audit – Page 6 – SafetyAtWorkBlog

Cabinet-making compliance

In March 2008, in Western Australia, a 22-year-old worker was crushed to death when a stack of veneered chipboard sheets toppled onto him. This sparked an audit campaign of the cabinet-making industry in 2009 by WorkSafe WA about which some results were released on 12 January 2010.

Such results are not often covered in this blog but the number of improvement notices provide a useful summary of the persistent hazards present in this industry and on machinery that is used in a variety of workplaces. Continue reading “Cabinet-making compliance”

Big fine for Queensland Rail – big risks in rail

Almost two years ago, two rail workers died in Queensland. According to the official report into the incident:

“At approximately 1056 on Friday 7 December 2007, two QR [Queensland Rail] Infrastructure Services Group (ISG) track workers were fatally injured as a consequence of being struck by a track machine (train) at Mindi, approximately 130 kilometres south-west of Mackay.

The collision occurred when Track Machine MMA59, in the process of conducting track resurfacing work on the Down line at Mindi, commenced a routine reversing movement.

During the process, two QR Systems Maintenance personnel, working on the same track and behind the track machine, were struck and fatally injured by this track machine.

Analysis of evidence and conditions surrounding the accident revealed:

An overall lack of compliance with elements of the QR SMS at the Mindi site; and

Inadequate communication and coordination between workgroups at the Mindi site.”

On 26 November 2009, Queensland Rail was fined $A650,000 over the deaths. The fine is only $A100,000 below the maximum fine applicable. According to a media release about the fine:

“The Workplace Health and Safety Queensland investigation found that QR’s safety management systems were inadequate for managing the separation of workers and plant, particularly when both were within the same section of track between signals.

It also found that QR knew the systems were inadequate and not working because it had been highlighted to management in a series of audits.”

Not only were Queensland Rail’s safety management systems inadequate, Queensland Rail knew they were inadequate because a series of audits had told it so.

Railway in Australia and elsewhere is one of the most regulated industries. It is also one of the industries with the most prescriptive set of rules. It is a complicated business but one where hazards are known and systems are in place to control these hazards.

The extent of QR’s failure to operate safely can be illustrated by some of the many recommendations made in 2008 by Queensland Transport:

The necessity for consistent and effective Worksite Safety Briefings by ISG personnel;

Preconditions to the reversal of vehicles in accordance with QR safeworking requirements;

Responsibilities and training syllabi for ISG Resurfacing personnel;

The necessity for pre-departure safety checks on ISG trains;

Provision of safe separation and segregation between ISG track workers and trains;

ISG SMS compliance monitoring, at the local level;

Fatigue management within QR, and in particular ISG rostering;

Management of the perceived relationship between ISG and Network Control;

Awareness of the priority of safety over commercial pressures by remote ISG staff;

Distribution of safety communications and documents within QR;

Representation for relevant stakeholders in operational change management processes;

Risk and change management training for ISG operational personnel;

Safety risks presented to ISG through the permanent coupling of track machines;

The safety value to QR of an enhanced and transparent reporting system;

The management of ISG district staff relationship issues; and

ISG and Network Access radio protocol compliance monitoring.

Many elements are familiar to other investigations in rail and other industries – fatigue, on-site communication, training, segregation, document control and distribution, local compliance enforcement, transparency in reporting…..

On 10 September 2008, the QR CEO Lance Hockridge said:

“When I arrived in November 2007, I found an organisation with a safety record that was improving but not what it should be. Only three weeks later we had a very tragic reminder of this when work colleagues Jamie Adams and Gary Watkins were killed at Mindi.

“Organisations hoping to achieve meaningful change must firstly be honest with themselves – we need to confront this reality and make the changes required.”

Queensland Rail did not face the reality of problems identified by safety auditors and two workers died.

The news of the record fine came at a time when the ownership of Victoria’s metropolitan rail network has changed from Connex to Metro. Victoria has a stressed rail service but has managed to avoid the controversy of Queensland Rail and RailCorp in New South Wales but this has been through luck rather than good management. The Victorian Government, and particularly the Transport Minister, Lynne Kosky, needs to read the Waterfall Inquiry report and the Queensland Mindi report to understand the personal, economic and political cost of not having a tightly managed, functional rail safety regime. Having been in power for just over 10 years, this government now owns all the Victorian problems and must account to the electorate for not fixing them.

The political risk was summarized in an editorial in The Age on 30 November 2009

“In September, a Senate report into federal funding of public transport found Melbourne’s network was badly managed in comparison with Perth’s government-operated system. A key problem was lack of accountability: it was unclear who was in charge. The consequences of the lack of an overarching transit authority to oversee the whole system are clear…..

New operators of trains and trams in new livery will struggle to deliver acceptable service unless the Government makes good its past neglect of infrastructure.”

The fact that the Victorian rail system is being privately operated will not be an acceptable shield when the first passenger train crashes with a jam-packed peak hour cargo.

Kevin Jones

New ISO risk management standard

I am old enough to remember the world of management before it had a risk management standard. In fact I was studying risk management in OHS when the Australian Standard 4360 was released. It substantially changed the way OHS was managed in Australia (and lined the pockets of the publishers). It increased the significance of management standards beyond Quality and helped considerably in progressing an integrated approach to managing a broad range of workplace risks.

[The process also instilled in me a distrust of the standards development process when I sat through a seminar from one of the risk management standards committee members where he spruiked a PC-based management system that “anticipated” the new standard…….. at $30,000 setup fee??? Clearly in this case, and I have been told in almost all cases, the participants always have one eye on the commercial benefits of participation]

Grant Purdy recently discussed the new international risk management standard ISO 31000 :2009. At one of his presentations he said that the new standard has a definition of risk that “shifts the emphasis from “the event” to “the effect” and, in particular, the effect on objectives.”

The previous risk management standard overlapped with auditable elements in other management standards – OHS, environment, and quality. This new definition may cause problems across these sectors.

Purdy said that risk is now not only perceived as a negative.

“Risk has in th past been regarded solely as a negative concept….[but] it is now recognised that risk is simply a fact of life that cannot be avoided or denied.”

He speaks of the traditional way of measuring risk as sometimes creating “phantom risks” due to an overstated likelihood. This seems particularly relevant to OHS and may be part of the reason that some OHS issues are seen as excessive or, at worst, a joke.

Purdy stated that there are 11 statements of effective risk management. [Modern management writers love numbers. I should write a book called “The hundredth time I have had to sit through a numbered list of strategies at conferences before walking out”] The statements are that risk management

creates and protects value

is an integrated part of all organisational processes

is part of decision making

explicitly addresses uncertainty

is systematic, structure and timely

is based on the best available information

is tailored

takes human and cultural factors into account

is transparent and inclusive

is dynamic, iterative and responsive to change

facilitates continual improvement of the organisation.

The implementation of this standard and other international standards is going to be confusing, initially, for Australian managers but the choice is easy. Why follow an Australian standard that needs explaining overseas when there is already an international standard that requires no explanation? Go global and expand your auditing and accountability options.

[Please note that ISO31000 is not an auditable standard but I suspect you will not have to wait long for one.]

Kevin Jones

New Cleaning Standard

The Victorian Government has released a revised cleaning standard for the hospital and healthcare sectors but many others would find the information of direct relevance, particularly those who like to state they meet “world’s best practice”.

The standard is supported by a good short newsletter.

Many businesses and industry OHS professionals can feel like they are audited to death. This is particularly so in the healthcare sector so it is with interest that the government has dropped the lodgement of scores for internal audits. However the benchmarking exercise will continue with three annual external audits.

Those SafetyAtWorkBlog readers who are also auditors, inside and outside the health system, may find the overview on auditors of interest.

Kevin Jones

Varanus Island is back to normal

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

Audit report says “could do better”

On 3 June 2009, the Victorian Auditor-General released the audit report, CLAIMS MANAGEMENT BY THE VICTORIAN WORKCOVER AUTHORITY. The objective of the audit was to assess the effectiveness and efficiency of VWA’s claims management.

The report found that the current claims management model

“has not substantially improved RTW [return-to-work] outcomes, or the effectiveness of agents’ case management practices”

Although the report notes that the system has not deteriorated.

The report also says

“Agents’ case management practices, on average, were considered generally adequate, however, there is substantial scope for improving agents’ performance.”

“Adequate” is not a ringing endorsement of the system and the workers’ compensation agents should pay particular attention to criticism of their performance.

Safety managers and professionals have been trying to incorporate psychosocial hazards into their safety management processes but it seems that agents are having similar problems:

“Agents did not systematically consider psychosocial barriers to RTW such as attitudes toward recovery, stress, anxiety, workplace issues, substance abuse, and family matters, when assessing the injured worker’s status, needs and risks to recovery. In most cases assessments were narrowly focused on the physical injury and its impact.”

The report notes that many issues raised are already being addressed by the Victorian WorkCover Authority.

Almost the only statements made on the workers’ compensation scheme by the State Ministers over the last decade have related to premium fluctuations, how the business costs of the system are being controlled or unavoidable. However it seems now that the system has only been cruising, but not improving, or keeping up with the contemporary workplace hazards and employee needs.

The white collar public service, in particular, has a high incidence of stress-related claims. The reality of the hazard has been acknowledged through preventative guidance notes from the OHS regulators and the general growth in the work/life balance movement. Yet in 2009, the workers’ compensation agents are criticised for giving this hazard insufficient attention.

Even when an audit report is politely critical, it remains critical and demands attention.

Kevin Jones

Management failures and a rape of a five-month-old baby

Earlier this year, SafetyAtWorkBlog reported on the attack on a nurse in the Torres Strait Islands north of Australia, the investigation of the issue by Queensland Health and the mechanisms introduced to get the working conditions and accommodation up to a safe level. In this case there was a clear link between occupational health and safety and the security of a worker.

OHS law in Australia obliges workers and those in control of a workplace to ensure the safety of people on their premises. Last week the Northern Territory government received a report (081128vol1-f9c6d46d-75d5-4a5e-95e7-7c040ae6600c1) into the security measures at the Royal Darwin Hospital. This hospital has undertaken fantastic medical work in the past, most noticeably, on a large scale following the bombings in Bali in October 2002.

However it failed to prevent the rape of a five month old female infant on 30th March 2006, while the indigenous baby was an inpatient.

Carolyn Richards, the Health & Community Services Complaints Commissioner, said in her report

As a result of a complaint reported to the Health & Community Services Complaints Commission an investigation was undertaken by the Director of Investigations, Mrs Julie Carlsen, who is employed as the Director of Investigations (DI) Health & Community Services Complaints Commission.

This report highlights that the Department of Health & Community Services (DHCS) needs to implement effective risk control mechanisms to minimise the risk of an assault on a vulnerable inpatient in the Royal Darwin Hospital (RDH). The investigation has led to the conclusion that DHCS (DHF) and RDH have not complied with the applicable Australian Standard. It has also revealed that crucial information has been withheld from an expert engaged by RDH to review security arrangements and from the DHCS (DHF) Security Manager based at RDH. This report also details inadequacies and failings by those responsible for managing RDH who have failed for over two years to implement and maintain better security for patients in the Paediatric Ward. It is published with the hope that it will cause DHCS (DHF) and RDH to give higher priority to improving its risk management and security procedures.

The Commissioner’s conclusions are worth including here so that OHS professionals and security officers can establish appropriate procedures for their workplaces.

1. On 30th March 2006:

There were no arrangements in place on the Paediatric Ward to ensure the safety and inviolability of vulnerable patients.

No risk assessment had been conducted.

The arrangements in place did not comply in any aspect with the Australian Standard which sets the benchmark for proper security.

There was no control on access to the Ward or to the patients.

The staff had not received adequate training, and possibly none at all, about the risks arising from lack of security arrangements.

In 2002 RDH had commissioned and received an expert consultant’s assessment and report on security arrangements at RDH. The Terms of Reference did not require 5B to be assessed. By 30 March 2006 the recommendations in the report had not been implemented in Ward 5B. This failure can only be described as shameful.

Following the rape of the infant police were not notified for about 2 hours.

2. Action taken by RDH after the rape to improve security was: (a) slow (b) inadequate, and (c) has not been adequately evaluated or reviewed to determine its effectiveness

3. RDH has a Security Manager on site as well as an NT Police member stationed at the hospital. Neither has been asked to evaluate the security on the Paediatric Ward either before or after the rape of the infant.

4. Staff working on the Paediatric Ward have not been trained at their induction on the elements of security arrangements to reduce the risk to vulnerable patients nor has there been adequate ongoing training of staff before or after the 30th March 2006 incident.

5. In 2007 the same expert safety and security consultant, as in 2002, was engaged to assess security arrangements at RDH. He was not informed of the rape of the infant in March 2006 nor was he asked to report specifically on arrangements in the Paediatric Ward.

6. On 21 November 2007 two investigation officers from the Health and Community Services Complaints Commission visited the Paediatric Ward by prior arrangement. They were able to enter the Ward and wander around, have entry to every part of it and stand at the nurse’s station, for about 25 minutes without anyone asking who they were and why they were there.

7. Management’s lack of commitment to the proactive identification of risks and to taking appropriate action has not created a culture where each member of staff takes responsibility for identifying and reporting risks and developing safe practices.

8. A security review of RDH was carried out by an expert hospital safety and security consultant who issued a report in 2007. The Security Manager of DHCS (DHF) was not given a copy even though he requested it. HCSCC enquired of RDH management why he was not given a copy and RDH have offered no explanation. On 31 October after this report was published to RDH and DHF the CEO of DHF advised this Commission that he had finally been given a copy and that he had seen a draft copy.

9. RDH Maternal and Child Health Clinical Risk Management Committee considered security in the Paediatric Ward following the incident. The Committee met on 16th May 2006, 2.5 months after the rape of the infant. It met a further 4 times. It submitted an action plan to the General Manager of RDH in July 2006. At its last recorded meeting on 5 September 2006 there had been no response from the General Manager on the recommendations, particularly with respect to installing CCTV cameras with recording facilities on the Paediatric Ward. There were still no recording cameras on the Paediatric Ward as at June 2008 although a CCTV system had been installed in the kitchen area to deter the pilfering of food. Dr David Ashbridge on 31 October 2008 advised, when responding to a draft of this report, that CCTV cameras were installed in Paediatrics on 25 August 2008.

10. The surveyors from the Australian Council of Health Standards which accredits RDH probably did not receive all relevant information about the incident of 30 March 2006 and what action RDH were taking. Those surveyors on 13 October 2006 were informed by RDH that the patient information pamphlet and admission interview are being reworded to reflect the changes to ward access. There was no verification throughout the investigation that any action had been taken by RDH to implement the recommendations of the review. Neither the report of ACHS nor records of information given to ACHS have been provided to the HCSCC. DHCS (DHF) was invited to provide me with those relevant documents in response to this draft. No response was received on this issue from DHF or RDH. According to the published information of ACHS the accreditation survey commences with a self assessment by the hospital concerned. This Commission specifically requested details and copies of the information provided to the ACHS surveyors but no response was received from either the CEO of the Department or the General Manager of RDH.

11. The governance arrangements at RDH do not promote adequate transparent accountability of the General Manager and the Department of Health and Families for the operation of the hospital. Control of all aspects of the day to day management of RDH rests in the hands of three individuals. This includes staff recruiting, training, security, nursing and medical services, procurement, record keeping, financial accountability and risk management. Such specialist management groups as exist are subordinate to the General Manager’s authority. The General Manager reports to the Director of Acute Services who reports to the CEO of the Department. I have been unable to find out what role the Royal Darwin Hospital Board has since its last annual report to 30 June 2006.

It is well worth obtaining the complete report to understand how such an individual tragedy occurred. As one media commentator has posited

“One wonders what the reaction would have been if a non-indigenous infant was raped.”

Category: audit

Cabinet-making compliance

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Big fine for Queensland Rail – big risks in rail

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New ISO risk management standard

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New Cleaning Standard

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Varanus Island is back to normal

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Audit report says “could do better”

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Management failures and a rape of a five-month-old baby

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