Welcome to the August 2011 OH&S Newsletter
This month we examine the need to focus on higher order controls with articles on our inadequate fatality risk prevention; messages, farming & supplier reliance; foreseeability, ongoing health & competency, Chinese job stress; higher order controls, social media & wasting money on safety; effective corrective actions & accepted practice excuse...Enjoy!
Why can’t we manage fatality risks?
A no blame culture & a focus on contractor safety has helped miner Xstrata halve its TRIFR in the 4 years up to 2010, according to its latest sustainability report - what has this change however done to fatality number?
Xstrata, which has a workforce across 5 continents, including Australasia, achieved a total recordable injury frequency rate of 7/million hours worked. This represents a halving of the rate since 2006, and a year-on-year improvement of 20%. This is fantastic improvement but is the reduction sustainable? Is the reduction more of a reflection of employment in the industry reflecting the effects of the global financial crisis?
According to the report, most of Xstrata's business operates "under demanding safety conditions which, if not carefully & consistently managed & mitigated, can expose employees & contractors to significant hazards, such as rock falls, mobile equipment, noxious gases & high-voltage equipment. Xstrata has also developed a culture in which high-potential risk incidents (incidents that could have resulted in a fatality, a life-threatening injury, major damage or an environmental disaster) are "readily reported". These incidents are fully investigated & are discussed by the group executive committee on a monthly basis with lessons learned being shared across the group at monthly commodity business executive meetings & through the group-wide circulation of good practices.
So is that making a difference to fatality occurrence? Are those discussions preventing fatalities? Apparently not and this is the kicker not just for Xstrata but for most high risk industries. Three workers were killed at Xstrata's managed operations in 2010, & a further seven at its jointly owned but non-managed facilities. This seems to reflect the fatality challenge in Australian industry recently with a fatality rate/100 000 workers remaining the same at 2.6 from 2004-5 slightly increasing to 2.9 in 2006-7 and then reducing and remaining at 2.6 for 2007-2009.
In mining our fatality rate has increased from 7.6/100 000 workers in 2004-5 to a high of 10.9 in 2006-7 to a reduction of 5.5 in 2007-8 to 7.2 in 2008-9. There are a number of industry commentators that would suggest that this variation is simply a result of denominator changes in the industry based on numbers of workers as opposed to effective fatality risk management. Fatality rates in our other highest risk industries have also all increased from 2004-5 with manufacturing (2.1 to 2.5), construction (3.2 to 4.5), transport (10.2 to 11.2), farming, forestry and fishing (15-8.5 to 20.4) whilst) demonstrating this trend.
We have become very good at managing injuries and not necessarily at reducing risk effectively. Over the same time period serious incident (/1000 employees) and frequency (/million hrs. worked) rates across these 5 high risk industries have respectively declined in mining (-27% to 19.3 & -25% to 8.6) manufacturing (-13% to 25.3 & -13% to 13 ) construction (-19% to 22.9 & -19% to 11), transport (- 15% to 25.3 & -13% to 12.8), farming, forestry & fishing -12% to 24.5 & -13% to12.7). Although most injury statistics are consistently falling in what appears to be a sustainable way, fatality statistics across especially high risk industries are not sustainably declining.
Coal Mines Insurance claims that injury claims statistics & compensation premiums have dropped dramatically in the NSW coal industry through an incentive program that focuses on injury management identifying that programs prior to 2007 had focused on injury prevention. There is no doubt that focusing on injury management is crucial to containing costs but it does not prevent incidents. In the same way that focusing on incident risks does not necessarily reflect the fatality risks of an organisation. Greater use of company & site risk registers is required to ensure that risk management practices reflect the level of risk both for non-fatal & fatal incidents. Perhaps just as Xstrata should have determined how the TRIFR was able to be reduced so should we all interrogate changes in our statistics! Was that reduction simply achieved by contractors not reporting incidents that may reflect on their ability to continue to provide services to Xstrata?
Are we sending the wrong message through our regulators?
A recent investigation into a fatality at sea has indicated that this may be the case with the recommendation reported. On 2 February 2011, the boatswain on board the Panamanian registered bulk carrier Hanjin Sydney died as a result of injuries he received after falling about 25 m from the hatch coaming of the ship’s # 8 cargo hold to the tank top below. The bosun had climbed onto the top of the hatch coaming to free a cargo runner that had jammed in the head of a davit the crew were using to lift iron ore residue from the hold. He lost his balance while pulling on the wire to free it and fell into the empty cargo hold. The ATSB investigation found that the crew had previous experience with the cargo runner jamming in the head of the davit. However, nothing had been done to prevent it from happening again.
As a result of the accident, Hanjin Ship Management have instigated the requirement for the ship’s safety officer to be more proactive in tool box meetings and safety ‘walk rounds’ to ensure that he is aware of issues which may not be automatically brought to his attention. The ATSB is satisfied that this safety action adequately addresses the report’s identified safety issue. However you have to ask would it not be better to have all involved in safety walk rounds & tool box talks rather than relying on one safety officer. Even better though, why not have an engineering rather than an administrative control to prevent this sort of incident?
Farming lifestyle perhaps not so healthy?
New research suggests that growing up on a farm seems to be linked to an increased risk of developing blood cancers as an adult. The risk of developing a blood cancer was three times as high for those who had grown up on a poultry farm. Previous research has suggested that farmers are at increased risk of blood cancers, thought to be related to exposure to pesticides or infections as a result of contact with farm animals. Most of this research has focused on adults, with little information on potential early life factors.
The authors base their findings on an analysis of more than 114,000 death certification records from 1998 to 2003 for those aged between 35 & 85 and resident in New Zealand. Information regarding the usual job of the deceased & that of at least one of the parents was extracted for 82% (94,054) of the records. During the study period, just over 3,000 deaths were attributed to blood cancers, & growing up on a livestock farm was associated with a higher risk of developing such a cancer. This association was not apparent for those who had grown up on arable/crop farms, although working on one of these farms as an adult was associated with a higher risk. The analysis showed that the overall risk of developing a blood cancer, such as leukaemia, multiple myeloma, & non-Hodgkin's lymphoma, was 22% higher for those growing up on a livestock farm compared with those who had not grown up in this environment. Poultry farms conferred the greatest risk, with those who had grown up in this environment 3 times as likely to develop a blood cancer as those who had not. Working on a livestock farm as an adult seemed to lessen the risk, with the exception of beef cattle farming, where the risk was 3 times as high. Mannetje, A et al: Farming, growing up on a farm, & haematological cancer mortality, J Occ Env Med, Online doi 10.1136/oem.2011.065110
Vessel manufacturer responsible for its sinking!
The Federal Court has imposed a fine of $242,000 on the manufacturer of the Malu Sara, describing the Commonwealth commissioned vessel, which took 5 lives when it sank in the Torres Strait, as "dangerously unseaworthy". Two employees of the Department of Immigration & Citizenship (DIAC) & 3 members of the public, including a 5 year old girl, were killed when the boat sank in October 2005. DIAC was also fined the same amount on 2010.
Federal Court Justice Collier found they died in circumstances that were "entirely avoidable", & the evidence of Subsee Explorer Pty Ltd's (SEPL) culpability was "overwhelming & conclusive". Comcare commenced proceedings against SEPL, claiming the Malu Sara failed to comply with buoyancy requirements, which would have ensured it remained upright & afloat when swamped. SEPL had designed, manufactured & supplied 6 new immigration response vessels to DIAC in August 2005. Less than 2 months later the Malu Sara sank after getting lost in fog & taking on water off Mabuiag Island. The vessel was never found with only 1 body recovered.
Before Justice Collier, SEPL accepted it had contravened the Act in not constructing the Malu Sara in compliance with the relevant Australian Standards, as required by their contract. The Court heard that the weather deck was not watertight, & its drainage was inadequate, compromising buoyancy. When loaded to its maximum capacity of 6 passengers, the vessel sat too low in the water, allowing water through the scuppers. A certificate supplied by SEPL falsely declared "positive buoyancy", & incorrectly cited void air compartments as being "buoyant material". Justice Collier found SEPL had supplied vessels that were "dangerously unseaworthy" & unsuited to operating in the open sea. She said it was "entirely foreseeable" that any failures in manufacture could place crews & passengers in a "life-endangering situation". Justice Collier also said the boat's inability to sit at anchor while waiting for rescue without taking on water & sinking was "inconceivably dangerous", & that it was "almost inevitable" that those on board would be thrown into the water. How much reliance do you place on your suppliers to provide plant & equipment to standards? Are you waiting for a sinking?
How foreseeable were these rescue boat issues?
On 16 May 2010, the chief engineer of British Sapphire was being medically evacuated using the ship’s fast rescue boat for the transfer. The fast rescue boat party consisted of the chief mate, second mate & fourth engineer. These officers were all injured when, during the launch, the ship’s fast rescue boat dropped 18 m & impacted the water below. The investigation determined that, in the process of lowering the rescue boat, the wave compensator mechanism on the fast rescue boat’s davit was activated early, before the rescue boat had reached the water. A fail safe interlock device should have prevented this by placing the wave compensator into standby mode, only becoming operational when the fast rescue boat was waterborne. However, the electrical installation of the interlock was incorrect & meant it could not work as designed, allowing the wave compensation unit to always operate and the fast rescue boat to make the uncontrolled descent to the sea.
The investigation identified safety issues relating to the commissioning, maintenance, testing, operating instructions & procedures for the fast rescue boat’s wave compensator & its safety interlock system. Further safety issues were identified relating to the job hazard analysis for the use of the fast rescue boat, crew resource management principles & approved training courses for fast rescue boats. The ATSB was satisfied that the action taken by BP Shipping & Davit International addresses these safety issues but remain concerned about the adequacy of training in the use of wave compensation units on fast rescue boat davits releasing a safety advisory notice to national & international maritime training institutions about this safety issue. How well do your safety devices on your emergency equipment function? Done a risk assessment for their use? Trained personnel in it?
How often do you assess personnel health & competency to complete their work tasks?
A coronial investigation into the death of a Tasmanian worker has highlighted the need to regularly assess the competency of staff, no matter how experienced they are. The 56 year old forestry worker was killed when he
was struck by the limb of a falling tree. He was wearing a safety helmet & other protective clothing at the time, but died instantly from a head injury. Coroner Hay found that a business established by the worker had been contracted by Gunns Ltd to harvest timber since 2004. On the day of the incident, a special harvesting machine that was usually used to fell trees was unavailable (after catching fire 2 weeks before), & the worker was using a chainsaw. When he placed a "backcut" in a tree, the head of another tree (that had been cut down earlier & was leaning against the first tree) broke off & fell on him. An inspector found the worker had been using "defective tree felling practices", & that he had failed to adhere to the Forest Safety Code. He also found that a Gunns employee, who was responsible for planning & monitoring the operation, had visited the site on numerous occasions, knew the worker had started "handfelling", but didn't check that his methods were sound. According to the Coroner, the worker had performed little manual felling of trees in the years prior to his death, & had not been assessed by the Forest Industry Training Board for his competency or health since 1994. He was also taking blood pressure medication to deal with stress at the time of the incident. The coroner was conscious of the potential cost to employers & employees, but recommended that tree-fellers undergo annual competency re-assessment & also provide a certificate of health fitness to undertake the tasks required of them. Are your personnel fit and competent for their current tasks?
Progress in China not always good for the workforce
The rise in stress-related heart disease & recent suicides at the Foxconn factory complex highlighted the dangers of increasing work hours & job insecurity, according to a new study. The study, led by researchers at Peking University, found a significant link between coronary heart disease (CHD) & job stress among workers in Beijing. During the transition from a planned economy to a market economy over the last 30 years, the labour market has undergone major changes.
Foxconn's Shenzhen factory created headlines recently after multiple workers leapt to their deaths. The company, is most famous for producing the Apple iPad, & also makes components for Sony, Dell and Hewlett Packard. The researchers say that little is known about the association between job stress & CHD among Chinese workers, whose working conditions are very different from those of more commonly studied in the west.
From a sample of 388 patients who were undergoing coronary angiography for suspected or known ischemic heart, they set out to test the value of job demand control & effort reward imbalance as predictors of CHD. They found those with CHD reported significantly higher job demand, higher job strain & lower social support. They also found the higher the demand or strain level, the greater the risk of CHD, compared to those with intermediate or lower levels of stress. The risk of heart problems from stress was higher among women. High rewards on the other hand reduced the risk. The researchers also factored in the effects of over commitment, which they define as excessive striving in combination with a strong desire of being approved & esteemed. How much do job strain, effort-reward imbalance & over commitment create a CHD risk at your workplace? Weixian Xu et al: When Job Stress Threatens Chinese Workers: Combination of Job Stress Models Can Improve the Risk Estimation forCoronary Heart Disease - the BADCAR Study, J Occ Env Med: 53(7) 2011.
Higher order controls required to reduce fatalities!
The Australian construction industry is recognising that higher order controls are not being relied on which is causing an increase in fatalities! Leighton’s Holding organisational strategy GM and his CFMEU counterpart
both agree that fatalities will not decline if higher order controls are not implemented.
Currently fatality rates in this industry are increasing. So it looks as though the industry wants to focus on using engineering controls to design at risk at the design phase. Concern has been raised that there is a constant reliance on procedural controls to reduce risk rather than an emphasis on higher order controls. Other countries such as the UK have had Construction and Design management (CDM) regulations since the early 1990’s which were updated again in 2007.
Some excellent findings that have arisen out of the CDM process is the reduction in fall related fatalities when industry moved away from prescribing heights that fall protection is required at to requiring prevention measures when working at any height. This would seem an important step when the majority of our fatalities occur at heights of less than 3 m.
Harmonisation is thought to require all in the construction procurement process to ensure the health and safety of those who may be affected by their undertaking. This is present, although worded slightly differently in current state based legislation but there have been very few cases where designers have been prosecuted so there would certainly need to be a change in interpretation and application of the legislation to see this as an effective deterrent.
Whist this industry and most others for that matter rely on procedural controls the lawyers get richer as our procedural controls are a documentation historical nightmare that generally demonstrate very clearly that we don’t do what we say we will. We also know that humans for all sorts of reasons sometimes ignore these processes so we can have a guaranteed risk of failure through the acceptance of these lower order administrative controls.
The other problem is that when we don’t follow an administrative control and it does not result in an incident it can reinforce that we don’t really need to follow it. Often not until we have an incident do we actually review these procedures rather than having a process which reviews their content, implementation and effectiveness based on the level of risk they control.
That is what makes lawyers rich and just watch as the economy continues to falter and less resources are available for health and safety how many more incidents will occur whilst we continue to rely on administrative controls. How much do you rely on administrative controls to manage your high risks?
Social media forcing a change to fashion practices that are making workers sick!
Italian fashion giant Versace has become the latest to back a drive to end a deadly sandblasting process that gives denim a fashionable worn look. A succession of major global retailers had already banned the process, after a high profile campaign by workers' rights groups. These had warned that sandblasting was causing the rapid onset of silicosis, a devastating and frequently fatal occupational lung disease.
Last month, Versace blocked public access to its Facebook site after the Clean Clothes Campaign bombarded the page with calls for a boycott of the company's jeans, after claiming that some of its clothes had been produced by sandblasting. So the company announced it had decided to take a more proactive approach and join other industry leaders to encourage the elimination of sandblasting denim and other materials as an industry practice. The next challenge is how to ensure that Versace are transparent in how they will enforce this ban along their supply chain. What poor practices are present for those along your supply chains?
Is your company wasting lots of money on safety that may not be working to protect workforce, company & investor interests?
Molson Coors Brewing Company-MCBC (UK) Ltd invested in excess of A$1.6 million in improving safety across their UK breweries in 2009-10 and may be asking why after being required to pay almost A$200K in fines & costs! MCBC has appeared twice in 1 day before Cannock magistrates for criminal health & safety breaches. MCBC was fined on 4 August 2011 after 3 men suffered serious chemical burns when 6,000 litres of caustic soda erupted from a faulty valve at one if its brewery’s. The same day, it was sentenced after a delivery driver was hit by a forklift truck & seriously injured at the same site.
In the first incident, 3 sub-contractors from a specialist engineering company were undertaking maintenance work. They were drenched in a liquid jet of caustic soda when repairing a valve on a line running from a detergent tank on 30 June 2008. Up to 6,000 litres of the chemical spilled out from the container. One was temporarily blinded and another of his colleagues, suffered 25% burns, which have left him with scars and continuing sensitivity, making it difficult for him to tolerate heat. The third man suffered minor skin burns and irritation to his eyes.
In the second incident, a delivery driver, was walking along the lines in the canning hall to find a space to deliver his load, when he was struck by a forklift truck, which trapped his left leg beneath the forks. His foot and left wrist were both fractured in the May 2008 incident and he has not been able to return to work. How well is your safety expenditure targeted?
Do your hazard/incident investigations produce corrective actions that work?
Well this SA employer was found not to when fined nearly $60,000, after an investigation of a workplace injury failed to notice a missing machine guard, & a second employee was seriously injured less than 3 weeks later. Port Lincoln Tuna Processors Pty Ltd was charged with and pleaded guilty to a breach of the State OHSW Act, and was fined $25,500 over the first incident, and $32,300 for the second.
The Magistrates Court heard that both workers were injured in early 2009 when they put their hands into the output end of a packing machine to clear scraps of cardboard, & their fingers were caught in the moving parts of the conveyor system.
The Court found the "incompetent" internal investigation conducted after the first incident failed to correctly identify the cause of the injury, or pick up that the purpose-built guard for the output end was missing. It had been removed during the Xmas maintenance shutdown. The Court also found there were no specific safe operating procedures (SOP) for the machine. The only signage read, "Beware of moving machinery."
Further, the Court heard evidence from the second injured worker that while she had been told on occasion not to put her hands in the machine, she was under conflicting pressure from other employees to do so. She said that if blockages weren't removed by hand the machine jammed up, requiring maintenance, and "everyone gets angry because that's a waste of time".
Following the intervention of the regulator, the employer prepared a new SOP that outlined how to properly deal with blockages and made it clear that hands were not to be placed in the machine. Industrial Magistrate Lieschke said the company's "main challenge" was to ensure actual work practices continue to conform to the new written SOPs. It also needed to ensure machines were recommissioned, in line with its policies, & to ensure it "thoroughly" investigated the causes of all injuries.
In fining the employer, Industrial Magistrate Lieschke took into account 2 other safety offences it had committed within the previous 4 years. The first involved inadequate guarding; the second resulted from the lack of a safe operating procedure for the injury-producing task. Industrial Magistrate Lieschke said both prior offences should have prompted the company to thoroughly investigate the first 2009 incident. How well do you do your root cause analysis and then how do you know that any corrective actions implemented actually work? Do any of the incidents you have repeat themselves and how could you show you are diligently working through a plan of actions to correct this in a priority that reflects the risk posed? Farrell v Port Lincoln Tuna Processors Pty Ltd [2011] SAIRC 54
Is common industry practice a valid excuse for non-compliance?
Not in this case it wasn’t where a mining employer was ordered to pay an injured labour-hire worker, who fell from a steep ladder on a 50-tonne dump truck, more than $1.2 million, after the NSW Court of Appeal confirmed that common practice was not necessarily the correct safe practice. A full bench unanimously dismissed Roche Mining Pty Ltd's appeal against a damages order, finding the employer could have minimised the fall risk by replacing the dangerous ladder with a transverse retractable stairway.
In April 2003 the worker was using his usual method to climb into the 785B dump truck's cabin, which involved negotiating the difficult last two steps of the ladder by reaching up to a bar under the windscreen and pulling himself up, when his hand slipped and he fell 2.5 m, injuring his hip, pelvis and lower back. Prior to the fall, his method of accessing the truck had been assessed as appropriate by a Roche safety officer.
Last year, Supreme Court Justice Hoeben awarded the worker damages, after he found the access ladder was "primitive" & too steep to comply with the relevant Australian Standard, and that the absence of continuous handholds constituted a "design flaw". He found the incident was foreseeable, & that Roche's insistence that drivers always keep 3 points of contact on the ladder showed it was aware of the risk. Justice Hoeben found that fitting a transverse stairway to the vehicle for a "relatively minor" cost of $20,000, as recommended by a 2002 mining guideline, would have reduced the risk of injury.
On appeal, Roche argued that fitting a transverse stairway was not common practice in the industry, and that it was impractical to retrofit all 42 of its 785B dump trucks. It also argued that it should not be held liable for the defect in the original design of the truck. Court of Appeal Justice McColl found the defect was obvious, & Roche failed to take reasonable precautions to protect the worker from it. She found the employer was aware of the fall risk, & said that fitting a transverse stairway was a reasonable precaution & not one "advocated with the benefit of hindsight". The Australian Standards on angle & handrail continuity both predated the accident, as did the mining guideline that recommended the stairway. These were both considered evidence that those regulating the industry were aware of the fall risk and the need to reduce it. In other words, common practice was not necessarily safe practice. The company was required to take into account possible employee "inadvertence or miscalculation" so the 3 point contact requirement was an inadequate control measure for this risk! Roche Mining Pty Limited v Graeme Wayne Jeffs [2011] NSWCA 184.
Written by Julie Armour