“Worthless” is not my phrase, and I make no assumptions about the JSA process as it is applied in your workplace, but I am interested in whether your organisation could pass the “worthlessness” test set out in the recent NSW District Court decision, Inspector Nash v Perilya Broken Hill Limited  NSWDC 28.
By way of background, On 8 June 2012, an employee of Perilya Broken Hill Limited (PBHL), Mark Pollard suffered a traumatic amputation of his right leg and other injuries when he fell down a haulage shaft at a mine in Broken Hill (Mine). At the time of the incident Mr Pollard, was trying to hang some weights from the bottom of a weigh flask to calibrate a load cell which measured the weight of ore in the flask.
The weights were in a metal basket and the weight Mr Pollard was hanging was about 10 tonnes. The weights and basket were in the bucket of a loader. Mr Pollard was trying to hang the weights by working from the bucket of the loader, the bucket being located in the haulage shaft.
Mr Pollard was secured to the bucket by personal protective equipment (PPE), a fall arrest system comprising harness and lanyard. His lanyard was tied to the bucket.
While Mr Pollard was working, the weights and basket came out of the bucket and so did Mr Pollard. His lanyard snapped, and he fell.
The case canvassed a range of issues in safety management, which I will look at in later posts, but for now, I want to consider the roles of the Job Safety Analysis (JSA).
One of the allegations pleaded by the prosecutor was PBHL failed to “assess the adequacy of the Job Safety Analysis”.
The Court took its direction for what a JSA required from PBHLs own documents:
I start by looking at what is required of a JSA. This may be discerned in the first instance from the defendant’s documents.
What is required in a JSA is detail that shows:
- how the hazards were identified;
- how the risks were assessed;
- how the decisions around necessary controls were made.
The Broken Hill Job Safety Analysis Procedure set out six steps in the JSA process. They included:
- A JSA must be conducted in a team setting.
- A JSA should be done on the job site
- Task supervisors must ensure compliance with the requirements for a JSA.
None of these requirements were met.
PBHL’s procedures said:
The success and value of the risk management process is determined by the quality of the consultation and communication process. Success hinges on involving the right people and using the right information, expertise and experience. Hence, identification and participation of stakeholders is critical.
The Court found that there was “no consultation or communication with the correct stakeholders”.
PBHL’s procedures said:
The less formal nature of … JSAs can present a serious risk in itself. It is essential that these tools are used carefully. If a significant or uncertain risk is missed or not properly managed, participants may be lulled into a false sense of security. Some things to look out for include:
- New tasks or one that is being done in a new place or using a new method
In relation to this, the Court said:
This was a new task using a new method. The “serious risk” warning should have been heeded.
The Court closely examined PBHL’s own requirements for its JSA process, ultimately finding the process to prepare the JSA was seriously flawed, the JSA itself was inadequate and:
The risk assessment did not involve all those doing the work and was not communicated to all of them. It stood the risk of being and was, for reasons I give, “next to worthless”.
It is also worth noting, the Court’s use of the term “worthless” is not random. The Court has adopted the language of “worthless” from PBHL’s own documents.
PBHL’s Risk Management Guideline gave several directions about risk management, for example:
A risk assessment is worthless if it does not involve communicating with the correct stakeholders.
Ultimately a risk assessment is next to worthless if it is done in isolation without involving those doing the work, or not communicated to all those doing the work or affected by the work.
The Court did not have to look for language to criticise the JSA process, it simply adopted PBHL’s own views.
PBHL employees accepted the inadequacy of the JSA, for example, Mr Harris, a shaft and fixed plant supervisor:
… agreed that it was not appropriate for one person to simply to write out a JSA and then present it to others without those persons having input into its development. He agreed that a JSA should be prepared as a team, particularly as some members of the team may not be aware of, or understand each of the steps of the task. He noted that this was an important consideration, particularly as there might be persons with different subject expertise performing various parts of the task. He also agreed that it would be important to have all members of the team involved in completing a JSA because if only one person completed the JSA, there was a risk that a step would be missed in the process, or a hazard missed or an appropriate control measure not identified.
The point to take away from a case like this is not the specific technical failures of PBHL, or how the work was planned or implemented. Rather, the case highlights:
First, organisations are accountable for what they say in their documented processes. If you are going to describe an in-depth, potentially convoluted process for preparing documents like JSAs, you need to recognise you are prescribing the standard against which you will be measured. Write your documents with the end user in mind to give workers some chance of following them.
Second, regardless of what you document, you need to understand if it is implemented and effective. Although it is not discussed in the PBHL case, it is extremely unlikely this case was the first time the JSA procedure was ignored in so many fundamental ways. The history of workplace accidents in Australia is fairly compelling – frontline risk assessment documents like JSA’s have little meaning to frontline workers and are often seen as an exercise in bureaucracy: A paper process workers have to complete before the work can commence.
The question that comes out of a decision like the PBHL case has nothing to do with PBHL. The question is, how do you know that your JSA procedures are any better in practice?