Learning Lessons from the Santika Nightclub Fire

For many years SafetyAtWorkBlog and its forerunner Safety At Work magazine reported on various tragic fires in crowded nightclubs around the world.  Several in recent memory include the 2003 Rhode Island fire that killed 100 patrons and for which, according to an Associated Press report from the time,

Superior Court Judge Francis Darigan Jr sentenced 29-year-old Daniel
Biechele to 15 years, but suspended 11 years of that sentence, and
also ordered three years of probation.

“Superior Court Judge Francis Darigan Jr sentenced 29-year-old Daniel Biechele to 15 years, but suspended 11 years of that sentence, and also ordered three years of probation.”

A brief report on the Rhode Island fire is in the OSHA media archives.

In March 2006, Safety At Work included an AFP report saying

“The municipal council has impeached Buenos Aires Mayor Anibal Ibarra after finding him guilty of dereliction of duty following a December 30, 2004 nightclub fire that killed 194 people.”

An earlier report on the mayor’s response is include at the CrowdSafe website.

Engineering and design company ARUP have provided SafetyAtWorkBlog with an article that analyses recurring elements of nightclub fires using the Santika fire in Bangkok from 1 January 2009 as a most recent incident.  Below is the introduction to the article which can be found in full in the pages listed above.

Our thanks to ARUP for the terrific article.

Kevin Jones

LEARNING LESSONS FROM THE SANTIKA NIGHTCLUB FIRE

by Dr Marianne Foley and Travis Stirling, Arup Fire, Sydney

In the early hours of New Years Day 2009, fire engulfed Bangkok’s Santika nightclub, killing 64 people and injuring more than 200.  Our knowledge of the events of that night is based on media reports and publicly available information, and the precise cause of the fire is still unclear.  However, we do know that there are strong correlations between this and many similar tragedies at entertainment venues dating back as far as the first half of the twentieth century.  While we wait for the results of the official investigation and coronial enquiries, it’s timely to ask questions about these fires.  Why do they happen over and over again?  Why do so many people lose their lives?  What lessons can be learnt?  And what practical measures can be implemented to stop them happening?

RECURRING MISTAKES

Arup’s analysis of case studies has revealed six themes that commonly contribute to the severity of high-fatality nightclub fires: insufficient exits, the presence of highly flammable materials, a lack of good fire safety systems, confusing environments, pyrotechnics and open flames, and buildings used inappropriately and maintained poorly.  By addressing each of these themes, we aim to provide design solutions that could mitigate the risk of future nightclub disasters.

[The themes in the full article are

  • Insufficient exits
  • Highly flammable materials
  • Fire safety systems
  • Confusing environments
  • Pyrotechnics and open flames
  • Buildings used inappropriately or maintained poorly]

Firefighter trauma

A major element of risk management  is business continuity.  This requires considerable planning, disaster recovery resources, and a long-term focus.

In early 2009 parts of Victoria, some not far from the offices of SafetyAtWorkBlog, were incinerated and across the State over 170 people died. In a conservative western culture like Australia, the bush-fires were the biggest natural disaster in living memory.

The is a Royal Commission into the Victorian Bushfires that is illustrating many of the disaster planning and community continuity needs in risk management.

The Australian Broadcasting Corporation’s “7.30 Report” provided a report on 5 August 2009 which originates from the views of the community and the volunteer firefighters.  One of the issues relevant to safety professionals and risk managers is the psychological impact on volunteer workers.  Many in the report talk of trauma.  Many in the disaster areas have not returned and their are many who remain psychologically harmed.

When a workforce is so closely integrated with a community, rehabilitation is a daunting task and changes a community forever.

Overseas readers may have experienced their own natural disasters such as hurricane Katrina, earthquakes, floods and wildfires.  Many of these stories are reported around the world.  In the recovery phase of any disaster, businesses need to rebuild but are often rebuilding with damaged people.  It would be heartening to see the OHS regulators and OHS professions becoming more involved over the long recovery period.

Kevin Jones

BHP Billiton’s safety record is again in the Australian media

BHP Billiton’s production report has generated some OHS-related interest in the Australian business media on 23 July 2009, but not all.  [SafetyAtWorkBlog has written several pieces about BHP Billiton‘s safety record]

The company’s iron ore production has fallen short of its May 2009 guidance.  Iron ore is the only division where production has dropped.  The Age newspaper reports that the five deaths “forced a production slowdown” and noted the Western Australian government’s review of BHP’s safety management.

Malcolm Maiden’s commentary in the same newspaper mentions the BHP production results but describes the five workplace fatalities as “production glitches”.   He writes

“Production glitches for both companies [BHP Billiton & Rio Tinto] might have been handled better if their iron ore operations were merged, as is now proposed.”

Safety management may have been improved.  Rio Tinto’s OHS performance is considerably better but the description of the fatalities as “production glitches” is cold.

This contrasts considerably with the coverage provided to the BHP results by the Australian Financial Review (AFR) which listed the issue on the  front page  with the headline “Poor safety record hits BHP output” (full article not available online without a subscription).  AFR says

“the safety issues overshadowed better than expected results from BHP’s petroleum and  metallurgical coal units….”

There was no overshadowing according to the writers in The Age.

The AFR article identifies a raft of safety matters that illustrates well the OHS status of BHP Billiton and emphasises just how serious the workplace fatalities are.

  • “Tensions with the WA government [over a variety of issues, including safety] have escalated…”
  • Seven BHP workers died in Australia and South Africa in 2008/09.
  • “Eleven BHP staff… died while on the job in 2008.”
  • On 22 July 2009 WA Minister for Mines & Petroleum, Norman Moore, praised BHP’s efforts to improve safety but said “It is very difficult to understand sometimes why fatalities occur within the safety frameworks that operate in most major mining companies…” said on 22 July 2009

Warren Edney, an analyst with the Royal Bank of Scotland and occasional media commentator, spoke in relation to the safety record of BHP’s Pilbara operations, where five workers died.  He said in the AFR article:

“It’s better than Chinese underground coalmining but that’s not a big tick, is it?… In part you’d say that we’ve undergone this mining boom in WA so you’ve got workers who haven’t had the safety brainwashing that other parts of the workforce may have had over the last 10 years.  Part of it reflects that and part of it may be that people get pressed to do things quicker.” [my emphasis]

It seems odd to compare the safety performance of an open-cut Australian iron ore mine with “Chinese underground coalmining”.  Similarly describing safety education and training as “safety brainwashing” is unusual.  SafetyAtWorkBlog has contacted the Royal Bank of Scotland for clarification of Warren Edney’s comments.

The AFR has almost been leading the Australian media pack on reporting of safety management in 2009,  partly due to the OHS harmonisation regulatory program and its impact on business costs.  This may also be due to some of the concerns about increased union activity on worksites under the new industrial relations legislation.  The AFR should be congratulated for discussing the OHS context of BHP’s iron ore production figures and providing a front page prominence.

Kevin Jones

A study of violence

Australian writer, Jeff Sparrow, recently recently a book that looks at violence and killing , “Killing: A Misadvanture In Violence“.  As part of promoting the book he has been interviewed on several radio shows, the one most relevant to SafetyAtWorkBlog, is the 3CR program, Stick Together, about his book.

Killing_fullcover_NEW.inddSparrow says that he wanted to investigate the “normalisation of killing” and l0oks at occupation which have killing as part of the job.  He analysed the killing of animals through the first-hand experience of kangaroo-shooting and visiting an abattoir.

Sparrow says that the abattoir was very much a factory that deconstructs animals rather than manufacturing items, such as cars.  This will be no revelation to anyone who has read Eric Schlosser’s book, Fast Food Nation, in which he analyses abattoirs, particularly meatpacking, in the context of food production.  Schlosser’s section on the worker safety and compensation processes in the US meat industry is confronting.

They are also possibly more directly relevant to OHS (or heartless capitalism) than Sparrow’s take on abattoirs, although Sparrow does mention how the structure of the workplace “controls the workers”.  This harks back to the dehumanisation of workers for the purpose of productivity where repetition makes the reality of the action of killing or dismemberment, mundane.

In comparison, the roo-shooters have a more detailed understanding of their “craft” because they are working in the wild, where things can go wrong, instead of on the killing floor.

Sparrow also looks at killing that is undertaken in other occupations, such as the defence forces, and workplaces, such as deathrow.  In these contexts Sparrow talks about the industrialisation of the war processes.

Ultimately, from the workplace perspective, Sparrow’s book sounds like an interesting resource for those who study the depersonalisation of the worker, or industrialisation.  For those who work on, or have responsibility for, production lines, this psychological approach to the book may help.

Kevin Jones

A sample chapter of the book is available for download.

Occupational violence in fast food restaurants and petrol stations

The Australian media has been abuzz over the last couple of days on several issues concerning violence.  Attention increases whenever there is video involved and the latest film of a bashing in Melbourne in a Hungry Jack’s store in the early hours of 13 July 2009 is getting a considerable run.

Most commentators are taking the bashing of 19-year-old Luke Adams as an example of “street violence”.  SafetyAtWorkBlog believes that the fact that this event occurred between customers in a workplace, raises questions about the obligations of retail store owners towards health and safety.

The case of Luke Adams again illustrates the reality that surveillance cameras can assist in the apprehension of criminals but does little to reduce the harm to employees and customers.  This seems to be contrary to the OHS principles in Australian OHS legislation.

SafetyAtWorkBlog would ask any retailers who choose to operate, particularly, during nighttime

  • Are the stores designed to reduce (hopefully eliminate) the risk of violent contact between customers and staff?
  • Are there restrictions on the age or gender of staff who work nightshift?
  • Is the first aid training provided to staff designed to accommodate the emergency treatment of severely injured customers?
  • Has the presence of a security guard been tried during nightshifts?
  • Would the company consider closing a store if the risks to staff and customers became unacceptable?

SafetyAtWorkBlog knows of at least one fast food restaurant in Melbourne that removed its public toilets because of the number of drug overdoses that occurred in the cubicles.  This store eventually closed its 24-hour store, partly, because of the unacceptable risk that developed.

The unfortunate linking of fast food restaurants with violent attacks is an issue of all-night trading as much as any other reason.  It was just over two weeks ago that a fight in the grounds of a Hungry Jacks restaurant in suburban Melbourne was reported and wrapped into the current topic of supposedly racist-based attacks against Indian students.

The attacks are not limited to Melbourne though.  A 19-year-old Korean student, Lee Joonyub, was killed in Sydney in 2008 after being stabbed at a fast-food restaurant

AIC Service Station Violence coverThe risk of occupational violence, as it is more traditionally understood, is increasing according to findings released on 16 July 2009 by the Australian Institute of Criminology.  Its report, which also received some media attention from radio, finds that

“The incidence of service station armed robbery has steadily increased over the past decade. ….. This opportunistic targeting of service stations has been attributed to their extended opening hours, their sale of cigarettes and other exchangeable goods, their high volume of cash transactions and their isolation from other businesses. Widespread adoption of crime prevention measures by service stations, such as transfer trays, could help reduce their risk of being robbed…..”

The full report is worth reading closely from an OHS perspective as it identifies the characteristics of services stations (and maybe other all-night retail outlets) that are attractive to the opportunistic robber.  We should not dismiss armed robberies as only involving monetary loss to retailers as the study showed that “one-third of armed robbery victims…were individual”.

The AIC report also states that

“…minimal staffing on night shift is seen to increase the risk of armed robbery victimization for service stations.”

This brings in all the OHS advice and research concerning working alone or in isolation.  However there must be some sympathy for employers trying to recruit night shift workers for industries where violence is an increasing risk.

The mention of the hazard control measure of transfer trays is gratifying as it fits with a higher order of control measure in OHS parlance by providing an engineering control.  However this needs to be backed up by specific training for employees on what to do when required to render assistance outside the enclosed booth.

The application of transfer trays may be valid for fast food stores at nighttime by only offering a drive-thru service and further reducing the risk of customer violence against employees.

Pages from VWAHotspots_retail_10_10Regardless of the physical harm from work tasks arising from working in retail, WorkSafe Victoria advises of four control measures for what it describes as the psychological system of stress, bullying and harassment:

  • Your workplace culture and management should encourage open and effective communication.
  • Develop, implement and enforce clear policies and procedures that address bullying, occupational violence, harassment and work pressure in consultation with workers (including young workers) and management.
  • Where money is handled, put in place security measures to reduce the risk of occupational violence.
  • Training and procedures should include all staff at risk, including any casual or on hire workers.

Kevin Jones

New Australian workplace safety statistics

New South Wales Workcover has released its statistics for 2007/08 on workplace fatalities, injuries and diseases.  Statistics are popular posts in SafetyAtWorkBlog and it is recommended that the full report be downloaded.

cover statistical_bulletin_2007_2008_5906Statistical incompatibilities continue between Australian States so the NSW statistics should be kept within that State however the report says

A total of 109,835 workplace injuries were reported in 2007/08, a reduction of less than one per cent from 110,160 in 2006/07 and a two per cent reduction in the incidence rate of 37.4 per 1,000 workers in 2006/07 to 36.5 in 2007/08.

Any reduction is good news but over the long term, the government initiatives may be failing.  A couple of aims of  the National OHS Strategy 2002-2012, to which NSW is committed, are:

  • to sustain a significant, continual reduction in the incidents of work-related fatalities with a reduction of at least 20 per cent by 30 June 2012 (with a reduction of 10 per cent being achieved by 30 June 2007), and
  • to reduce the incidence of workplace injury by at least 40 per cent by 30 June 2012 (with a reduction of 20 per cent being achieved by 30 June 2007).

Pages from NationalOHSStrategy200212According to WorkCover’s Annual Report for 2002/03 the incidence rate “remained steady in 2001/02 at 20.3”.  But the statistical report quoted above says the incidence rate is 36.5 in 2007/08.  Clearly the incidence rate has increased by 16.2 over this period.

SafetyAtWorkBlog is, sadly in this case, written principally by an Arts graduate whose grasp of statistics has been illustrated before.  But it seems curious that a percentage reduction is being applied to a non-percentage benchmark that is

“the number of injuries per 1,000 employees working in New South Wales”.

There is a lot of room for statistical wriggling in this definition.

SafetyAtWorkBlog is researching more statistical data on the National OHS Strategy to see who is going to meet the target and what will be done by those who do not.

But then again, the world is ending in 2012 which equates to good planning on the government’s part.  Non-achievement of OHS targets? Who cares, it’s armageddon anyway.

Corporate manslaughter and accountability

Corporate manslaughter, or industrial manslaughter as it is referred to in Australia, was not allowed to gain traction in Australia, except for in the Australian Capital Territory.

3i14 coverThe policy has been allowed to fade from the books of most of the Australian left-wing parties but for a while, corporate manslaughter was THE issue.  In fact over the last 10 years, it has been the only time that directors and CEOs from thousands of companies have paid serious attention to safety management.

The offence of corporate manslaughter seems to have lost little of its momentum in England.  Recently England instigated its first prosecution for corporate manslaughter.

It reminded SafetyAtWorkBlog of an interview we conducted with David Bergman on the issue in April 2002.  David Bergman has been the Executive Director of the Centre for Corporate Accountability for ten years and, only last week, was part of a conference in London on “Directors’ Duties, Corporate Manslaughter and Safety Enforcement“.

Below is the text of that 2002 interview

Manslaughter Lobbying – 2002 Interview with David Bergman

David Bergman is the CEO of the Centre for Corporate Accountability (CCA) located in London, England.  He spoke exclusively to [Safety At Work magazine] about the issue of “corporate killing” legislation and the activities of his organisation.

SAW: Can you provide an outline of what the CCA does?

DB: The organisation is a not-for-profit organisation. Its core purpose is to promote worker and public safety and it does this by focussing on two ideas – improved law enforcement and greater corporate accountability. We have three main activities, we run a work-related death advice service which is a core of our work whereby we provide free, independent and confidential advice to families bereaved from work-related death on how to ensure that an adequate criminal investigation is undertaken into the death and that the evidence is subjected to proper scrutiny by prosecuting bodies who have the duty to determine whether criminal offences have been committed.

We give that advice because, traditionally in Britain, lawyers whom families may go to are often only concerned with issues of compensation. We are concerned with issues of corporate criminal accountability.

We also undertake research into the role of the criminal justice system in the investigation, prosecuting and sentencing of companies and those who control them.

Finally we undertake some lobbying work. We try to lobby for appropriate changes to Law and practice in this area.

SWA: Is you lobbying receiving a sympathetic ear?

DB: There are two focuses of our lobbying. There’s the central Government and there is an organisation that is at arm’s length of the central Government, the Health and Safety Commission and Executive. Different departments of the central Government are responsible or different activities.

In Britain we lobby two Government departments. The Home Office is responsible for traditional criminal law and therefore the whole issue of the offence of manslaughter and how it applies to companies. The other department is Transport, Local Government and Regions which is responsible for general safety issues and has an oversight role of the Health and Safety Executive and Commission.

The Government has promised reform on the law of corporate manslaughter and on the sentencing of companies. In relationship to that we lobby the Home Office. It is difficult to say whether we are effective or not as the Government has committed themselves to making this change but it has been a long time coming and there is no Bill before Parliament and it clearly is not a priority of the Government which is why, of course, we need to lobby.

SAW: Sometimes there are activities in the justice system which can work counter to your lobbying or the will of the people. Have you seen evidence of that?

DB: The Courts can only apply the current Law as it stands. If you want change, this will come through changing the Law or changing the policy of the investigation and prosecution bodies to ensure that more cases come to the Courts. It is true to say that in terms of levels of fines there has been the traditional problem in ensuring that the Courts impose sufficiently appropriate fines commensurate to the offences committed when that offence has been committed by the company or individuals who control them. That would be the main criticism of the Courts, but beyond that the Courts can only apply the Common Law and also can only deal with cases that come before it.

So if there are deficiencies in the Law, that’s not the fault of the Courts, that’s the responsibility of the Government to change. And if there is a failure on the investigation or prosecution bodies to investigate appropriately or fail to prosecute particular companies or individuals; that is a failure on their part and that is where we need to change practice.

I wouldn’t saw that the Courts are a core part of the problem.

SAW: What has been the response to your lobbying from some of the employer and business representative organisations?

DB: We have been involved in establishing coalition campaigns on safety law and corporate accountability that bring together safety organisations, trade unions and families bereaved from work-related deaths. There are two core issues – the reform of the law of manslaughter and the enactment of this new offence of “corporate killing” as it is referred to in Britain, which the Government is committed to but to which no priority is being given.

Secondly there is the imposition of safety duties on company directors. At the moment under British Law, there are no clear safety duties imposed on company directors, safety obligations are placed on employers or manufacturers. Directors, as separate legal entities from the companies, have no clear legal obligation to ensure that the company complies with safety law.

The two groups mainly in opposition are the Confederation of British Industry (CBI) and the Institute of Directors. There is recognition by industry that a new offence of corporate killing will be enacted and there is a sort-of acceptance. What they’re doing is lobbying to make it more difficult for companies to be convicted of the offence.

The Institute of Directors is lobbying against legal obligations on company directors. Although the Labour Government can well be said to be more interested in safety than a Conservative Government they do listen carefully to what industry says.

SAW: Recently the Australian Industry Group had some concerns with the Industrial Manslaughter Bill that is currently in the Victorian Parliament in Australia. One of their concerns is there needs to be an emphasis on education and not retribution. They don’t believe that such an Act will promote safety, it will only penalise

DB: Our response to that sort of argument is that, first of all, under current law companies escape any form of accountability, even for very serious failures on the company management’s part. Normally there is a situation of immunity and companies don’t get prosecuted for serious offences. That has two effects – a lack of moral justice and a sense from bereaved families and the community that there are some legal entities that are not accountable. There is a problem in the social fabric.

Secondly, if there is immunity under Common Law, and companies know that they can escape accountability, there is inevitably going to be a lack of deterrence in the system so that some companies will feel that we don’t need to change our safety management systems because it is unlikely that there is any serious impact if something goes wrong.

Companies, of all legal entities who get caught up in the criminal justice system, are rational beings. If there is a sense that there will be more cost for them by taking a particular action than if they don’t take a particular action, they won’t take that action. Individuals commit offences for all sorts of reasons which are irrational while corporations operate from a much more rational base. So they are much more likely to be deterred.

In our view, these changes are important for accountability issues which the argument that you mention does not deal with. They are also important for deterrence which links directly back to safety. That is not to say that, hand-in-hand with other approaches for change in criminal law, there ought not to be attempts to ensure that companies are able to comply with safety law so that offences aren’t committed.

SAW: The AI Group says that Government has failed to provide any evidence that such a law will reduce the level of workplace death and injury.

DB: If you look at any reform in Criminal Law, there is never any evidence to say that if we change the law in this particular way there will definitely be a reduction in the number of deaths, or whatever. The fact that you may reform the law of murder in one particular way doesn’t necessarily mean that there is a reduction in murders.

You ask industry to show in any research in relation to any other Criminal Law reform that says “we’re going to change the law because if the law is changed there is evidence to suggest that fewer offences will be committed or fewer deaths will take place.” It just doesn’t happen. That’s not the way that Criminal Law reform happens.

Criminal Law reform takes place because there is a perception of a lack of justice.

This argument doesn’t carry any weight because there is never any evidence that a particular legal reform is going to cause a particular change but what you can be sure of is that there will be greater accountability and you can speculate that there will be greater deterrence.

SAW: Some people assert that an Industrial Manslaughter offence will encourage a change in workplace culture.

DB: The thing about changing corporate culture is that you are more likely to change it when you change the Law. That’s the important effect that law reform has, it changes the perception about a particular conduct. I would argue that changing law would have an important effect upon the corporate culture. There is no question about that.

The problem with a lot of the corporate social responsibility arguments is that they are all about voluntary codes and about trying to get companies to do particular things. There will always be some good companies that will comply with them. Compliance with those codes doesn’t get to the companies who will commit offences anyway.

SAW: The UK has had some high profile cases that generate discussion on corporate manslaughter. We have covered some of those in the last few years. But one that seems not to be going away is some of the issues associated with Railtrack, the privatised rail transport company, after some very public fatalities and incidents. Are they incorporating accountability into their new organisational structures?

DB: Clearly, after the Paddington disaster and others, rail safety became a priority in this country. I would say that this was a very good thing but it also subsumed attention to other industries where there is a far higher level of death and injury, like the construction and manufacturing industries.

Those disasters were partly responsible for increasing the debate on the need for a new offence on corporate killing, for Directors’ safety duties and also, the reason why the Government decided to take Railtrack out of private ownership.

Families of victims from the Paddington disaster are still pushing for the application of corporate manslaughter against Railtrack. The Crown Prosecutor initially refused to prosecute for manslaughter however the families have got the Crown Prosecutor to reconsider that decision.

SAW: Have you had any interest in the moves on corporate killing from outside Britain?

DB: Australia is the one country where it has been addressed. Canada has put in some important reforms in this area recently.

If there is reform in the area of corporate killing in the next few years, there might be an impact on other jurisdictions.

Kevin Jones

This interview appeared originally in Safety At Work magazine Vol. 3 Issue 14 on 30 April 2002.  It remains Copyright – Workplace Safety Services P/L

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