The excesses of paperwork in the risk and safety industry is evidence of the mythology that paperwork demonstrates safety. Similarly the idea that numerics and metrics demonstrate safety is based on the same delusion. All data whether quantitative or qualitative is interpreted, there is no such thing as objective data.
The delusion that volume and weight of paperwork demonstrates safety is what drives new risks of ‘tick and flick’, paperwork fatigue and misguided notions of evidence. If people get to court they get a huge shock to see their paperwork being used against them (https://vimeo.com/162034157).
Those that drive this delusional mythology such as Regulators and the Federal Safety Commission are plainly out of step with what the courts and leading lawyers in WHS declare (https://www.amazon.com.au/Paper-Safe-triumph-bureaucracy-management-ebook/dp/B07HVRZY8C). Indeed, it is sometimes the Regulator who gets castigated by the court for a misguided sense of what comprises evidence. If testimony contradicts paperwork, the court is most likely to dismiss the validity of the paperwork, what it now calls ‘paper systems’.
Moreso, any sense of understanding human decision making or the social psychology of influence would show that the by-products of excessive paperwork drive: Toxicity in culture; deficit views of safety and load up safety as a workplace embuggerance. I run training groups across industry every week and the feedback is loud and clear, workers detest excessive paperwork and ‘tick and flick’ is alive and well in the workplace. Indeed, we have a company in the ACT that makes a fortune out of selling generic SWMS. You can even buy generic SWMS at Officeworks (https://www.officeworks.com.au/shop/officeworks/c/facilities-supplies/workplace-safety-equipment/registers-compliance-documents/safe-work-method-statements). Such is the delusion that paperwork is an end in itself. All this nonsense and delusion is driven by the Regulator and regulation mythology.
Paperwork in itself does not ‘prove’ compliance, it proves one is good at completing paperwork. Similarly, completing some method of incident investigation doesn’t mean one has conducted a thorough investigation, it means one has completed a commonly agreed investigation process. The Danny Cheney investigation is a classic example of commonly accepted biases in investigation techniques. Many popular methods have more holes in their assumptions and design than swiss cheese. In the SEEK program (https://cllr.com.au/product/seek-the-social-psyvhology-of-event-investigations-unit-2/) I demonstrate how many of these popular methods overlook dozens of elemental factors in investigation.
All paper work, including investigation methods are only as good as the ideology of the designer. If the design methodology is positivism, such as the regulator assumes then, critical analysis in human, culture and social psychological factors will be missing. Paperwork design is not neutral, it is the embodiment of the bias of the designer. This ideas that iCAM is some industry standard contributes to the mythology.
Isn’t is strangely predictable how any investigation or enquiry by a Regulator ends up in more regulation and inspection regimes? The Boland report is a classic example (https://www.safeworkaustralia.gov.au/system/files/documents/1902/review_of_the_model_whs_laws_final_report_0.pdf). This was also the case with the Getting Them Home Safely Inquiry (https://www.accesscanberra.act.gov.au/app/answers/detail/a_id/3048/~/getting-home-safely-report) in the ACT. Of all the recommendations in the Report it was the cultural issues that were ignored and the employment of more regulation through audit and inspection was implemented. When your problem is a nail then the only solution is a hammer.
Here are some positive suggestions in how to make paperwork effective to support other evidence that your actions for safety ‘works’.
- Get away from this idea in safety that paperwork design is neutral.
- Explore the biases of the paperwork design and use such paperwork critically. Then amend the paperwork to pick up on gaps.
- Think much more about confirming that safety works by observations, conversations, visual evidence and verbal evidence.
- Dump this idea that the existence of paperwork is a defense in itself, its not.
- Understand that the Regulator has an agenda and a political imperative and that this shapes their thinking and demands. Regulators are not neutral, neither is the Regulation.
- Think more about ALARP (https://vimeo.com/162637292). What is your defendable position should something go wrong?
- Be very careful of the language you use in inductions, posters, policies and training. Ensure you don’t refer to things like zero because this also will be used against you in court (https://vimeo.com/163648220).
- Think more about how you will give account of your actions to tackle risk than reporting it in paper. If something goes pear shaped your testimony will be required.
- Remember that any attention to petty detail is a waste of time (https://vimeo.com/163499152). Indeed, just focus on high risk and ensure that your paperwork accurately reflects what you do.
- Remember that quality is better than quantity. Your paperwork needs to be useable not a burden. If it’s a burden, you won’t do it well.
3. PAPERWORK from Human Dymensions on Vimeo.
Dr Rob Long
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The Cullen Report on the investigation into the Piper Alpha Piper disaster revealed how injured workers on oil rigs were flown by the company to an expensive Aberdeen hotel, the ‘Royal’ and were treated like kings and assigned light duties…..all to negate an LTI. The bonus system as based on LTIs would have allegedly threatened the company’s bonus of a quarter of a million pounds. Every man and his dog knew that the statistics had been fiddled. During safety meetings arguments broke out as to why an accident was not classed as an LTI, or why the incident had not been reported. It was no longer the safety department but better known as ‘the Bluff Department’!
In relation to Esso, the Royal Commission severely criticised Esso’s safety management system stating ‘the IOMS, together with all the supporting manuals, comprised a complex management system, it was repetitive, circular, and contained unnecessary cross-referencing. Much of its language was impenetrable’ (Dawson, 1999:200). The report also heavily criticised Essos focus on LTIs….this ‘lack of focus on process issues is a matter of grave concern’ (T6535). To put it bluntly Esso’s focus on lost time injury rates distorted its safety effort and distracted the company’s attention from the management of major hazards.
Unfortunately, the aforementioned behaviour became all but normalised and this normalisation of deviance was again shown in the two Space Shuttle disasters of Columbia and Challenger….NASA knew the ‘O’ ring shrunk in cold weather yet were prepared to accept the risk, similarly portions of foam had fallen off the orbiter on prior take-offs but had not struck the orbiter on those occasions and NASA simply accepted the risk, but unfortunately the last incident resulted in the orbiter being struck on the wing and the shuttle burnt up on re-entry.
The perfidy continues even during coronial and public inquiries. The Joy report into CFA Fiskville was constrained by its narrow terms of reference and the coroner’s 3: 15 cut off times following the Hillsborough disaster are classic examples:
https://www.weeklytimesnow.com.au/news/opinion/fiskville-parliamentary-committee-sees-through-cfa-smokescreen/news-story/be4583194662dd6716291531c265f9a1
https://www.liverpoolecho.co.uk/news/liverpool-news/315pm-cut-time-original-hillsborough-10314418
Recent blog by Kevin JOnes shows the regulator has learned nothing: https://safetyatworkblog.com/2019/06/18/the-potential-of-undocumented-safety-safety/
The CFA Fiskville final report is also worth reading:
https://www.parliament.vic.gov.au/enrrdc/inquiries/article/2526
Love that sub-heading ‘Worksafe broke the law’. Too often they remain unchecked and consumed with power.
A couple of points – with accident/incident investigation training it’s all about the process rather than the outcome- follow the process and truth will be revealed.This may be the case, if highlighted during the training that you are seeking the truth and the answers you get about causes etc may not be comfortable to yourself or the organisation.
From my observations, most investigations avoid the uncomfortable deep cause and focus on the superficial, less embarrassing causes.
With JSEA, Safe Work Methods and Permit to Work training (especially noticeable in induction training) the message that comes across, is that completing the paperwork will save you, the process is the important step. In reality what happens on the job is most important.
Why does this occur? One reason- it’s because training sees completion of the training or induction being the end of the training process. They have completed the theory training or passed the assessment they are good to go. Training needs to move the finish line to the actual ongoing on the job application of the skill.
Training the skills and knowledge complete paperwork processes is easier that developing the skills and knowledge to work safely.
Another reason- is the implied message giving during the training- completing the paperwork will keep you save. We as industry doesn’t focus enough about what happens on the job is most important, at at best JSEA, PTW etc , is only about how we imagine the work we be performed. So we can place it just above your horoscope, newspolls and economical predictions in predicting the future.
As someone mentioned Piper Alpha, it’s the ones who disregarded the procedure and jumped that survived the fire.
Unfortunately John, Safety thinks those processes are objective, neutral or both. They only reveal the bias of the designer. In the safety industry that bias is considerable. All incident investigation systems I have seen are appalling.
I agree. With years of shipyard experience safety seemed to be nothing more than paperwork and a meeting here and there. Over the years I’ve come to the conclusion that nobody will care more about your safety than you. The workplace needs a culture of safety and quality over finishing the job. We claim to be there, but years in the industry and I’ve never been at a job that would rather you do everything by the books over getting the job done quickly, but none would admit that. At the end of the day, the adults working should be watching over their own safety, but more genuine conversations need to be occurring at the trade level. Let’s create an actual concern for safety and not just something we throw up a powerpoint about or have a 5 minute toolbox talk once a week about.
Cale, I agree. Where the problem comes in is where the “adults” doing the job have a culture of working dangerously, and all the newcomers are inducted into this way of working. Changing this culture is then the challenge, and a challenge it is indeed. I certainly do not know the answer, but I believe paperwork is not the answer. How to get a culture where the best (fast as well as safe) workway is the norm is a much more difficult issue to address – designing a set of procedures and forms is easy – if I can (and have) do it. However, never has any of my paperwork designs been challenged to determine if they drive the correct outcomes – in fact I believe in hindsight I may have done more harm than good.
Cale, and a good definition of culture would be handy. Most are pretty narrow.
Wrong answer Strategic planning is the first step of managing a Win, Win “No Blame Safety Culture”
Dennis, in my experience strategic planning is mostly about window dressing.
No matter how beautiful your strategy, you should occasionally look at the results – Winston Churchill
We all accept in organisations that we never achieve projected plans. We review them the following year and all accept that golas are not achieved and we don’t get upset about it. We know we are fallible and are subject to social context, the Economy, even the weather. The idea is, we learn from our failures and fallibilities and accept we don’t achieve all our goals. It’s only is Safety that an absolute goal is set, the ultimate framing for failure.
None better thinking on strategic planning and goals than Michael Learning to Plan, Planning to Learn; Raynor The Strategy Paradox; Sloan Learning to Think Strategically or Moscowitz The Psychology of Goals. Of all the industries its only Safety that doesn’t know how to plan and set goals which of course means it can never be professional or ethical under zero.
All good points guys. I won’t add to this paper except to say “Keep doing something about it!”
John, doing lots. Couldn’t be busier in making a practical difference.
Back in July 2015 I can recall a classic example involving a subcontractor during construction of the Origin Energy Combabula Gas Field Facilities project:
The principal contractor engaged a subcontractor to install cladding on a compressor house. It was categorised as a high risk work and involved working at height and the use of two elevating work platforms (EWPs). A safe work method statement (SWMS) was a mandatory legislative requirement and permit to work was issued in accordance with project protocols.
The activity attracted the attention of the executive leadership team, which was conducting a “hypothesis testing” exercise using a behavioural safety observation to fulfil their key performance indicators.
During the behavioural safety observation I decided to review the log books for both of the EWPs used for the activity. The serial numbers of the log books did not correspond with the equipment and further investigation indicated the log books had been switched (Machine A was equipped with log book of Machine B and Machine B was equipped with the log book of Machine A).
The daily preoperational visual inspections had been verified but the quarterly mechanical inspections were overdue and had been overlooked during the daily preoperational checks. Furthermore both EWPs had been brought onto the project by the subcontractor and circumvented project requirements covering introduction, inspections and authorisation of powered mobile plant.
The permit to work process failed to identify any of these anomalies.
Moreover, the principal contractor was accredited to AS/NZS 4801 under the JAS-ANZ auditing scheme although the entire project covering construction of seven different gas field facilities never included any independent surveillance audits from the conformity assessment body.
Some months earlier an employee with the principal contractor fell almost 5 metres and suffered serious internal abdominal injuries after scaffolding collapsed during construction at another project in the eastern region.
Behavioural safety observations often reported unsafe acts, which included demonization of employees that failed to wear chinstraps with their safety helmets when working at height or not maintaining three points of contact when climbing or descending stairwells.
“Organisations have no memory” – Trevor Kletz