Tag: LTI

Due diligence: understanding performance or measuring activity?

~ My safety thoughts ~ 3 Comments

This morning I was doing some work with contractors talking about the concept of health and safety assurance, both in the context of reasonably practicable and due diligence.

One of my areas of interest and concern when working with organisations to understand if their health and safety risks are being managed, is that a great deal that is done in the name of safety and health is characterised and measured in terms of “activity”. In my experience, very little regard is had to the “purpose” of the activity, whether that activity achieves the relevant purpose and whether the purpose is beneficial for safety and health outcomes.

I have looked at these issues previously in my articles, A short primer on due diligence and Lead indicators: Reinforcing the illusion of safety.

As an example, the group discussed the idea of management “walk arounds” or safety conversations. Amongst the group we were able to identify a number of potential “purposes” for this activity, including to confirm whether risks were being controlled, to demonstrate management commitment to safety and to understand any concerns from the workforce.

Most of the organisations involved in the discussion had the “number” of safety conversations managers held as a key performance indicator.

In every case however, the only measure applied to this management task was the number done, that is a measure of “activity”. There was no measure, or even consideration given to, whether this management activity was effective in achieving the purpose. Moreover, none of the organisations had even turned their mind to the possible negative ramifications of this management activity.

In my experience, whatever the intention of the manager while conducting a walk around or safety conversation, if they are perceived by the workforce as being an unnecessary intrusion on their working day or worse, a manager simply trying to tick their KPI’s for the month, they can have profound, negative effects on health and safety and completely disengaged the workforce from the safety message that managers are trying to deliver.

100% compliance with the scheduled numbers of management safety conversations might look good on a traffic light scorecard and might give a sense of comfort, but there is a significant risk that the activity is actually undermining safety performance and contributing to the illusion of safety.

I am not saying all management activities are negative, I am just saying that most organisations do not know what the impact is. Rather, we make assumptions based on the numbers – if we do a lot, the outcome must be good.

Is it?

Having finished the morning discussions, I was reading the news from ABC online, when I came across the following article:

Eddie McGuire’s comments ‘incredibly disappointing’, Cabinet ministers say

The article deals with the recent controversy over comments by various AFL football commentators in the context of violence against women.

Christian Porter, the Social Services Minister linked the comments to the Government’s new $30 million domestic violence campaign, and the report goes on to state:

According to Mr Porter, the Stop it at the Start campaign has already had 25 million individual views, making it the most successful domestic violence campaign launched by any Government. [My emphasis added]

I could accept this comment if the “purpose” of the campaign was to get as many individual views as possible. However, I would have thought a more appropriate measure of success for a domestic violence campaign – one that is presumably linked to its “purpose” – would be a reduction in the instance of domestic violence.

A similar dilemma occurred a number of years ago in relation to Victorian railway safety and the “dumb ways to die” campaign. This campaign was also hailed as a success based on its very high level of traction in social media, although I understand the number of fatalities on Victorian railways actually increased (see for example Dr Rob Long’s comments in Dumb Ways to Die and a Strange Sense of Success).

It seems that style over substance, or activity over purpose is not limited to health and safety management, but it does represent a threat to the management of whatever problem it is applied to.

Health and safety initiatives are, or at least should be, designed to achieve outcomes in the workplace. They are not initiatives for their own sake, nor are they perpetuated as wellsprings of activity.

Every health and safety initiative should have a clearly articulated understanding of its purpose, and a set of criteria by which that purpose will be achieved. We also need to bear in mind the ongoing safety paradox; while safety initiatives have within them the potential to improve health and safety, equally they have the potential to undermine health and safety and make our workplaces less safe.

What do you know about your safety initiatives?

 

More consultation on safety legislation in Western Australia

~ My safety thoughts ~ 1 Comment

At some point, someone will make a decision, but hot on the heels of the “Green” WHS Bill seeking comment on WA’s general health and safety legislation, stakeholders are now being asked to comment on options for “modernising” health and safety laws for mining, petroleum and major hazard facilities.

To the extent that it matters, you can find out more here:

http://www.marsdenjacob.com.au/wp-content/uploads/2014/10/Consultation-RIS-Resource-Safety-WebVersion.pdf

and submit comments here:

http://www.marsdenjacob.com.au/structural-reform-resources-safety-legislation-wa/

You have until the 19th of December.

If the history of harmonisation across the country is any measure, there will be a fair amount of administrative juggling within businesses and the usual parade of lawyers and safety consultants telling us that the sky is falling and we are all going to jail (no one ever has in Australia by the way!) – and then we will just get on doing what we are doing today, tomorrow.

Oh, (and again for what it is worth), Safe Work Australia’s own research (Safe Work Australia. (2013). The effectiveness of work health and safety interventions by regulators: A literature review. Canberra, ACT: Safe Work Australia) has found:

We do not know whether many of the strategies used on a regular basis by work health and safety regulators, such as introducing regulations, conducting inspections, imposing penalties for non-compliance and running industry campaigns are effective in achieving the desired policy outcome of reducing work related deaths, injuries and disease.

Seems to me to be a lot of fuss and nonsense for very little return.

Paper Based Safety Systems in a Contract Environment

~ My safety thoughts ~ Leave a comment

Two recent cases have highlighted the focus that is put on documented safety systems following a serious workplace incident. The cases have also shown that despite the mountains of paperwork deployed in the name of safety, organisations still struggle to understand if health and safety risks are being controlled.

The cases are also instructive because they both arose in the context of contractor safety management.

The first case, Hillman v Ferro Con (SA) Pty Ltd (in liquidation) and Anor [2013] SAIRC 22, examined the perils of contractors creating safety management systems to meet the requirements of the client, rather than the risks of their work.

On 16 July 2010 a fatality occurred during lifting operations at the Adelaide desalination water plant. A rigger employed by Ferro Con (SA) Pty Ltd was killed when he was struck on the head by a 1.8 tonne steel beam.

The Company, Ferro Con, and its Director, Paolo Maione were prosecuted under South Australian health and safety legislation, and in June 2013 were handed fines of over $200,000.

The case has attracted a lot of attention because Mr Maione was able to call on an insurance policy to pay his penalty – effectively avoiding the punishment of the Court. However, the judgement also offers good insights into the weaknesses of “paper based” safety management systems, a compliance mentality and lack of assurance. The judgement also explores some issues in the Principal/Contractor relationship.

It seemed clear from the case that the “safety system”, such as it was, was designed to meet the need of the client, not manage the risk associated with the work:

No detailed JSA’s for different types of lifts, or lift plans, were required by Adelaide Aqua. Ferro Con took its cue for the level of safety planning it would use in its work from Adelaide Aqua, and not from the foreseeable hazards of its work activities. Ferro Con was more focussed on complying with contractual requirements than taking all reasonably practicable steps to minimise the foreseeable hazards its business created.

The inappropriate nature of safety documents in a contracting relationship was also looked at in Nash v Eastern Star Gas Ltd [2013] NSWIRComm 75, only this time, from a Principal’s perspective.

In August 2009, Bruce Austin a working director of a small business, The Saver Guys, died from head injuries after he was hit by a length of pipe that was being extracted from the ground.

There were many different entities involved in the contractual arrangements, and a number of parties were prosecuted. This case, however, looked at the safety arrangements in place between Eastern Star Gas Ltd (ESG) and Austerberry Directional Drilling Services Pty Ltd (ADD).

The case provides some useful insights into the expectations placed on businesses removed from the conduct of the physical work by a contractor. It also demonstrates how an organisations’ own, documented safety management systems (in this case a contractor safety management system) can be used to show that the organisation is not meeting its obligations.

The general “failure” in this case was that:

ADD did not have a documented safe work procedure or method (SWP) for the Activity and no job safety analysis or risk assessment for the Activity was conducted by ADD

However, the criticism of ESG, the defendant in the case, related to both ADD’s system, and ESG’s own system and conduct. The Court noted:

  • ADD OHS documents, including 42 SWPs, were from another job.
  • ESG did not require any documents specific to the job it was doing.
  • ESG did not check if the safety documents were appropriate.
  • No inquiries were made by ESG to check if the safety documents addressed the activities on this job.

The Court also noted that ESG operated in breach of its own contractor safety management system, for example:

  • ESG’s contract representative did not ensure the work was subject to Hazard identification and risk assessment, including that a safe work procedure approved and JSAs were done.
  • There was a requirement to assess contractor performance, but there was no program for that assessment, and no assessment was in fact done.

These were not things that the Court thought were a good idea – these were requirements set out in ESG’s own system.

The Court found that the:

… defendant had, in its paper systems, a roll (sic) for auditing and for checking. However, what it did not do was to comply with its own systems and that included a failure to carry out any checking of safety issues at the site.  If documented safety systems are not complied with, then that failure creates a significantly legal risk. More importantly, however, if the documented safety systems represents what should be done to create a safe workplace, non-compliance far from being a legal risk, means that our workplaces are not safe.

If documented safety systems are not complied with, then that failure creates a significantly legal risk. More importantly, however, if the documented safety systems represents what should be done to create a safe workplace, non-compliance far from being a legal risk, means that our workplaces are not safe.

Contractor safety management series: Introduction

~ My safety thoughts ~ 1 Comment

I have just finished finalising a presentation for a case involving the death of a worker employed by a subcontractor that was 2 companies removed from the Principal. The case involved the prosecution of the Principal in respect of a fatality.

Earlier this year I prepared a post and presentation on the Hillman v Ferro Con (SA) decision, which also involved the death of a worker employed by a contractor. You can access the blog post and video presentation here.

Contractor safety management seems to be an ongoing struggle for a lot of businesses, so I thought that I would do a series looking at a number of cases that examine the issues around contractor safety management. At the end of the series I will try to bring together a number of the issues raised to see if we can’t structure some key guiding principles.

At this stage, I am planning a series of 10 or 11 video presentations looking at some of the key cases across a number of jurisdictions over the last few years.

The first case in the series is Nash v Eastern Star Gas, a recent decision of the New South Wales Industrial Court which was handed down on 6 September 2013. You can access the blog post and video presentation here.

I hope you enjoy the series, and I look forward to any comments or feedback.

Conactor safety managment series Part 1: Nash v Eastern Star Gas

~ My safety thoughts ~ 2 Comments

In August 2009, Bruce Austin a working director of a small business, The Saver Guys, died from head injuries after he was hit by a length of pipe that was being extracted from the ground.

Mr Austin’s business had been contracted by another entity, Applied Soil Technology Pty Ltd. The relevant work was being overseen by Austerberry Directional Drilling Services Pty Ltd, who had in turn been engaged by Eastern Energy Australia Ltd on behalf of a related corporation, Eastern Star Gas Ltd.

At the time of the accident, Mr Austin and others were trying to recover a blocked pipeline from under the ground.

Although a number of entities were prosecuted and convicted in relation to the fatality, this case looked at the safety management arrangements in place between Eastern Star Gas and Austerberry Directional Drilling. The case provides some useful insights into the expectations placed on businesses removed to an extent from the conduct of the physical work by a contractor. It also demonstrates how an organisations’ own, documented safety management systems (in this case a contractor safety management system) can be used to demonstrate that the organisation is not meeting its obligations.

You can access a copy of the decision here, and the video presentation here.

References in the Presentation:

Hillman v Ferro Con (SA)

Safety risk and safety data: Exploring management line of sight

~ My safety thoughts ~ Leave a comment

I have recently done a video presentation on a fatality at the Adelaide Desalination plant, which you can find by following this link.

Recently, I was reading some of the transcript of the South Australian Senate Inquiry into the desalination plant (which you can find by following this link), and was struck by one manager’s description of all of the activity undertaken in the name of safety:

We start with the inductions when new staff join the project. So, at 6.30am, usually three times a week—I attend probably two of them; I was in one yesterday—we induct new staff onto the job. The first thing I point out is the list of non-negotiables. The second thing I point out is for each person to look after their mate. It starts there. We then have a standard list of documents. I will read from this list, because it’s quite a large list. There is the HSC risk register, task specific for each job. There is a construction execution plan. There is a JSA, task specific.

We have daily start cards for each area, which is another thing I introduced. I am not sure if we gave you a copy, but it’s a small easily-filled-in card where a work team can assess the risks of adjacent trades, etc. So, that is a specific thing. We have a pre-start meeting every day. There are SafeWork instruction notices posted at each of the work areas. We toolbox the job weekly, because the pace of this job changes. You can go out there in two-day gulps and the whole access can change, so we need to make sure people see that. We have the non-negotiables in place. We have site and work-front specific inductions, which is what I told you about. Again, I attended one yesterday.

I have regular safety walks. I have trained all of my management team and the two layers beneath that to go on safety walks. We have our OHSC risk register. There is a just culture model in place. So, if I need to address an incident and it turns out that this person needs retraining or perhaps needs to be disciplined or work outside the fence somewhere, we use this just culture model for that. We have all been trained in that. There are safety KPIs for management. There is a safety enhancement committee, which is a mixture of workers and staff. I actually chair a weekly safety leadership team, and that’s improving safety over and above. We are looking to refresh it all the time. And so it goes on. I have two pages of this stuff.

Now, there may have been far more information that sat behind all of this activity, but it seemed to me to be a typical approach to safety management – and one that typically gives no insight into whether the risks in the business are actually being managed.

One of my particular areas of interest in the context of safety management is “management obligations”, and more particularly how managers (at all levels) get assurance that the health and safety risks in their business are being effectively managed. It is a concept that I have referred to before and written about (Smith, 2012) as “management line of sight”.

An area of speciality for me is management obligations training; courses that are designed to help managers understand their legal obligations for safety and health, and how their behaviour – what they “do” – contributes to effective safety management.

Over the last 3 or 4 years I have put the following scenario to the various courses:

Who here knows about a risk in their business or area of responsibility that could kill someone?

Invariably, most hands go up.

Who has safety information that comes across their desk on a regular basis.

Again – most hands go up.

OK. What I would like you to do is to think about the risk. Then I want you to think about the data that you have looked at in the past 3 months.

Pause ……

What does that data tell you about how well the risk is being controlled?

And then the lights come on, with the realisation that their organisations spend inordinate amounts of time and resources producing volumes of information that tell them nothing about whether risks in the business are actually being controlled.

This “gap” was most recently highlighted in the Royal Commission into the Pike River Coal Mine Disaster (Pankhurst et.al, 2012), in which 29 men died in an underground coal mine explosion in New Zealand. The Royal Commission noted the following:

The statistical information provided to the board on health and safety comprised mainly [LTI rates]. The information gave the board some insight but was not much help in assessing the risks of a catastrophic event faced by high hazard industries.

… The board appears to have received no information proving the effectiveness of crucial systems such as gas monitoring and ventilation. (My emphasis).

Typically, in a training course discussion there is no meaningful consensus on  what the “crucial systems” are in a business, much less how we prove that they are effective.

What we can say with a high degree of certainty is that traditional measures of safety performance do not prove the effectiveness of crucial systems – certainly LTI and other personal injury rates do not, and we have known that for at least 25 years. However, other indicators are equally poor in creating insight into the control of crucial systems. The number of management site visits do not enlighten us, nor do the number of audit actions that have been closed out, the number of “behavioural observations” don’t help, the number of people trained, the number of corrective actions completed, the number of JHAs or “take 5s” done and on it goes.

These things are all indicators of activity, which are designed to ensure that the safety management systems are effective, but ultimately, they leave us in no better position as far as understanding the effectiveness of crucial systems.

There is another interesting challenge that falls out of exploring management line of sight, and that is, what should I be looking at?

Historically, and as I touched on above, we typically consider safety in the context of harm and risk: what can hurt people and how likely is it that they will be hurt? But line of sight and assurance demands a wider gaze than hazards and risks.

The Royal Commission (2012, volume 2, p. 176) also stated:

Ultimately, the worth of a system depends on whether health and safety is taken seriously by everyone throughout an organisation; that it is accorded the attention that the Health and Safety in Employment Act 1992 demands. Problems in relation to risk assessment, incident investigation, information evaluation and reporting, among others, indicate to the commission that health and safety management was not taken seriously enough at Pike. (my emphasis)

“Crucial Systems” mean more than gas monitoring or ventilation. They are more than the control of physical risks. They incorporate broader organisation systems around hazard identification and risk assessment, contractor safety management, management of change, incident investigation and so on. All elements that are designed to work together so that the “system” as a whole is effective to manage risk.

If organisations are weak insofar as they cannot “prove” that physical risks are being controlled, the reporting, assurance and line of sight to prove that these other “crucial” systems are effective is almost non existent.

When was the last time you received a report “proving the effectiveness” of your incident investigations, for example?

What are the “crucial systems” in your business, and how would you “prove” that they were effective. Food for thought.

References

Pankhurst, G., Bell, S., Henry, D (2012). Royal Commission on the Pike River Coal Mine Tragedy. Wellington, New Zealand

Smith , G. (2012). Management Obligations for Health and Safety. CRC Press, Boca Raton

25 Years on: Remembering Piper Alpha

~ My safety thoughts ~ 4 Comments

In the past few weeks I have been asked to do presentations and share my views about the legacy of Piper Alpha in this, the 25th anniversary year of the disaster.

For me, the positive legacy is the advancement in safety regulation, engineering and “safety in design” that has seen the improvement of the physical safety of high hazard workplaces. Safety in design has also improved the “survivability” of disasters so that when accidents to occur, their consequences are better mitigated.

The ongoing disappointment, however, is the persistent failure of management oversight and assurance to properly understand if health and safety risks are being managed. This is a failure that has played out in every major accident inquiry since Piper Alpha and continues to undermine effective safety management.

You can see a video presentation of these ideas and concepts here.

Fatalities, Insurance and failed paper systems: Hillman v Ferro Con (SA) [2013] SAIRC 22

~ My safety thoughts ~ 5 Comments

On 16 July 2010 a fatality occurred during lifting operations at the Adelaide desalination water plant. A rigger employed by Ferro Con (SA) Pty Ltd was killed when he was struck on the head by a 1.8 tonne steel beam.

The Company, Ferro Con, and its Director, Paolo Maione were prosecuted under South Australian health and safety legislation, and in June 2013 were handed fines of over $200,000.

The case has attracted some attention because Mr Maione was able to call on an insurance policy to pay his penalty – effectively avoiding the punishment of the Court. It has long been thought, in my view correctly, that insurance to pay for effectively criminal penalties is counter to public policy and unlawful and it will be interesting to see if there is any “public policy” response to the decision.

Over and above the insurance aspects of the case, the judgement offers some good insights into the weaknesses of “paper based” safety management systems, a compliance mentality and lack of assurance. The judgement also explores some issues in the Principal/Contractor relationship.

You can see a video presentation about the case here.

Also, set out below are links to various references and materials referred to in the discussion if you would like to explore some of the concepts further.

Links to material referred to in the presentation.

Video presentation – case review: Capon v BHP Billiton Iron Ore Charge No. 1917/11

Video presentation – case review: Fry v Keating [2013] WASCA 109

Court judgement: Silent Vector v Shepherd & Anor [2003] WASCA 315

Court judgement: Hillman v Ferro Con (SA) Pty Ltd (in Liquidation) & Anor [2013] SAIRC 22

Article: Borys, D. (2009). Exploring risk-awareness as a cultural approach to safety: Exposing the gap between work as imagined and work as actually performed. Safety Science Monitor, 13(2), Article 3.

What should your health and safety manager know?

~ My safety thoughts ~ 1 Comment

In November 2012, the Pike River Royal Commission[1] (Commission) published its report into the underground coalmine explosion in New Zealand in which 29 the miners were killed.

The Commission made some very clear and unambiguous observations about the sort of information that senior executive management, up to and including the board, should receive about health and safety.  The Commission (2012, volume 2, p. 53) stated:

The statistical information provided to the board on health and safety comprised mainly [LTI rates]. The information gave the board some insight but was not much help in assessing the risks of a catastrophic event faced by high hazard industries. … The board appears to have received no information proving the effectiveness of crucial systems such as gas monitoring and ventilation. (My emphasis).

I do not know how long the safety profession has understood that statistical information about injury rates provides no meaningful insight into the effectiveness of safety management systems, yet it persists as a fundamental measure of performance.

What major accident inquiries of the past 25 years, and the Commission make clear, is that effective health and safety management requires more.

However, I think that there is a legitimate question mark over the health and safety profession’s capacity to deliver truly effective health and safety management.

I have been doing a lot of executive level assurance work lately: Working with senior managers and boards to help give them insight into whether or not the health and safety management system is operating effectively. Often, the starting point for this work is to sit down with the most senior health and safety manager of the organisation and asked the question:

What are the key things that I should be concerned about, and how do we know that they are being properly managed?

More often than not, the senior health and safety manager cannot answer those questions and they are often very reluctant to give an opinion about whether or not the safety management system is operating effectively. In a number of cases, the health and safety manager believes that it is not their job to know if the health and safety management system is working effectively – that is the job of line management.

For what it is worth, in my view this is a complete misinterpretation of the notion of line management responsibility, and a complete abrogation of the obligations of a health and safety professional.

I believe that health and safety professionals are responsible for building a system that is effective to control the health and safety risks in a business. It is not the job of the health and safety professionals to ensure that that system is implemented; that is the responsibility of line management. However, it must be the obligations of the health and safety professionals to know whether that system is effectively implemented and to be able to advise the organisation one way or the other.

The Commission (2012, volume 2, p. 176) also stated:

Ultimately, the worth of a system depends on whether health and safety is taken seriously by everyone throughout an organisation; that it is accorded the attention that the Health and Safety in Employment Act 1992 demands. Problems in relation to risk assessment, incident investigation, information evaluation and reporting, among others, indicate to the commission that health and safety management was not taken seriously enough at Pike.

Typically, the senior executives in the organisations that I work with have never received a report or a presentation from anyone that gives them assurance that critical health and safety system elements are working. True, they have never asked for it but they did not know they needed to and nobody has ever told them otherwise.

They are not given advice that elements like incident investigation, hazard identification, risk assessment and so on are actually being implemented in accordance with the requirements of the documented system and are operating effectively (or not) to control the risks that they were designed to control.

The fundamentals of safety management have not changed:

  • Do you know what the hazards in your business are?
  • Do you know the risks that arise from those hazards?
  • Have you developed controls to manage those risks?
  • Are the controls implemented and effective?

What we cannot hide from, is that effective safety management and governance requires that we provide honest and accurate information to the most senior levels of an organisation about the crucial safety system elements and critical risks in our business – whether those elements are effective, and those risks are controlled.

Currently, it appears that as a “profession”, we do not, and we may not even be equipped to.

As a health and safety professional, ask yourself:

  • What information does your board get?
  • Is health and safety taken seriously enough in your organisation?

And most importantly, how do you know that the safety management system is operating effectively and the risks in your business are being controlled?

[1] Pankhurst, G., Bell, S., Henry, D (2012). Royal Commission on the Pike River Coal Mine Tragedy. Wellington, New Zealand