of the privatisation of France Telecome and speaks to a current employee bemoans the loss of camaraderie.

What is surprising about this article is that it seems France, and particularly France Telecome, are way behind other Western nations in having control measures in place for employee support programs and change management.

It is not as if France is ignorant of workplace stress issues or that workplace suicides have only occurred at France Telecome.  A major reason for its experiment with the 35-hour week was to

“…to take advantage of improvements in productivity of modern society to give workers some more personal time to enhance quality of life.”

In January 2008 (well before the current financial crises), the Institute for Economic and Social Research published “Workplace suicides highlight issue of rising stress levels at work “.  After some suicides at Renault and Peugeot it assessed the issues, acknowledged the trade union assertion that

“…excessive isolation of workers due to high workloads and fierce competition leads to a malaise in companies and thus call for a reflection on choices of work organisation.”

The article also reported

“The French Democratic Confederation of Labour (Confédération française démocratique du travail, CFDT) welcomed the ‘recognition of psychological factors being the cause of an occupational accident’ as it ‘opens the way to taking into account a form of suffering and malaise that, until now, has been minimised by companies’.”

A longer-lasting improvement will only come if this recognition is built on by all social structures in France.  Perhaps it should look across the channel at how the Health & Safety Executive and the corporate sector have responded to the report by Dame Carol Black – “Working for Health” – calling for an integrated approach to health management involving work, public health, health promotion and other elements of social capital.

France Telecome held an extraordinary Board meeting on 15 September concerning its suicide rate.  It made the following commitments:

  • “The national health, safety and working conditions committee (CNSHSCT) will be meeting on Thursday next week in the presence of Jean-Denis Combrexelle, the Ministry’s Director General for Employment.
  • To stop the phenomenon from spreading, it has been decided to immediately put in place a freephone number to promote dialogue. Psychologists from outside the company will be available to listen to and talk with any employees who may be having difficulties.
  • The first meeting for the negotiations on stress will be taking place on Friday September 18. On this occasion, the employee representatives will appoint an external consultancy to conduct an audit of the situation within France Telecom.
  • These negotiations will focus on the prevention of stress and psychosocial risks in the event of geographical or professional mobility among staff. To address this issue, a forward-looking employment and skills management (GPEC) system will be set-up with a view to offering employees and their direct managers visibility over their professional development and support.”

Didier Lombard, France Telecom’s Chairman and Chief Executive Officer, has set a tight timeframe for improvement.  On 15 September 2009 Lombard said

“December’s France Telecom will not be the France Telecom of today.”

Kevin Jones

UPDATE 30 SEPTEMBER 2009

Agence France Presse has reported a 24th suicide associated with France Telecom.  According to the report the 51-year-old male jumped to his death from an overpass onto a busy highway.  His suicide note to his wife expressly referred to the work environment as a reason for his action.

 

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