The permanently life altering personal damage occurrences (Accidents) I have been associated with
by the Late George Robotham
During my 38 years involvement in OHS I have been associated with 13 fatalities, a case of paraplegia, a serious burns case and a major stress incident. The following are brief details of the permanently life altering personal damage occurrences (Accidents) I have been associated with and some close calls. With many it was good luck, not good management, that more serious life altering personal damage did not occur.
There are lessons to be learnt from personal damage occurrences, the reality is that these lessons are often not widely communicated and acted upon. We do not have a National system for reporting, recording and analysing permanently life altering personal damage occurrences, this seems to me to be a priority if we are serious about managing OHS. Taxonomies of industry personal damage occurrence experience are a fertile avenue for improvement.
The life of an OHS person can be tough, we are often ignored by all and sundry and when the inevitable happens we have to help organisations cope with the aftermath.
Terminology used in OHS,
Probably the best example of a lack of scientific discipline in OHS lies in the terminology “accident”
The term “accident” implies carelessness (whatever that means), lack of ability to control its causation, an inability to foresee and prevent and a personal failure. How can we make meaningful progress on a major cost to Australian industry if we persist with such, sloppy, unscientific terminology? The term “accident” affects how the general population perceives damaging occurrences and the people who suffer the personal damage, inferring the event is “an act of god” or similar event beyond the control and understanding of mere mortals.(Geoff McDonald)
The term “accident” is best replaced by the term “personal damage occurrence”. Instead of talking about “permanent disability” we should be talking about “ Permanently life-altering personal damage”
There is a poor understanding in the community of the reasons why personal damage occurs. We are quick to make the assumption that the worker was careless, when one examines personal damage carefully one will also identify a range of work system factors that contributed to the personal damage as well. Most of these work system factors are the responsibility of the employer at both common and statute law. Blaming workers for their careless behaviour is an emotionally appealing approach that is usually not all that productive in the bigger picture of preventing personal damage at work
- Damage to people at work has a number of adverse outcomes:-
§ Financial loss to employer, worker and community
§ Pain and suffering
§ Dislocation of lives
§ Permanence of death
- Damage to people from work falls naturally into one of three Classes.
- Class I damage permanently alters the person’s life and subdivides into
- non fatal
- Class II damage temporarily alters the person’s life
- Class III damage temporarily inconveniences the person’s life (Geoff McDonald & Associates)
Geoff has investigated many thousand Class 1 damage occurrences in his career and maintains the most effective way to make meaningful progress in safety is by focusing on the class 1 phenomena. I have been involved in 3 projects with Geoff where we have either analysed critical incidents or personal damage occurrence experience and I found the results very impressive, the analysis of the critical incidents and personal damage occurrences really targeted control actions in an appropriate manner.
One of the biggest myths in the safety business is that preventing Class II and Class III personal damage will automatically prevent Class I personal damage.
This is an incredibly simple technique that it is rare to find used. Essentially a taxonomy is a collection of like. The most well known taxonomy is the phylum of plants, their botanical names.
Examination of personal damage occurrence taxonomies on an industry basis can provide meaningful insight into your safety problems. Examination on a national basis is even more powerful, I find it hard to believe our national government is serious about safety when we do not have a national method of collecting, reporting and analysing Class 1 personal damage.
A Permanently life altering, Class 1, fatal, 13 at work
18 year old office girl drove a company car from the mine to the nearby township to do company business, on the return journey she was observed driving excessively fast. She was attractive, friendly, vivacious and liked by all. What ended up happening was such a waste. On the return trip she was driving very fast around a curve and lost control of the car, the car rolled several times and she was catapulted out through the windscreen. She was not wearing a seat belt.
I comforted her until the ambulance arrived. As she lapsed in and out of consciousness she said “George, please do not let me die” We put her on the aerial ambulance to Rockhampton Base Hospital where she died the next day. Subsequent investigation revealed some sensitivities about the causes. Had the organisation been more responsive to her problems and needs the incident could have been prevented.
I do not mind admitting I hit the grog for awhile after this. Of course this was before the days of critical incident stress de-briefing.
Moura Disaster storey
When I was working in the corporate safety department of a major mining company I was focused on the 7 open-cut mines and had no responsibilities for the 2 company underground mines. My view was and still is that some of the safety work being done in the open-cut mines was very good.
On the 7th August 1994 Moura underground coal mine suffered an underground explosion that saw 11 men entombed in the mine and the mine closed. If my memory serves me correctly the head of the Mining Wardens enquiry into the disaster said “What happened at Moura represents a passage of management neglect that must never be repeated in the mining industry” The people who said what happened at Moura was an enormous stuff-up are understating the situation. Professor Andrew Hopkins wrote a book called “Managing Major Hazards” on the Moura disaster that I think should be compulsory reading for every manager, supervisor and OHS professional.
What happened at Moura was about the culture of the organization and communications as much as it was about safety.
Those who complain about the effort and cost of implementing safety measures should have been around to see the slump in the company share price, shareholder dissatisfaction, pain and suffering, cost, effort, media crucifixion , ruined reputations, wrecked careers, psychological trauma, union backlash, enormous investigation effort, massive counseling effort, threat of regulator action, legal action against the company and company officials and strained relationships I saw.
There was a massive investigation effort after Moura and much chest thumping about implementing the lessons learnt. While I only have media reports to go by an incident in a New Zealand underground coal mine where a number of men were killed said to me some of the lessons from Moura had not been implemented.
The snake storey
Draglines have a crew of 3 to operate the dragline and the associated bulldozer and 4wd.An employee drove the 4wd near the bulldozer and got out and spoke to the operator. He then walked back to the 4wd and commenced to get in it. When earthmoving equipment operators are working on a standard path they often do not look behind themselves when reversing, people who work around earthmoving equipment know they have a responsibility to be vigilant about the proximity of the earthmoving equipment. The bulldozer was reversed into the 4wd, killing the employee. During the investigation a snake trail was discovered in close proximity to the 4wd. The hypothesis was that the employee who was killed was distracted from the proximity of the bulldozer by the snake.
Motor vehicle accidents storey
As a mine Safety Adviser and volunteer ambulance bearer I attended a number of motor vehicle accidents. It was quite noticeable that the dead ones were often the ones who were not wearing seat belts, too much grog did not help.
B Permanently life altering, Class 1, non-fatal
Tom was cleaning inside a dragline and was overcome by solvent fumes. He squatted on the shoe of a dragline to clear his head and get his breath back and was crushed between the shoe and a walking platform when the dragline walked.
Most major bones in his body were broken and he received a punctured lung, he was made a paraplegic and had shortened life expectancy.
It was clearly a design fault in the dragline that was reluctantly recognised by the manufacturer. I would not be surprised if draglines are currently being constructed around the world with the same design fault.
Vibration in earthmoving equipment storey
The effect of vibration in earthmoving equipment is well documented. There was a time when the so-called anti-vibration seats in earthmoving equipment actually made the situation worse, hopefully we have moved on from those days. Serious spinal column damage was often an outcome.
The electrician storey
An electrician was seriously burnt in a 415 volt switchboard explosion, he experienced massive burns with much scarring, psychological damage and about 18 months off work. Some of the essential factors were production pressure, inexperience, suspect high voltage testing equipment, the ergonomics of the switchboard and test and prove dead not carried out.
As a result of this incident the organisation carried out a comprehensive critical incident recall process that resulted in many safety enhancements. This process was by far the most effective safety change process I have ever seen.
The Clive storey
Clive was a miner in the crew that maintained draglines. The massive chains that are attached to the massive dragline buckets are referred to as jewellery. Through lack of communications Clive got 2 fingers crushed by the jewellery and was referred for surgery. The only trouble was the doctor amputated a finger that was perfectly ok.
Access to earthmoving equipment storey
A number of serious incidents had occurred during access to earthmoving equipment. A project I led was the Access to Earthmoving Equipment project. Work required included:
v Carrying out a literature review;
v Thorough statistical analysis of company accident data
v Developing a check-list to assess access systems;
v Field assessment of access systems
v Discussing access requirements with maintenance and operational personnel;
v Designing and installing prototype access modifications;
v Assessing the adequacy of the prototype modifications;
v Developing access purchasing specifications and maintenance guidelines; and
v Providing written guidance on desired characteristics of access systems.
v Presenting to industry forums in Qld. W.A. & N.S.W.
Through the employer association we successfully applied for Federal Government funding to extend the original research work. Thorough statistical analysis of Qld mining industry accident data was the starting point. This work provided significant input into the writing of an Australian Standard for “Access to Earthmoving Equipment”.
As part of the project I visited a major earthmoving equipment supplier who expressed contempt that we would dare to question the safety of their equipment.
The project gathered a fair head of steam at the time and changes were made. I note examples now of where the lessons learnt are not being applied in the Australian mining industry. The report and recommendations were never fully utilised as the recommendations have a lot of applicability to access on smaller earthmoving equipment used in the construction industry, trucks and a wide range of general equipment used in industry.
Anne was a female secretary who was being harassed and bullied by a female supervisor. The manager decided to manage the situation himself without help from the people trained to work with these matters and he attempted to keep the matter under wraps because of the senior and sensitive position of the supervisor. By the time I became involved as a rehabilitation coordinator Anne had a certificate for 3 months off work with a stress-related condition, her lawyers had commenced legal action against the company in the Anti-Discrimination Commission and all parties involved were bitter & twisted. It was interesting to see how some in management closed ranks and made Anne out to be the problem. I emerged from this matter pretty disgusted about how Anne had been treated by a company that made a lot of noise about their commitment to health and safety.
C Should have been permanently life altering except for luck
Oxy-acetylene equipment storey
When I worked in the mining industry the industry experienced a number of potentially fatal explosions in oxy-acetylene equipment gauges and regulators. Investigations revealed coal dust was accumulating in the equipment through faulty design. It was a major task to get the equipment manufacturers to acknowledge there was a problem and change their design.
The grinding wheel storey
A machinist was doing some work with a 3 inch tool post grinder. The grinder changed speeds by fitting drive belts onto drive pulleys. The machinist thought he was halving the speed of the grinding wheel but doubled it so the speed rating of the grinding wheel was exceeded and the grinding wheel exploded. The machinist lost a bit of his ear, it was a miracle he was not killed. The area where the incident occurred was a high pedestrian traffic area, fortunately no one was in the area at the time the grinding wheel exploded.
The Toyota Hilux storey
I think it was the early 1980’s when the company I worked for replaced Toyota Landcruiser utes with the newly released Toyota Hilux utes in many applications. The early Hiluxes had a high centre of gravity, stiff suspension and a marked tendency to roll over. I got to dread the combination of apprentice, wet road and a Hilux
The explosion storey
Open cut coal mines use a lot of explosives to loosen the overburden prior to mining. I was called to a crib hut that was peppered with holes in the walls. The inhabitants of the crib hut reported they had dived to the floor for their safety when an overburden explosives shot had been detonated. The Drill and Blast foreman had mucked up his calculations of the powder factor of the shot and put nearly twice as much power into the shot as he really wanted.
The Alex storey
I got a call about midnight one night to go to the mine to investigate a company motor vehicle accident. At the scene I found a Falcon sedan on its roof, backtracking the skid marks in the dirt road it became obvious the car had become airborne as it topped the sharp hill in the road. The driver came staggering out of the bush all covered in blood, I made arrangements to take him to hospital. His storey was he swerved to miss a dingo and he stuck to this.
It rapidly became obvious he had been drinking at the onsite boozer for several hours and decided to race another person back to town in their company cars. He took the dirt road thinking it would give him a short cut and an advantage in the race to town.
Through a combination of circumstances he was not terminated. I was told to ensure his replacement car was dingo coloured when the rest of the company cars were white and to tell everyone about this.
The Sam storey
Like a lot of people in the mining industry in those days Sam, a foreman, had a drinking problem. He had a history of incidents involving the grog. After spending a long time at the onsite boozer he had a motor vehicle accident in his Toyota Hilux 4wd on the way back to town. The ute rolled several times and end for ended at least twice, the early model Hiluxes were renowned for their lack of stability. Virtually every panel on the Hilux was bent and the cab smashed down to dashboard level. Sam said to me that he released the seat belt and lay down on the driver’s seat when he saw what was happening, that probably saved his life.
Safety construction management plans storey
When started with X road and bridge construction, noise barrier, earthwork , concrete construction organisation the senior OHS person explained to me that an important part of my duties was to prepare safety management plans for the start of every construction project. The organisation had a big template safety management plan and the idea was that one should identify the type of work being done eg confined space, trenching, manual handling etc. and put the required safety precautions for this type of work from the template into the safety plan. Basically the safety precautions in the template were based on the statutory requirements for the particular class of work (assumes of course the legislation was right and catered for varying circumstances). I did a few safety plans and noted the expectation was these be done in the office. There was no inspecting the site or discussion with the workforce and only limited communication from those in charge of the project.
About a month after I started I got a call that an excavator had hit a power line on a road construction job and I go over to investigate. After interviewing the excavator operator and the supervisor I go to the project office and ask the Project Manager for the safety management plan so I can check out what is said in the plan about operating equipment near powerlines (The safety management plan had been prepared by the senior safety person) Much scrambling in filing cabinets and cries of “ It is here somewhere” Finally the safety management plan was located and I noted there was nothing on it about operating equipment near powerlines. I talk to various workers and it rapidly became obvious none of them were aware a safety management plan existed.
From then on I tried to ensure the development of the plan included input from workers, involved a walkthrough of the site and input from the project manager and supervisor. Prior to each new project being started I would endeavour to have a safety induction that included discussion about the safety management plan. There was a fair bit of resistance to the foregoing approach from, particularly, project supervisors .
This incident was the start of about 5 incidents over 6 months where equipment struck power lines. Fortunately the electrical protection in the system blew and there were no injuries. There were issues about how adequately insulated the operators were from the cab of their equipment. There were many meetings and discussions about the topic and eventually a set of procedures were developed to be included in the safety management plans. The thing that made the most sense to me was the fitting of “tiger tails” on the power lines in the area where equipment was operating to improve visibility of the power lines (operators in the various incidents said they simply did not see the powerlines) A senior member of management held a series of meetings with the workers and supervisors to explain the new procedures.
A week later I go to a road construction job with earthmoving equipment, tip-trucks and excavators operating under power lines. No “tiger tails” The project supervisor ( who had attended one of the sessions with the senior manager) got offended when I suggested, in a caring and gentle way, that he should lift his game. When I complained to the manager he said he was not surprised as supervisor x was pretty slack on most things including safety, this was just accepted and there were no disciplinary actions.
Confined space work-storey
Started with this company with the remit to review the Safety Management System.
Was there a week and they came to me and said, by the way we have these and presented me with 32 Improvement Notices and 5 Prohibition Notices. Has to be a record for one visit from a safety inspector. These were overdue for a response to Workplace Health & Safety Qld.
A number of the Prohibition notices were about confined space work. The company made water tank bodies for mining haul trucks, large mixing bowls for concrete mixers and some other confined space work.
Got on talking to the workers and got a few war stories about people being partially overcome by fume in the confined spaces and having had to be assisted out. The workers said they had been trying to get management to improve confined space work procedures in the workshop but the management ignored them.
The interesting thing was some of the workers did confined space work with the company product at the mines and were aware of and used the mines strict confined space working procedures when on the mine-sites.
Some of the problems I discovered were no confined space risk assessments, no confined space entry permit, the fume extraction was not effective particularly in the large water tanks with many baffles, there was no pre-entry test of the atmosphere, there was no continuous monitoring of the atmosphere, there was no off-sider to ensure the worker inside the confined space was safe, there were no emergency procedures, the respiratory protective equipment being worn was inappropriate, there had been no training in confined space work and what procedures that existed were not being followed.
All in all the biggest stuff-up in safety I have ever seen, particularly when you consider we are talking about something that can make a real difference to the workers lives.
Rapidly became obvious management was not interested in my findings or making changes so I got an outside organisation to audit the organisations confined space work. The auditors report was very damning as I knew it would be.
George goes about implementing the auditors recommendations and eventually the General Manager becomes aware of what is going on and tries to stop the process. He & I had what could be described as a forthright expression of views at a safety committee meeting where he tried to browbeat me into submission. I told him he should get advice from his solicitors on the matter and reminded him this came about because of an Improvement Notice from the government safety inspectorate.
A couple of days later major transformation from the General Manager, I am guessing he saw the solicitors, very keen to see the changes completed.
New gear was bought and other changes made. The union rep. came up to me & said he had been trying for 2 years to get the confined space work changed and I was a bit of a hero to a number of the workers.
As a safety person I was treated like crap by the management team, the same as the way they treated the workers.
Since then I have noted the company has been the subject of 2 Enforceable Undertakings with the Qld Government. Not a surprise to me, slackest outfit on safety I have ever come across.
I first wrote the above paper nearly 20 years ago when the C.E.O. of an organisation I worked for came to me and asked me to give him 10 things the organisation had to do to have a good safety management system. The paper now contains about 50 suggestions. The paper reflects my practical experience in safety and the personal damage occurrences outlined above.
Lessons I have learnt from my exposure to personal damage occurrences
Organisations need robust safety management systems and plans. Employees must be involved in the development of these and the information needs to be communicated to the workforce. Safety management systems can easily become overly complex and driven by masses of paperwork that the workers do not know about, care about or use. The safety management system must be real world stuff that makes a meaningful difference up the sharp end. I say the acid test of your safety management system is what happens in the field at 2am, when it is pouring down rain and there is no supervisor around. The safety management system must be thoroughly audited regularly.
Highly visible, demonstrated management commitment and strong safety leadership are vital to the success of the above. Having a few senior management Safety Champions needs consideration. The leadership style of formal and informal leaders needs to be assessed, feedback from the workforce on leadership style is important as is appropriate learning.
OHS personnel must be determined, have strong personalities and understand management of organisational change.
Properly constructed safety culture / safety climate survey instruments can provide useful feedback.
An emerging field is using psychological data gathering, principles, process and techniques in OHS.
The inexperience and psychological makeup of younger people can lead to personal damage occurrences.
Relying on compliance with legislation to prevent Class 1 personal damage is a false hope.
Developing effective emergency response plans is difficult, they must be regularly practiced.
Team building, change management and project management methodologies can aid safety change.
Do not take things too seriously and celebrate success.
The OHS person needs to spend a lot of time in the field and not become office bound.
Communications must be succinct and relevant to the workplace of the receiver.
Not wearing seat belts and driving under the influence is the pathway to disaster.
When initiating change, remember, People support what they create.
Critical incident recall is a highly effective means of improving safety standards.
Harassment and bullying can have devastating effects on victims and is difficult to manage.
A focus on permanently life altering personal damage (Class 1) is essential. If you are not careful you can waste far too many resources on minor incidents that have little potential to progress to Class 1 damage. Many have said this is one of the problems with zero harm approaches.
Behaviour based safety is but one weapon in the safety armoury and is not the definitive solution it is often made out to be.
Taxonomies of industry Class 1 experience are a powerful means of positive change.
Australia needs a National system of reporting, recording and analysing Class 1 personal damage.
OHS project teams using change management and project management methodologies can be an effective means for positive change.
When serious accidents occur management sometimes indulge in arse covering and the injured party does not receive much understanding or sympathy.
The lessons from serious accidents are easily lost with the passage of time.
Properly targeted, interactive learning is a fantastic means of positive safety change. Learning must have a learning needs analysis as a precursor and use action and experiential learning models.
Equipment manufacturers are often slow to acknowledge the safety problems with their products.
There are a lot of incidents where good luck, not good management reduces the extent of personal damage.
Developing and introducing procedural controls is not always to be relied upon. Safe working procedures should be succinct, use simple English and boosted by photographs and diagrams, If you do not make them easy to use they will not be used.
Get to know your people and be responsive to their concerns. Interpersonal problems can result from relatively minor issues, be constantly alert for these problems.
Managers, supervisors and OHS personnel must manage by walking around.
Sometimes people pay a high price for a moments inattention.
Human beings inevitably make mistakes at times and it is not appropriate to rely on their behaviour to be safe at all times. The work environment, systems and equipment must be designed to accommodate this.