Safety At Work Blog

As one gets older, the “where are they now?” columns in the newspapers or the summer magazine supplements become more interesting.  The articles of faded pop stars and political one-time wonders are diverting but every so often one makes you stop and think.

OHS is not renowned for “where are they nows?”.  The discipline and the profession has few celebrities but there are important people.  One such person is Jim Ward.  Jim’s story is long and involved but he came to the public’s attention as a survivor of the 1998 gas explosion at the Esso gas plant in Longford Victoria.  The blast, which killed 2 workers, crippled the State’s gas supply for almost 2 weeks.  A Royal Commission was held into the disaster.

Usually a worker’s evidence may be reported on for a day or two in such an investigation but Jim Ward became more than that primarily due to the attempt, according to some, by Esso Australia (a subsidiary of ExxonMobil) to scapegoat Jim.  This attempt was roundly condemned in the Royal Commission.

In the Australasian Mine Safety Journal, Jim Ward has written a short personal account of what happened that day but, more importantly, how that day has changed his life.

After the failure of steel exchanger and before the fatal explosion, Ward writes:

“I raced to a doorway and looked out into the gas plant where I saw a thick white fog rolling down the walkway. This white fog was a cloud of vaporised hydrocarbon. Gas – highly flammable gas.

Out of the fog stumbled two zombie-like creatures. Two men – blackened from head to toe. They were covered in soot which had been blown from the inside of the huge steel exchanger when it violently ruptured. They had their arms out in front of them trying to feel their way through the fog, blinking as if trying to catch some daylight to help guide them to safety.

Over the roar of the jet–engine–like sound of gas spewing into the atmosphere I yelled – I yelled at them to get into the control room. Into the control room and to relative safety. Ninety seconds later the gas found a source of ignition and a second, much louder explosion shook the control room building again.

What followed from that moment on was sheer unadulterated terror.”

In his article he goes on to explain the psychological impact of that day and the diagnosis of his post-traumatic stress syndrome.  Ward rightly points out that mental health is poorly understood in the workplace.

Many employers are satisfied if they get through a single day without a problem or complaint but silence is not compliance and there may be mental health issues that require attending to even though they are difficult to identify.

Ward’s article is a timely reminder that the measurement of a successful OHS management system or a more personal “safe system of work” has changed and that business needs to scrutinise OHS auditors on the mental health assessment criteria.

Perhaps, most particularly to Australia, it is necessary to gauge OHS laws through contemporary hazards, such as mental health.  The law will exist for decades and need to be able to adapt to emerging hazards, many of them not coming from the physical.

His article also means that workers need to consider colleagues as more than just colleagues and look to their humanity.  In the past many of us are inclusive and dismissive when we refer to someone as a work mate.  People are more than that.

It may be, as this article is written on 9 November 2009, that Jim Ward’s message has already been learnt by the survivors and emergency workers of the World Trade Center from 2001.  But for many outside the United States it is also two days before Armistice Day, the end of the World War which really brought  shell-shock or combat stress reaction and post traumatic stress disorder to the public mind.

When remembering the fallen in war and work we should also ask “where are they now?”

Kevin Jones

Readers outside of  New South Wales may vaguely remember that in 1996 four miners died in a coalmine in the Hunter Valley 0f New South Wales.  They may also remember that the was some press about the prosecution of some directors of the mining company.  It was one of those incidents and court cases that should have gained broader attention that it did.

As OHS stakeholders in Australia ponder the ramifications of the Government’s proposed Safe Work Bill, it is important to also ponder the legal legacy of the Gretley mine disasater.  It may provide non-NSW and non-mining readers with a better understanding of the resistance to the new harmonised laws from the mining industry in both New South Wales and Western Australia.

On 15 October 2009, Andrew Vickers of the Construction Forestry Mining & Energy Union used the Gretley saga as a justification to call for the harmoinised legislation and support systems to allow for variations to meet the special needs of the mining sector.

On the other side of political fence, Ken Phillips of the Institute of Public Affairs, a conservative thinktank, produced a document about the politics of the Gretley saga.  The publication was supported by a video, available below. Phillips’ paper is a useful illustration of business’ opinions of the unions and New South Wales’ OHS legislation.  This legislation is a centrepiece to the ACTU and union movement’s concerns and opposition to many elements of the current draft Safe Work Bill.

Prominent sociologist, Andrew Hopkins, has written about the OHS management issues raised by the disaster and its aftermath.

SafetyAtWorkBlog believes that these political and safety resources can provide a primer to many of the issues being discussed in the current debate on OHS laws.

Kevin Jones

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

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

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

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

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

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

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

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

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

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

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

Kevin Jones

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.”

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]

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

According to various Australian media reports, the natural gas plant at Varanus Island in Western Australia is now back to full capacity following the major pipeline explosion in 2008.

The government has estimated that the explosion blasted $A2 billion from the state economy and will be pursuing the pipeline’s owner, Apache Energy, through the courts.

The government says the pipeline was inadequately maintained and corrosion led to the failure of the pipe.

Apache has already been in the courts seeking an injunction to stop the Western Australian Mines & Petroleum Minister, Norman Moore, from seeing a ”a federal-state government report into alleged regulatory lapses that may have contributed to the Varanus Island blast”.

Apache’s move is peculiar but the WA government has become more involved in the investigation of this explosion than others and the company has not been happy with the investigation process for some time.

Kevin Jones

Three years ago I had the privilege of arranging for Dr Lee Clarke of Rutgers University to attend the Safety in Action Conference in Australia.  Lee had a book out at the time, Worst Cases, and spoke about the reality of panic.  Lee’s studies have continued and are, sadly, becoming more relevant.

Recently, Rutgers University posted a video interview with Lee on Youtube.

Shortly after the World Trade Center collapse in 2001, I asked Lee to write something about the event from his experience and perspective.  He wrote a piece for a special edition of Safety At Work magazine.  The article has been available through his website for some time and is now available through here by clicking on the image below.

I strongly recommend Lee’s books.  As he says in the video, they’re quite fun, in a sad sort of way.

Kevin Jones

In 2005 I had the great opportunity to spend some time with Peter Sandman, a world renowned risk communicator.  We spoke about worst case scenarios and risk communication in those times of avian influenza and smallpox threats.  The interview has gained additional poignancy in this time of swine flu.  

Although the audio is “noisy” as Collins St in Melbourne had more traffic on a Sunday morning than I expected, I think some readers may find this excerpt very useful at the moment.

Click on the magazine’s cover image below to download the interview transcript.

[For Peter Sandman's current commentary on swine flu, see http://www.psandman.com/index-infec.htm#swineflu1 and especially http://www.psandman.com/col/swinecomm.htm]

Kevin Jones

There’s an opportunity to follow the hearings of the Victorian Royal Commission on last summer’s horrendous bushfires via a live web stream. Here is the link to the Commission’s home page: http://www.royalcommission.vic.gov.au/ The “live stream” link on that page takes you to a live broadcast of the hearings underway at the time.

Fortunately, the catastrophe of the summer’s bushfires don’t happen often (unfortunately, the enormity of some people lighting fires does happen too often). What is even more rare is for us to be able to listen to first-hand witness experiences of decision-making in extreme conditions and to gain insights from listening to those experiences.

I often have the Royal Commission’s live stream running in the background while doing other work. I do that because I’d prefer to hear the witnesses reports directly. Of course, there will be a final report, but hearing the tone and context of the questions and answers are the sort of things that can be very difficult to recreate in a written report.

Monitoring the live stream is highly recommended for all safety professionals; doubly so for those people who work in larger businesses or organizations. A rare chance to observe and compare decision-making processes and lines of communication in complex situations to see what did and didn’t work.

Col Finnie
col@finiohs.com
www.finiohs.com

Fail to Plan, Plan to Fail, as the old saying goes. It is the same in business as in life. The more we can plan for the uncertainties the more they are no longer uncertainties.

Some of the potential threats to a business, a Safety Leader should be aware of, include a natural disaster, terrorist attack, cyber terrorism, fire, pandemic, and equipment breakdown, loss of a key employee or process, financial downturn, or a sneeze in one part of the world that turns into a cold in another part of the world, as we are seeing in our globalized community. They can all affect not only the company we work for but the employees’ health and safety.

You name it, as we can all attest, if it has happened to one it can happen to anyone. A Safety Leader needs to put in place a plan to prevent these threats from happening; or if they do happen, a plan to prevent further harm to the organization, by way of a Business Continuity Plan.

For example, if I owned a coffee shop, that had a fire that burnt down the building that I serve coffee in, perhaps my contingency plan would be to know where I could access an Atco trailer, and have the necessary stock on hand at another location, so that I could serve coffee the very next morning. Thereby, remaining in business until a new building could be built.

It is key to have a plan for every possible scenario (such as a work-at-home policy during a health scare such as swine flu), as some companies are already pandemic planning and are putting the necessary means in place to be prepared. There are as many scenarios as there are actual risks that could affect your venture. Look at what your neighbours are doing. Try to develop a rapport with your neighbours to see how you can assist each other in a crisis. 

Some basic elements a Safety Leader needs to ensure are part of their “disaster recovery” plan start with involvement of your staff, as they are key stakeholders to the success of your enterprise. They can form a team that can inspire each other and brainstorm, plan, analyze, develop and practice your plan. Recognize that as a leader, you can’t necessarily fix everything and don’t need to do it all themselves. Involving others of your organization will assist in preparing your staff in the event that an emergency happens, and recognize the importance to be able to delegate responsibility before and during a crisis.

Overall, this is an area in which can be overseen by you and your team but it would be advisable to enlist in outside services for help. Even if it is just to consult with someone with experience in this area, and get a fresh perspective on the plan to confirm “Will it work?”

Preparing for a threat involves succession planning. You may be asking yourself of all the duties I already have how do  I include preparing for things that could happen as opposed to what is currently happening?

When you look at how risk is defined as an uncertain event or condition that, IF it occurs, has a positive or negative effect on a business’ objectives.  Missed objectives are likely caused by unforeseen events and inadequate risk management. Therefore, it is crucial to the success as a leader of his or her organization and overall to be aware of the areas of risk that could impact the operation.

The most important leadership skills and characteristics to possess in order to be a successful leader during a crisis as described by Clarke Murphy, who heads the CEO Search Practice for Russell Reynolds, talks about three crucial leadership skills needed in a time of crisis: Communication, Agility, and Decisiveness. Eric Santillin added a fourth one: Inspiration.

Be willing to listen to those of your organization who are in the trenches, when they tell you of something they foresee could go wrong, Stop and listen, then ensure you ask them how they would fix it.

Secondly, recognize that managing crisis is part of the job of leadership. Leaders are sometimes the variable that makes the difference. It is during the crisis that others will look to you to see how bad it really is, and you need to have the skills to pull it all back together again when it all falls to pieces. It is important to be a strong communicator, and be able to guide employees through a crisis with reassurance. That you believe you have a strong team that can work through the crisis, and that everyone is the most important part of the team.  

Some say that a leader is born but most leaders are taught. Special training can be an enhancement to become more skilled in crisis management. Do some soul searching, most especially ask yourself, how do I handle crisis in my personal life?

This can be an indicator. Do you have a complete meltdown at missing the bus, or breaking your shoelace? Perhaps a few courses could assist you, both personally and professionally.

Possessing skills in areas such as crisis management, risk management and security management help a leader further his or her career development by being able to be adaptable and enabling the owner of the company to know they can rely on you at the end of the day. Confident, that you will not abandon the ship when left at the helm. It is my belief that these skills effectively separate a leader from the competition during a job search.

“Companies now want candidates who have already had experiences going through a massive change program. That is no longer a nice to have. That is a must have,” says John Ellis, Managing Director of Boyden UK.

Especially in our globalized community where more and more, we are affected by the events that happen. But in a crisis, companies need leaders accomplished in reducing cost, conserving resources, and managing day-to-day. But ultimately have the ability to protect the most valuable asset their employees.

Crisis Management- Pamela Cowan, Director, Safety Developments