Doing less with more

Article in Hoist magazine by Jim Galante 3 April 2009. Suggests there are "double dividends of integrating lean thinking and ergonomics."

Managers today face more challenges than ever before. They are being told to cut costs whilst maintaining or even increasing production rates; and maintaining quality. Staffing levels are being reduced, and so there is the need to "do more with less."

There are further issues when you consider "the American workforce is aging and many of the next generation of workers are looking more toward white collar jobs."

Many think good applied ergonomics can help. Whereas in the past it seen as “a nice thing to do” because it made the worker’s job easier and making them happier, the benefits of improved quality and productivity; and reduced possibility of injuries are being recognised. "Ergonomics today has become an essential and fundamental part of a well run business."

According to Galante, ergonomics can play a significant role in achieving the goals of lean thinking. "Improving productivity by reducing or even eliminating waste is a core lean value. Good ergonomics eliminates excessive body motions and limits the number of repetitions in most work tasks. Good ergonomics will reduce mistakes and will improve quality - more lean values."

Galante references the Ergonomic Guidelines for Manual Material Handling, published by the EASE Council. This considers four applications in which lean thinking and ergonomic principles are related and essential to creating effective, sustainable programmes. They are:

1 Removing waste - Removing wasted, unnecessary motion can have a significant positive impact on systems and processes as well as decrease lead times and inventory, increase quality and substantially increase productivity.

2 Flexible processes - Understanding the whole organisational system requires all business processes to be flexible. This will significantly aid a company’s ability to respond to changes which are occurring in the marketplace. This can be flexibility in set-up/change-over, the type of assist device, inventory controls or linkages (transporting or storing materials).

3 The negative impacts of fatigue - Ergonomic assist devices can dramatically reduce or even eliminate the forces required to perform a task as well as reduce the associated reaching, bending or stretching. They will reduce fatigue and stress that would be experienced by the worker. These symptoms are often a precursor to a lost time injury.

4 The needs of the office and the service sector - By focusing on strategic placement of parts, products, tools and equipment and reviewing the layout of the work area, human stress and ergonomic related injuries can be reduced. The white paper discusses these changes and presents practical solutions and improvements.

The bottom line

In today’s demanding work environment companies need to take every advantage and a good ergonomics programme compliments a good lean initiative. The two together with all their tools, techniques, and philosophies will prove to be vital contributors to success both in the short- and long-term.

About the author

James J. Galante is the chairman of the EASE Council. Ergonomic Assist Systems and Equipment (EASE) is the resource for trends, information, practices, equipment, and organisations that focus on ergonomics and improving the working interface between people and the materials they must move and use to reduce injury, increase productivity while providing a significant return on investment. Visit the EASE website for these many resources at www.mhia.org/ease.

Mobile phone as a source of ignition

I have been aware of several stories over the years about mobile (cell) phones starting fires at petrol stations. However, I have never seen any real evidence of them being true.

The website Snopes.com, which looks at rumours and urbane legends has studied it, and concludes there is no evidence to support any of the stories.

A useful reference for the next time the story is circulated.

Andy Brazier

Total liable for Buncefield blast

BBC website20 March 2009

Nearly 4 years after the explosion at the Buncefield oil depot in Hertfordshire, a judgement has been reached on which company was liable for the damages

The depot was owned by Total and Chevron in a joint venture called Hertfordshire Oil Storage Ltd (HOSL), but was operated by Total.

The ignition of the vapour cloud which followed the spillage of 300 tons of petrol, caused an explosion which measured 2.4 on the Richter Scale.

The court's view was that "Total had failed to discharge the burden of establishing that HOSL was responsible for the negligence of the supervisor." This was based on the fact that

* All those working at the site had contracts with Total;
* The terminal manager who was the most senior member of staff on site was appointed by Total and line managed by Total.
* All safety instructions were developed by Total.
* Total's head office staff to develop an adequate system for preventing the overfilling of a tank.

In a statement Total said: "We still believe... our joint venture partner should accept their share of the responsibilities for the incident.

"As a consequence we will be considering our grounds for appeal."

The Guardian was more damning of Total, blaming sloppy practices and inadequate risk assessment. Judge David Steel described the events leading up to the blast as "remarkable"

Des Collins, representing a number of claimants said "This judgment is a shocking indictment of the way in which this ultra-hazardous operation was conducted by Total." "What is equally shocking is the degree of irresponsibility demonstrated by Total over the past three years in its failure to recognise the ultimate futility of the series of defences which it adopted."

The court listed various reasons for the explosion, including the negligence of supervisors and a series of failures in risk assessment and prevention. The judge was also critical of a "near miss" at the plant in August 2003.

"I am left with the clearest impression that practices within the control room were at best sloppy," said the judge.

The Financial Times quoted more from Justice Steel including "overall want of planning and monitoring all contributed to the disaster"

Also, that Total declined to call several key witnesses during the civil trial, including the two supervisors on duty at the time and its operations manager.

The only director of the depot’s operating company that did testify was found by the judge to be "somewhat evasive and unwilling to face up to the difficulties of reconciling his evidence with the contemporary material".

The court was told during trial that there had already been a “near-miss” at the site when a tank gauge stuck in August 2003.

The supervisors working on the night of the 2005 explosion, were "somewhat ironically" awarded certificates of competency less than a week before, the judgment notes.

Councils get banned jargon list

Widely reported in the press including BBC on 18 March 2009

The Local Government Association (LGA) has published a list of words they consider to be jargon and not suitable for use in documents issued to the general public.

LGA chairman Margaret Eaton said: "The public sector must not hide behind impenetrable jargon and phrases."

According to the BBC the 200 banned words are

Across-the-piece

Actioned

Advocate

Agencies

Ambassador

Area based

Area focused

Autonomous

Baseline

Beacon

Benchmarking

Best Practice

Blue sky thinking

Bottom-Up

CAAs

Can do culture

Capabilities

Capacity

Capacity building

Cascading

Cautiously welcome

Challenge

Champion

Citizen empowerment

Client

Cohesive communities

Cohesiveness

Collaboration

Commissioning

Community engagement

Compact

Conditionality

Consensual

Contestability

Contextual

Core developments

Core Message

Core principles

Core Value

Coterminosity

Coterminous

Cross-cutting

Cross-fertilisation

Customer

Democratic legitimacy

Democratic mandate

Dialogue

Direction of travel

Distorts spending priorities

Double devolution

Downstream

Early Win

Edge-fit

Embedded

Empowerment

Enabler

Engagement

Engaging users

Enhance

Evidence Base

Exemplar

External challenge

Facilitate

Fast-Track

Flex

Flexibilities and Freedoms

Framework

Fulcrum

Functionality

Funding streams

Gateway review

Going forward

Good practice

Governance

Guidelines

Holistic

Holistic governance

Horizon scanning

Improvement levers

Incentivising

Income streams

Indicators

Initiative

Innovative capacity

Inspectorates

Interdepartmental

Interface

Iteration

Joined up

Joint working

LAAs

Level playing field

Lever

Leverage

Localities

Lowlights

MAAs

Mainstreaming

Management capacity

Meaningful consultation

Meaningful dialogue

Mechanisms

Menu of Options

Multi-agency

Multidisciplinary

Municipalities

Network model

Normalising

Outcomes

Outcomes

Output

Outsourced

Overarching

Paradigm

Parameter

Participatory

Partnership working

Partnerships

Pathfinder

Peer challenge

Performance Network

Place shaping

Pooled budgets

Pooled resources

Pooled risk

Populace

Potentialities

Practitioners

Predictors of Beaconicity

Preventative services

Prioritization

Priority

Proactive

Process driven

Procure

Procurement

Promulgate

Proportionality

Protocol

Provider vehicles

Quantum

Quick hit

Quick win

Rationalisation

Rebaselining

Reconfigured

Resource allocation

Revenue Streams

Risk based

Robust

Scaled-back

Scoping

Sector wise

Seedbed

Self-aggrandizement

Service users

Shared priority

Shell developments

Signpost

Single conversations

Single point of contact

Situational

Slippage

Social contracts

Social exclusion

Spatial

Stakeholder

Step change

Strategic

Strategic priorities

Streamlined

Sub-regional

Subsidiarity

Sustainable

Sustainable communities

Symposium ­­

Synergies

Systematics

Taxonomy

Tested for Soundness

Thematic

Thinking outside of the box

Third sector

Toolkit

Top-down

Trajectory

Tranche

Transactional

Transformational

Transparency

Upstream

Upward trend

Utilise

Value-added

Vision ­

Visionary

Welcome

Wellbeing

Worklessness

Deadly rules

Article in The Guardian by Cath Janes on 14 March 2009

A refreshing article that explores some of the issues about health and safety being allowed to go over the top. Some excerpts below



Our office has fire doors which we actually prop open with fire extinguishers. We know we shouldn't - but we do it anyway. These are the words of an office manager who wishes to remain anonymous.

The Health and Safety at Work Act (HSWA) celebrates its 35th anniversary this year, so health and safety should be second nature by now. But it's not. Employees continue to complain about the inconvenience of fire drills and computer monitor adjustments. Yet experts continue to point at the Health and Safety Executive's (HSE) reports of 2.1 million people suffering from illnesses they believe to have been caused or worsened at work.

"Health and safety should be a powerful unifying agenda between employers and the workforce, not a matter for confrontation," says Judith Hackitt, chair of the HSE. "The problem tends to be the misinterpretation of what is actually required." One recent initiative tries to dispel the idea that risk assessments need to be 10 pages or more for every task. "We have shown what's 'good enough' and that's all you have to do," says Hackitt.

David Symons, director at WSP Environment & Energy, a consultancy firm says "The problem is that health and safety is applied by people who don't have a deep understanding of what needs to be done. It's no wonder that it is seen as an impediment to the day job. It's not the legislation that's an issue, it's the implementation of it." "We are all adults," he says. "Let's just communicate the principles well. Communicate badly and it comes off as patronising. And if that's the case, and health and safety isn't being achieved, something has to be done about it."

"Paperwork is a sign of bad health and safety management," claims Lawrence Waterman, chairman of another consulting firm, Sypol. "If you are not rigorous in reviewing procedures you get a lot of bureaucracy and lose track of what you are asking people to do. Yes, it can be sensible to jot things down but there's a fine line between risk management and bureaucratic obstruction.

"That's why health and safety is a job for professionals. They can weave safety procedures through good business practice and not have it hanging about as a separate dynamic."

Business psychologist Pearn Kandola. "Humans want to fight against those rules though. We like to be free and intuitive and follow our emotions.

"There's also a reason why health and safety isn't second nature. It's because humans are risk-takers. We are not naturally safe and don't like health and safety, or the people who implement it, because we perceive them to be rule-bound and boring. While their role is essential it is never going to appeal to us, because we don't like rules and regulations."

Which, in the fight against the ministry of the bleedin' obvious, is a snag. Are employees ever going to prove they don't need to be warned against sticking their wet fingers in plug sockets? Surely what lies at the heart of health and safety is common sense, and we all have that ... don't we?

"You hear people saying that it is all about common sense," agrees Duff, "The problem is, they don't use it. We are not rational beings and accidents are often the result of irrational behaviour. We think we are great at making our own rules, but we are not."

Is this still a reason to treat employees like children, though? Problems in the workplace often lead to demotivation, low productivity and withering loyalty. Health and safety is no exception. On one hand you are considered savvy enough to close a deal with a client, yet on the other you are considered a prime candidate for a box-lifting demonstration. It's little wonder health and safety rankles. It's almost a reminder that you are not as in control as you thought you were.

"Which is why risks should be managed in a proportionate way rather than wrapping people up in cotton wool and taking the fun out of life," warns Derek Draper, senior consultant at Connaught Compliance. "The bonkers conkers stories just trivialise health and safety and detract attention from the task of keeping people safe at work. Risk assessment needn't be complicated though. After all we do a subconscious risk assessment every time we so much as cross the road."

Hackitt, of the HSE, has a final suggestion. "Challenge your employer but do it constructively," she says. "Don't turn health and safety into a management versus workforce confrontation issue. Offer solutions or more common sense ways of approaching the problem. Remember, it's about doing what is sensible, reasonable and practical to reduce risk, not eliminating it, and still getting on with your job."

Andy Brazier

Oops, we did it again - Why we make mistakes

Book review in The Independent on 18 March 2009 by Sophie Morris

The book is Why We Make Mistakes by Joseph T Hallinan, an American Pulitzer Prize-winning journalist.

The book has attracted winning reviews, with one critic predicting that it would change the face of mainstream behavioural science. Subtitled "How We Look Without Seeing, Forget Things in Seconds, and Are All Pretty Sure We Are Way Above Average", Hallinan's book is, according to its author, "a field guide to human error. People can look at it and see the mistakes they make, and find some of the reasons behind those mistakes."

The book says that error is a not personality or intelligence issue, and simply something to do with the way humans are designed. The very way we think, see and remember sets us up for mistakes. We are subconsciously biased, quick to judge by appearances and overconfident of our own abilities. Most of us believe we are above average at everything – a statistical impossibility that leads to slip-ups.

Until I read the book I can't tell whether there is anything new here.

Andy Brazier

Night shifts spark cancer pay-out

Article on BBC website by Kenneth Macdonald on 16 March 2009

The Danish government has begun paying compensation to women who have developed breast cancer after long spells working nights. It follows a ruling by a United Nations agency that night shifts probably increase the risk of developing cancer.

There has been growing evidence that night shifts are bad for you for years. Symptoms include disturbed sleep, fatigue, digestive problems and a greater risk of accidents at work. Cancer is now being added because there is a 'probable' link.

Dr Vincent Cogliano of the IARC said they reached their conclusion after looking at a wide number of studies of both humans and animals.

He said there was evidence to support the hypothesis that alterations in sleep patterns could suppress the production of melatonin in the body.

"Melatonin has some beneficial effects in preventing some of the steps leading to cancer," he said.

"The level of evidence is really no different than it might be for an industrial chemical."

What is not clear from this article is how big a risk factor night work is compared to others.

Andy Brazier

New computer to help cut hospital mistakes

Article on theBeattie Group website on 17 February 2009

A new computer has been launched in the UK that "could be the key to eliminating some of the 40,000 mistakes made each year in NHS hospitals"

The Panasonic CF-H1 Toughbook Mobile Clinical Assistant (MCA) has been developed in conjunction with NHS nurses to give them wireless access to patient notes at the bedside - spelling the end of the clipboard at the end of each bed.

It will give nurses access to up-to-the-minute electronic patient records, has a series of security features aimed at minimising the room for human error on high-pressure wards, enables other clinical staff such as doctors and pharmacists to check up-to-date medical history at patients' bedsides leading to them making quicker and better-informed decisions, is able to read barcodes in order to cut out any room for misreading labels and further ensure that the right treatment is given to the correct patient at all times.

Jon Tucker, product head for the MCA at Panasonic, said: "Hundreds of mistakes are estimated to be made in hospitals every week at the moment, either through poor communication or basic human error.

"Nurses are often required to memorise information, like changes to medication, then input the details into a computer off the ward afterwards which can result in delays in data input or forgotten information.

"Disjointed communication with other departments and between shift workers has also been a cause of mistakes in treatment.

"This computer enables nurses to update a patient's central records at the bedside during ward rounds, dramatically reducing the potential for mistakes."

Quiet cars may need alert for pedestrians

Article by Tom Greenwood in Detroit News on 17 February 2009

The National Federation for the Blind is concerned that electric and hybrid cars are so quiet the blind and visually impaired could be killed or seriously injured by walking unknowingly in front of them.

Tom agrees and tells a story from the recent North American International Auto Show where he was investigating "green" technology. He says "Believe me when I say they were absolutely silent; my vision and hearing are fine, but I found myself looking over my shoulder to see if a vehicle was creeping up on me."

The NFB is advocating for quiet vehicles to be equipped to emit a continuous sound and wants additional research on the problem.

Scientists from the Human Factors and Ergonomics Society tested a number of visually impaired individuals and asked them which of six types of sounds -- engine, horn, hum, siren, whistle and white noise -- they preferred as warnings.

By far the most preferred sound was that of an automobile engine, followed by white noise and hum.

Incident Investigation: Rethinking the Chain of Events Analogy

Article on EHS Today By Allan Goldberg on 17 November 2003. It disputes the often used notion that incidents occur due to a 'chain of events' suggesting the logic behind the chain may be its weakest link.

The safety profession often refers to a chain of events and then looks for the weak link as a means of identifying what went wrong that allowed the incident to occur. We then very often go further and identify a specific human error that was made, and the person who made it. That person, and/or what they did or didn't do, is thought of as a weak link in the sense of a "performance" chain. Rigid adherence to this way of thinking can lead to some significant errors in improving safety performance. We can and should avoid them.

There are three main problems that this traditional thinking about the chain of events analogy can lead to:

1. Incidents are not linear sequences and instead multivariable meaning there are many different possible paths to an incident.

2. The "weakest link" approach implies that there is only one "main" cause for a given incident whereas most incidents have multiple causes

3. Looking for the weak link creates a focus on the point of failure which is usually well removed from the best point of control. This leads t overemphasis on behavioral approaches and misses the true root causes.

Every link in a physical chain is in fact only connected to one other on each end. The real world chain of events, however, has many more "options" in terms of inputs and outputs. Breaking a single "link" will not necessarily preclude the end event from occurring.

Human actions are a combination of attitudes, beliefs, moods, training, awareness and many other factors. The point being, we may not respond to a given situation today the same way we did yesterday. The key idea here is that many sets of inputs and outputs are possibilities in incident causation. We must be very careful to avoid thinking about causation in a purely linear manner.

Root causes are likely to apply to a whole series of potential incidents, not just one event. These root causes are in fact the key to prevention of future incidents. And contrary to what all too many people may think, human error is not one of them! Human error itself is a symptom that there are other problems in the management of the work that is taking place. These error problems themselves have root causes. When a worker makes an error or fails to follow a procedure, there are reasons that set up the situation. These are the root causes that must be found.

Avoiding Pitfalls

1. Recognize the multivariable nature of incident causation.

2. Understand the Principle of Multiple Causes.

3. Realize the point of failure and the point of control are not necessarily the same. Seek to understand the problem as part of the overall system, and identify where the system itself can be best controlled.

Andy Brazier

Human error 'doing more harm than enemy'

Western Morning News on 26 January 2009

Air Chief Marshal Sir Jock Stirrup, the Chief of the Defence Staff (CDS), reported as saying accidents and mistakes in combat zones do more to undermine British troops' fighting abilities than attacks by the enemy, according to the head of the armed forces.

Sir Jock said that more than half of "accidents and incidents" which have led to troops being killed or injured on operations were down to human error.

The CDS also admitted that troops who make mistakes were too afraid to own up to their failings because of concerns they would be unfairly punished.

In an article for a Ministry of Defence publication, Sir Jock said that the absence of a "just culture" in the forces meant the military had failed to learn valuable lessons from its mistakes.

Since March 2003, 320 troops have died on operations and several thousand have been injured. And while the vast majority have been killed by enemy action, the CDS said that errors made by British troops had played a significant part.

In an article for "Desider", a magazine for the defence, equipment and support arms of the military, Sir Jock wrote: "Evidence shows that more than half our accidents and incidents are down to human factors. In other words, it is our people who are causing the most damage to our fighting capability. We must do something to drive down the number of accidents and incidents.

"One of the most effective ways of doing this is to promote a culture that encourages open and honest reporting that allows for a structured investigation of errors.

"This action should address all individual, systemic and environmental issues relating to an incident and allow us to learn from what took place.

"The actions and feedback will prevent us making the same mistakes again. It is the justness of what we do that gives rise to a just culture."

The CDS added: "To me, such a culture is based on trust. It suggests a working environment where individuals are encouraged to contribute to providing essential safety information and where they are commended for owning up to mistakes."

Sir Jock then asked: "Do we have a just culture in place? Is there a tolerant and non-punitive environment where mistakes can be admitted freely before they can cause an accident?

"My sense is that it is not as well established as it might be, nor as comprehensive as I would wish. The greatest challenge for senior leaders and those with command responsibility, including me, is to make a just culture a fact, not just an aspiration."

Sir Jock's comments come soon after the publication of a document in which General Sir Richard Dannatt, the Chief of the General Staff, revealed that 10 out of the 89 soldiers killed in combat in 2007 were "entirely avoidable accidents".

New Study Shows Patient Safety Benefits of Ensuring Rest for Doctors

Article by Jennifer Anderson 2 February 2009 on ergoweb.com website.

The University Hospitals Coventry and Warwickshire NHS Trust conducted the new study, which was reported by the BBC.

Nineteen junior doctors working on the endocrinology and respiratory wards at the hospital participated in the 12-week study. Nine were put on a 48-hour per week pattern that met the conditions of the European Working Time Directive (EWTD) and 10 were on a traditional pattern, where they worked up to 56 hours.


Two senior doctors, who were unfamiliar with the shift patterns of both groups, reviewed their errors by checking case notes.

Doctors working to the EWTD pattern made 33 percent fewer errors than their colleagues on the traditional pattern, and there were fewer potentially life-threatening events.

Andy Brazier

'Human error' kills Google seach

Article by David Walker 2 February 2009 at T3 gadget website

Apparently someone at Google inputted the symbol '/', which contrived to label all sites as unsafe for a portion of Saturday afternoon (UK time). This left all sites in the Google universe classed as unsafe, with the warning 'This site may harm your computer' appearing under the website name. Even if you went to Google, Google Maps, Gmail or indeed any other Google site.

Initially, Google blamed the non-profit website StopBadware.org, but later changed tact and offered up a new statement taking full responsibility.

Andy Brazier

Prosecuting doctors won’t stop them making mistakes

Article in The National (Abu Dhabi)by Justin Thomas 4 January 2009.

It appears that there are draft proposals for criminal sanctions to be brought against negligent doctors in Abu Dhabi.

Justin says that whilt he agrees healthcare professionals need to be held accountable, "such accountability and possible culpability, should only be a small part of a system-wide approach to reducing errors and improving patient safety. In fact, individually punitive measures are actually more likely to lead to a deterioration in patient safety rather than improvements."

All human beings make errors. Punishing people for slips and lapses does not improve safety or performance; if anything, it breeds resentment and fear, which in turn can lead to the development of a blame-culture, scapegoating and cover-ups.

The article says that several studies in the UK have estimated that at least 10 per cent of all hospital admissions result in adverse events, with 50 per cent of these mishaps being viewed as preventable. Also, the UK government estimates that annually there are 10,000 adverse drug reactions, 400 deaths involving medical devices, 28,000 complaints about medical care, and £400 million (Dh2.1 billion) paid out in clinical negligence settlements.

"In terms of improving patient safety, the dismissal or even incarceration of errant professionals will have little impact, and in some cases may even make the situation worse, especially if practitioners become defensive, risk averse and demoralised."

"The answer to preventing error and improving patient safety lies in the development of organisational safety cultures, where staff have an active awareness of the potential for things to go wrong and know about things that have gone wrong previously, as well as the circumstances and causes leading up to such incidents. Such a culture should actively encourage people to speak up about mistakes, with a view to learning from them and minimising the likelihood of a recurrence."

Andy Brazier

100 years of flight safety advances

A very interesting article from Flight International by David Learmont published 5 January 2009

Well worth reading the whole article, but some of the key messages are summarised below.

Wilbur Wright wrote to his father: "In flying I have learned that carelessness and overconfidence are usually far more dangerous than deliberately accepted risks." Whilst, in the 1930s First World War pilot Capt A G Lamplugh described of the risks of flying as "Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect." Both had clearly learnt that no activity can be completely risk-free, but that risk should be managed so as to remain within acceptable bounds.

Most safety lessons are learnt through experience. Father of the Flight Safety Foundation Jerry Lederer said in 1939 that "strange as it may seem, a very light coating of snow or ice, light enough to be hardly visible, will have a tremendous effect on reducing the performance of a modern airplane". The challenge has always been to disseminate learning. In January 2002 a Bombardier Challenger 604 business jet at crashed on take-off from Birmingham. It had been left on the ramp overnight and not de-iced before take-off was attempted.

Airframes, engines and aircraft systems have continually become stronger and more reliable, but as these improved the aircraft could also fly faster, perform a greater variety of tasks, and operate in worse weather conditions.

As the machinery became more reliable it caused less accidents. The role of the human became the focus of those who would improve aviation safety, really staring in the 1970s covering both on-board crew and maintenance.

Cockpit or flightdeck ergonomics started to improve in the 1960s, and really stepped up in the 1980's when cathode ray tube instrument displays (later replaced by liquid crystal displays) started to appear. This provided opportunities to improve crew situational awareness because data regarding performance and navigation could be integrated rather than being displayed as disparate pieces of data. This not only reduced the potential for individual confusion, but provided both pilots with the same picture of what was going on rather than allowing each to develop their own pictures that may not be identical.

In the 1970s KLM invented the concept of crew resource management (CRM) with the objective of improving the way crew communicated and worked together. This is now officially accepted globally as a critical part of multi-crew pilot training.

Technology alone has rarely eliminated a serious risk, but since the mid-1990s real progress has been made in reducing what had been the worst killer accident category - controlled flight into terrain. The ground proximity warning system (GPWS) has been replaced by Enhanced GPWS (EGPWS) which provides pilots with a graphic picture of their position and height relative to terrain, plus audio alerts. It is stated that there have been no incidents of controlled flight into terrain involving aircraft fitted EGPWS, but 5% of the world's big jet airline fleet that do not have it.

The windshear alert was developed in the late 1980s after meteorologists improved their understanding of phenomena such as windshear and micro­bursts associated with storm cells, and how these can affect aircraft close to the ground just after take-off and on approach. Pilots' awareness of the risk has also been improved.

Information technology has allowed company and global databases of safety data to be developed. Downloading data from aircraft allows engineers to recognise where operational best practice has been breached and to spot the technical signs of impending equipment failure.

In addition, the adoption of safety management systems and global auditing of airlines has made its contribution. But it may be argued that liberalisation of the market has allowed greater competition and therefore greater passenger choice. Where there is a choice of another airline to fly with, a carrier that has suffered an accident also suffers commercially.

Andy Brazier

Formula 1's virtual reality

Article from gradprix.com by Joe Saward on 14 January 2009

Apparently Formula 1 has been using simulators for sometime for testing technical components and this will become more useful now that circuit testing has been banned in a bid to save the teams money. Highly-advanced rolling-road wind tunnels, transient dynos, seven-post rigs, Computational Fluid Dynamics (CFD) and computers to "crunch away to work out every conceivable race strategy" are being used along with "driver-in-the-loop simulators" where the F1 drivers sit in "virtual" F1 cars and drive them.

It is suggested that use of simulator technologies in Formula 1 started when teams recognised that they could make money by working with computer gaming companies to create entertainment for the public. The first racing computer game was Gran Trak 10released by Atari in 1974.

The article gives an interesting summary of the history of simulation.

"Modern simulation techniques can be traced back to the 1920s when an American engineer called Edwin Link, who had begun his career as a builder of organs and nickelodeons, used his knowledge of pneumatic pumps and valves to create the first flight simulator" He developed a device which became known as the Blue Box. It was an aircraft cockpit that the pilot sat in and was able to 'fly' using instruments alone - until this time learning to fly in cloud was done in the air and was known to be rather dangerous. The Blue Box produced pitch, roll and yaw motions which were controlled by the pilot. The Army Airforce made the first purchases in 1934 after a number of trainee pilot fatalities, and in the end 10,000 were sold with more than half a million aircrew from different nations using them to train.

The boom in civil aviation after World War II created a greater need and pneumatics were replaced by hydraulics in simulators by the 1960s. They incorporated "six degrees of freedom", which meant that the platforms on which the cockpits were mounted were able to generate roll, pitch, yaw motion plus surge (longitudinal), heave (vertical) and sway (lateral). Visuals were introduced, with the earliest versions using cameras that filmed models of the ground. By the 1970s wide-angled screens with film footage came in, to be followed by curved mirrors and ultimately plasma screens with virtual imagery.

Other uses of simulator included army ground vehicles and automotive simulators use to understand how drivers behaved in different situations. Today there are reckoned to be 1200 professional flight simulators in the world.

Back in Formula 1: McLaren is believed to have spent as much as $40m on its system using technology developed for the Eurofighter aircraft. The driver sits in a full-size F1 monocoque, in front of a large, curved plasma screen. The whole device is mounted on a hexapod which moves around an area about the size of a professional basketball court, in response to the driver's steering and pedal input. Conversely Williams have used a fixed simulator which has been "amazingly cost-effective, with a budget of probably a tenth of what has been spent at McLaren." Apparently Williams can download data from practice sessions on the track to the simulator to try out different set-ups, which can then be tried to ensure the cars have the optimum set-ups

Andy Brazier

Surgical checklist 'saves lives'

Article on BBC website 14 January 2009.

A one-page checklist devised by the World Health Organization (WHO) has been tested in eight cities around the globe (Seattle, Toronto, London, Auckland, Amman, New Delhi, Manila and Ifakara, Tanzania). It focuses on basic good practice before anaesthesia is administered, before a patient is cut open, and before a patient is removed from the operating theatre, and is designed to promote effective teamwork and prevent problems such as infection and unnecessary blood loss.

Data was collected from 7,688 patients, 3,733 before the checklist was implemented, and 3,955 afterwards. The rate of major complications fell from 11% to 7%, and the rate of inpatient deaths following surgery fell more than 40% from 1.5% to 0.8%. Findings were similar across all the hospitals in the study.

Dr Alex Haynes, who led the study, said the checklist had a significant impact at every hospital site in the study. "Even many clinicians who were initially sceptical of the idea became advocates once they saw the benefits to safety and consistency of care."

Dr Kevin Cleary, NPSA medical director, said: "The results of the study give clear evidence that a simple intervention leads to dramatic improvement in outcome for patients undergoing surgery."

UK Health Minister Lord Darzi is quoted as saying "The beauty of the surgical safety checklist is its simplicity" and "Operating theatres are high-risk environments. By using the checklist for every operation we are improving team communication, saving lives and helping ensure the highest standard of care for our patients."

The checklist is already in use in Scotland and the National Patient Safety Agency (NPSA) has ordered all hospitals in England and Wales to use it across the board by February 2010.

I'm a strong advocate of checklists for certain tasks, although their overuse can be counter-productive. What I don't understand is why it will take so long to get this implemented. The checklist is readily available for use. You can download it from the BBC website.

Andy Brazier

Take a Nap! Change your Life

A very interesting book by Sara Mednick. Available from Amazon

The book talks about how napping during the day to supplement night-time sleep is part of human nature. It makes specific reference to health and safety, including the role of fatigue in the Exxon Valdez accident.

A few snippets.

* In 1950's studies were done where subjects were kept in small flats without windows or clocks. After a short transitional phase people would sleep six to seven hours at a time that would represent night and roughly 12 hours later would return to bed for a shorter time. It is suggested that this is a natural sleep pattern.

* Before the light bulb was invented adults would typically get as much as 10 hours rest during the average weeknight. Today the average (in USA I presume) is 6.7 hours.

The book explains when to nap and for how long, but the basic message I take from it is napping can have great benefits, with small naps greatly reducing fatigue. I would not say I would follow detailed advice particularly, but it has encouraged me to take more naps whereas in the past I may have felt it a slightly silly thing to do. Also, it backs up advice I have given in the past for shift workers to have the opportunity to take short naps at works, especially when working nights.

Andy Brazier

The Fun Police

Cutting Edge documentary on Channel 4 last night (4 December 2008).

I don't think anyone in the health and safety profession ever expected this documentary to be particularly informative, and it wasn't. And, it is no surprise that people are saying on the internet today that they are disappointed or even angry about how the profession was represented.

But I have found five newspaper reviews of the program, and I don't think any have said it showed how ridiculous health and safety is. All noticed that the start of the program did labour some of the issues, making it look like health and safety people see danger everywhere. But all recognised that there are many serious issues, and the people shown were doing the right thing.

The following quotes are taken from the various papers:

The Telegraph - "If the popular press is to be believed, they’re full-time killjoys and agents of an increasingly spineless culture. Yet watching them as they trudge from one premise to the next, harangued, mistrusted, occasionally shouted down, it’s quite heartbreaking. They may be meddling and almost neurotically preoccupied with catastrophic scenarios, yet on the evidence of this documentary, presented by health and safety expert Ed Friend, their intentions are noble. Perhaps it’s worth considering too, whether they are any more to blame for our risk-obsessed culture than insurers and an increasingly litigious public?"

The Guardian - "This film is nicely non-judgmental. It simply shows these health and safety people, going about their business, doing what they believe is right. And Ed certainly believes it. He's passionate about health and safety, if that's possible. He's not going to shut up about it until there are no more accidents. And even though he's clearly the most annoying and ridiculous man in the world, there's also something quite admirable in that."

The Times - "One of the inspectors said he gets angrier and angrier at the “absolute waste of human life” presided over by lazy companies. His job meant he was an “expert in human misery”. There would never be a recession in “health and safety” — sadly. "

The Independent - "For anybody approaching the film in a Littlejohn state of mind, there was plenty here to confirm any prejudices; being of a nervous, risk-averse disposition, I was less sure about the message. Most of what Mr Friend had to say about the dangers of everyday life wasn't entirely stupid; the joke lay in his bothering to point it out, and in his somewhat pedantic manner. This being TV, it strikes me as entirely possible that in pointing out danger on every hand, he was only doing what he had been asked to do ("Go on, Ed, show us a risk"). Even if he was as neurotic as the film made out, that hardly amounts to an argument about health-and-safety regulation in general. I don't suppose, either, that Ms McIlravey's anxieties about glue would seem quite so petty if you'd found that the glue on the back of your falsies was eating through your actual nails, which is apparently one of the possibilities."

The Herald - "There is no health and safety in this country," Ed stated, "only accidents and ill health." The Fun Police convinced you we need more Ed Friends, not fewer."

My view on the program is that it was pretty boring and a missed opportunity. It will not be worthy of further consideration, unless Ed Friend becomes a TV celebrity as a result.

Andy Brazier

How to influence people at work

Article in the Times by Carly Chynowth on 3 December 2008. Gives 10 points as follows:

1. Build raport - people enjoy doing business with people they like. Take time to ask about family, holidays etc. It smoothes the way, just like WD40;

2. Earn respect - this is better than being liked. Showing you know what you are doing and are a good leader, and able to bring a sense of order and cohesion will earn you respect;

3. Get your message right - clear and concise. When under pressure we tend to add lots of extraneous words (e.g. 'I hope you don't mind');

4. Get things in context - understand and hence avoid the cultural and professional constraints that others are working under and cause barriers to progress;

5. Open your ears - listening to others means you will know what motivates them and hence how best to influence them;

6. Reciprocity matters - doing something helpful to someone means they will want to help back (e.g. a Big Issuer seller sold far more copies when he held the door open for people);

7. Get the timing right - talk to people when they are least likely to be pressured;

8. Give up the glory - let others take the credit and do not get emotionally attached to your ideas;

9. The element of style - the way you look and act has a big influence, but beware of changing to try and suit the circumstances;

10. Don't manipulate - direct people but let them work our the path for themselves.

Andy Brazier

OECD-CCA Workshop on Human Factors in Chemical Accidents and Incidents

Another long report from the Organisation for Economic Cooperation and Development (OECD). Published 2008. Available free from the OECD website

The report presents the main output of the OECD-CCA Workshop on Human Factors in Chemical Accidents and Incidents, which took place on 8 and 9 May 2007, in Potsdam, Germany. The overall objective of the workshop was to explore human factors related to management and operation of a hazardous installation, and to share information on assessment tools for analysis and reduction of human error in the chemical industry, including small and medium size enterprises (SMEs).

Seems to provide a good summary of issues, but I can't see anything particularly new.

Andy Brazier

Guidance on Developing Safety Performance Indicators

Guidance published by the Organisation for Economic Cooperation and Development (OECD) specifically related to chemical accident prevention, preparedness and response. Second edition published 2008 and available free from the OECD website

It is a very long document, and so will take some studying. But it lays out why you want Safety Performance Indicators (SPI) and how to develop them. Also, there seem to be lots of examples of indicators to use.

The introduction reads "Safety Performance Indicators (“SPIs”) provide important tools for any enterprise that handles significant quantities of hazardous substances (whether using, producing, storing, transporting, disposing of, or otherwise handling chemicals) including enterprises that use chemicals in manufacturing other products. Specifically, SPIs help enterprises understand whether risks of chemical accidents are being appropriately managed. The goal of SPI Programmes is to help enterprises find and fix potential problems before an accident occurs.

By taking a pro-active approach to risk management, enterprises not only avoid system failures and the potential for costly incidents, they also benefit in terms of business effi ciency. For example, the same indicators that reveal whether risks are being controlled can often show whether operating conditions are being optimised."

The Guidance divides SPI into two types: "outcome indicators" and "activities indicators."

* Outcome indicators are designed to help assess whether safety-related actions (policies, procedures and practices) are achieving their desired results and whether such actions are leading to less likelihood of an accident occurring and/or less adverse impact on human health, the environment and/or property from an accident. They are reactive, intended to measure the impact of actions that were taken to manage safety and are similar to what are called “lagging indicators” in other documents. Outcome indicators often measure change in safety performance over time, or failure of performance. Thus, outcome indicators tell you whether you have achieved a desired result (or when a desired safety result has failed). But, unlike activities indicators, they do not tell you why the result was achieved or why it was not.

* Activities indicators are designed to help identify whether enterprises/organisations are taking actions believed necessary to lower risks (e.g., the types of policies, procedures and practices described in the Guiding Principles). Activities indicators are pro-active measures, and are similar to what are called “leading indicators” in other documents. They often measure safety performance against a tolerance level that shows deviations from safety expectations at a specific point in time. When used in this way, activities indicators highlight the need for action when a tolerance level is exceeded.

Thus, activities indicators provide enterprises with a means of checking, on a regular and systematic basis, whether they are implementing their priority actions in the way they were intended. Activities indicators can help explain why a result (e.g., measured by an outcome indicator) has been achieved or not.

Andy Brazier

Simulation will increasingly be used to train pilots for optimum operations

Very interesting article by David Learmount from Flight International, published on the Flight Global website on 25 November 2008

It refers to an analysis of global airline safety data by the UK Civil Aviation Authority (CAA) that said "pilot judgement, decision-making and/or handling are key factors in 75% of catastrophic accidents, whereas technical failures tend to be causal in the less serious events." This is despite advancing technology and improved aircraft, and is expected to remain the case for the foreseeable future. However, the article does say "It is important to note that this [statistic] does not imply that the pilot was at fault or to blame, because it is now well-established that 'pilot error' cannot continue to be the scapegoat for the many and various factors that can lead to the error occurring."

Quality pilot training at all levels remains the critical factor in preventing the most serious accidents. Whilst some airlines are beginning to use simulation to improve crews' wider operational and flight management skills there is a danger that this is at the expense of getting "raw" flying practice, which get less of operationally because of high degrees of automation. Apparently ongoing studies "show that handling skills degrade with time, while cognitive skills are less time-sensitive, and that recent manual flying practice does improve manual flying performance."

The CAA data "highlights the crucial importance of pilot performance in safety, and therefore reminds us to invest resources in anything that might support it - [for example] training and simulation facilities - and to minimise influences that might adversely contribute, [like] time pressure, fatigue, and distraction."

An interesting development is that airlines are using simulators not only to train pilots to fly and manage aircraft, but to fly procedures specific to their own requirements to reduce costs and increase the operational efficiency of the airline. An example is Emirates, who are looking beyond using simulators to meet regulatory requirements, employing them also to hone crew decision-making skills in situations where there are operational options purely from the safety point of view, but where one of the outcomes will be the more efficient.

It is seen that "tier-two" airlines are bringing more training in-house, and are getting quite sophisticated in the business case analysis they are undertaking with respect to their operations. They don't have this barrier to change that the tier-one airlines do. I'm sorry but I haven't seen, for example, British Airways, innovate when it comes to this stuff - they just won't.

Andy Brazier

AWG slashes picking errors with Voice

I'm always interested in claims of quantifiable reductions in human error. In this press release BCP, a systems and software house specialising in the retail and wholesale distribution markets, say one of their clients has reduced their 'picking error' by 97.3% saving over £100,000 per year.

The picking they refer to is people taking items from the shelves in a warehouse to fulfill orders. In the past these people were given a written list of items. This has been replaced by an automated voice instruction to headphones via a wireless system. They have to confirm their understanding by repeating the instruction, which is checked using voice recognition.

The following quote regarding user acceptance gives an insight into why this has been successful - "Pickers, initially sceptical, have adapted to Voice quickly, finding it simple to learn and adopt. Assemblers - even those who’ve been with us for years and very settled into the old system - really like the new technology. They’re keen to extend it to other warehouse activities as they’ve found it makes their jobs much easier."

Andy Brazier

The Hawthorne Effect

I had cause to refer to this recently, and struggled to remember the name. Hopefully a summary here will help me remember in future.

Studies carried out at the Hawthorne Works (outside Chicago) between 1924-1932 showed that changes in the working environment could improve productivity. But the improvement was only short lived, leading to the conclusion that people were responding because something had changed, and not to the change to the environment itself.

There is an article on Wikipedia

Floods, fire and theft rank with ill-advised cost-cutting

Article in Risk Management suplement of the Financial Times By Andrea Felsted on 18 November 2008

"As the economic outlook for the UK becomes more gloomy, so the risks that businesses face multiply because, according to Peter Jackson, sales and marketing director for Aon Risk Services in the UK, "when times are tougher, the worst is more likely to happen."

One reason the risks are higher is because business have more stock because it is difficult to shift. Because of financial constraints they may wish to cut back on insurance, but actually lose more if there was a fire or through theft.

Other cost saving may be cutting back on maintenance, equipment may be replaced less regularly, or plant may be repaired rather than replaced. Directors need to be particularly aware of the risks as they may be held personnaly responsible if someone dies as a result of that equipment failing. Companies should have a clear idea of the minimum level of maintenance spend they can live with rather than just incrementally cutting and seeing what goes wrong.

John Scott, head of risk insight at Zurich Financial Services UK, says that when companies cut costs “management often take their eye off the ball on the simple, really key stuff around health and safety. We often see an increased trend of workplace injuries. That is something that is a consequence of tightening belts. Well-managed companies try to do both. They try to cut back but without jeopardising staff safety.”

Research commissioned by FM Global, an insurer of commercial and industrial property, suggests that risk management is not an area where costs should be cut.

Some 71 per cent of UK investment analysts it polled believed that companies should pay more attention to their risk management activities during the next five years.

Just culture

A flow chart of an individual's culpability following an unsafe act has been around for some time. I think it was developed by Professor James Reason, and I know a few companies use it (or at least claim to ) to guide their disciplinary processes.

Anyway, I was looking for a copy of the chart, which was proving difficult. Eventually found it in the following paper from Flightsafety.org. Titled 'A roadmap to a just culture: enhancing the safety environment' and published September 2004. It was prepared by the Global Aviation Innovation Network (GAIN) working group for safety information sharing.

I think the paper's forward by Reason gives a very good account of the issues:

"The term ‘no-blame culture’ flourished in the 1990’s and still endures today. Compared to the largely punitive cultures that it sought to replace, it was clearly a step in the right direction. It acknowledged that a proportion of unsafe acts were ‘honest errors’ (the kinds of slips, lapses and mistakes that even the best people can make) and were not truly blameworthy, nor was there much in the way of remedial or preventative benefit to be had by punishing their perpetrators. But the ‘no-blame’ concept had two serious weaknesses. First, it ignored - or, at least, failed to confront - those individuals who wilfully (and often repeatedly) engaged in dangerous behaviours that most observers would recognise as being likely to increase the risk of a bad outcome. Second, it did not properly address the crucial business of distinguishing between culpable and non-culpable unsafe acts."

Andy Brazier

Report into Morecambe offshore helicopter crash

Accident occurred on 27 December 2006 whilst the helicopter was approaching a gas platform in Morcambe Bay. The two pilots and five passengers were killed.

Report No: 7/2008. Report on the accident to Aerospatiale SA365N, registration G-BLUN, near the North Morecambe gas platform, Morecambe Bay on 27 December 2006.
Report published 23 October 2008 by the Air Accident Investigation Board and available at their website.

The report suggests the co-pilot who was flying the helicopter on its approach to the gas platform became disorientated, probably due to darkness and weather. Handover of control to the pilot was not precise and the pilot himself was not ready to take control. This meant there was not enough to time to work out what to do before the helicopter hit the water at a speed that was not survivable.

This is a difficult accident to comment on. We usually look for root causes in systems and organisations so that we can make good recommendations. This accident is an example of how individuals can fail, and sometimes those failures will result in accidents. In others words, if we accept risk we sometime have to accept tragedy.

The report makes six recommendations, but none in my mind are particularly earth shattering, asking for reviews of standard operating procedures and suggesting some areas for research. A comment is made that a simulator was available for training, but had not been used. No recommendation is made, and given the level of experience of the pilots in this case it is difficult to see whether such training would have had much impact on the risks.

Andy Brazier

Legal Professional Priviledge

An issue came up with a client of mine recently where there appeared to be some confusion regarding legal professional privilege. Luckily I have happened to stumble upon a document on the HSE website which seems to sum things up quite nicely. From this I understand that the only documents that anyone can claim to be priviledged are ones where a client asks their solicitor for legal advice. Any other document (e.g. accident investigation report, audit report etc.) will have been produced for a different purpose and so an HSE inspector could demand a copy if it was considered essential for their investigation.

The text from HSE is shown below - aimed at HSE inspectors.

33. Your powers under section 20 cannot compel the production of documents which are entitled to be withheld on grounds of legal professional privilege.
34. Legal professional privilege extends to communications, statements, reports and information created during the course of a solicitor-client relationship, the broad purpose of which is the obtaining and giving of legal advice.
35. If a document was created for several purposes, it will attract privilege only if the dominant purpose was obtaining legal advice. Such advice may relate to criminal or civil proceedings, actual or contemplated. Legal privilege attaches to communications between solicitors and expert witnesses, but not to the expert's opinion on the case or the documents or objects on which the expert based the opinion.
36. The privilege is that of the client, so that the client is entitled to waive privilege and show you the document or use it in evidence.
37. If a company has prepared a report on an accident, for example, this will be privileged if the dominant purpose was the obtaining of legal advice, but it will not be privileged if it is prepared simply because there has been an accident, or for avoidance of further accidents. You should remember, however, that you would only be entitled to see such a report if it is 'necessary'. An engineer's report that was obtained for the purpose of deciding whether to contest proceedings (civil or criminal) would be privileged.

Technology that eliminates error

I am always on the look out for the claims of technology that eliminate the chance of error. What they all seem to overlook is that, just because one type of error may be eliminated a new type is usually introduced that may actually be worse. I'd say in most cases the chances of recovering an error is usually greatly reduced. These downsides of technology have been known about for many years, but still seem to be overlooked. Also, I very much doubt many of the bold claims are ever properly checked with actual experience.

Here are a couple I have found recently.

Air Products Uses Masternaut Satellite Tracking 18 September 2008. Peter Birdsall, UK Transport Manager, sees this product as "eradicating any chance of human error." I presume he means the satellite tracking combined with customer order information means that delivery drivers cannot turn up at the wrong location. However, what about the programmer error? If the wrong information is entered into the system I would say it would be very unlikely that anyone would notice.

Kelsius wireless monitoring 15 September 2008. Apparently this "monitoring to internet solution removes human error." It seems to rely on wireless sensors being placed in fridges which send information to a centralised database. The information can be used to prove compliance and will alarm if there is a problem with the fridge. However, how do you know the sensor is in the right place or that the alarm points are set correctly? Will this stop the visual checks?

Hospitals purchase blood tracking system 13 September 2008. Use of bar codes on blood used for transfusion is seen as "eliminating the sources of human error." But you still need to make sure the right bar codes are attached and the correct information stored as with this system I am pretty sure most visual checks of data will stop, or become far less effective.

Andy Brazier

Full Disk Encryption should be a legal requirement

Article by PR Artistry at Source Wire on 9 September 2008

If relates to the many recent stories of sensitive data going missing. This would not be such a problem if it had been encrypted.

Marc Hocking, Chief Technology Officer of BeCrypt is quoted as saying "If security is too cumbersome people will find a workaround." In other words, it is no good saying to people they musty encrypt data or even providing a technical solution that takes time and effort.

Hocking goes on to say "encryption technology is now available that is easy to roll out to all computers and data storage devices within an organisation, it can be centrally managed and it is transparent to the end user, so it does not affect their ability to do their job."

Andy Brazier

Formula sickens New Zealand babies

Article by Catherine Woulfe in the Sunday Star Times on 21 September 2008

Heinz changed the supplier of their branded formula baby milk, which consequently meant its ingredients were different. A sudden change to diet of a baby can make them unwell, and this happened in quite a number of cases.

Heinz published an unreserved apology explaining and stated that "human error had let the 400 cans of changed formula slip onto shelves with no warning." But Heinz's idea of a warning was a leaflet under the can lid. But when someone is buying a brand they have been buying for sometime, if the packaging remains the same (as it did in this case) would anyone have actually read any of the leaflets? Pretty poor management of change, especially given the sensitivity of the product.

Andy Brazier

"Worst ever decision"

Widely reported, including by Tom Cary in the Telegraph on 22 Sep 2008

Watford were awarded a goal in their match against Reading on 20 September. Unfortunately everyone, except the referee and his assistant could see it was several meters wide. It seems the result will stand and there will be no replay.

Andy Brazier

The economics of ergonomics

Article by Mike Kind published at HBRF.com on September 26, 2008.

Article states that "over half of employees who use computers for at least 15 hours per week reported musculoskeletal disorder (MSD) issues in the first year of a new job?" It represents
* 50 percent of all lost work days
* Costs U.S. companies over $61 billion per year in lost productivity.
* Results in pay outs of approximately $20 billion annually in benefits for these issues
* At an average cost of a work-related MSD of $27,700.

MSDs are injuries to muscles, tendons, ligaments, joints, cartilage, nerves, blood vessels and intervetebral discs of the spine. They vary from simply being annoying to to crippling and disabling.

The five may ergonomic risk factors are:

* High rate of movement repetition
* High forces
* Poor, deviated work postures
* High contact stress
* High vibration of part of the body, especially in cold conditions

Andy Brazier

UK: Slow Mailing Invalidates 500 Speed Camera Tickets

Article in TheNewsPaper.com 7 June 2008

Police in Sussex, England have been forced to cancel 500 speed camera citations after an employee loaded the wrong envelopes into the machine, delivery was slowed enough that a court could have invalidated many of the tickets for lack of proper notice.

"Some notices were sent by second-class post as a result of human error in loading the postal machine... we've canceled all relevant tickets," Chief Superintendent Peter Coll explained.

Using second class saved £45 in postage costs but the canceled tickets were worth £30,000 in revenue.

Seems a bit strange to me. The police have 28 days to get the notices to drivers. They must be sending them late for this error to have caused a problem.

Andy Brazier

A crisis of enforcement: The decriminalisation of death and injury at work

A paper written by Professor Steve Tombs and Dr. David Whyte June 2008. It is available from the Crime and Justice website.

According to the paper "At least twice as many people die from fatal injuries at work than are victims of homicide." The figure of 1,300 work related fatalities was calculated from the HSE data for work place fatalities (241 for year 2006-7) and an estimated figure for road deaths that are work related (considered to be about 1000 of the 3500 killed on UK roads each year). This is compared with with 765 homicide victims.

The report argues that the recent trend towards the `light touch' regulation of business has in effect `decriminalised' death and injury at work. Also, a reduction in the capacity of bodies such as the Health and Safety Executive to inspect business and take appropriate action due to budget and job cuts has led to a situation where the vast majority of the most serious injuries, as well as many deaths, are not subject to any form of investigation. This raises questions about whether the current policy preoccupation with `conventional' crimes such as homicide, street violence and theft should be complemented by a much greater focus on workplace crimes and harms.

Professor Steve Tombs said "Violent street crime consumes enormous political, media and academic energy. But, as hundreds of thousands of workers and their families know, it is the violence associated with working for a living that is most likely to kill and hospitalise."

Dr David Whyte said: "HSE enforcement notices fell by 40% and prosecutions fell by 49% between 2001/02 and 2005/06. The collapse in HSE enforcement and prosecution sends a clear message that the government is prepared to let employers kill and maim with impunity."

The report is described as being part of a project that aims to "stimulate debate about what crime is, what it isn’t and who gets to decide." That being the case I hope the authors are not offended by my comments that follow.

I find the logic of the report very difficult to follow. I just can't see a comparison between work related accidents and murder being valid or useful. Equally, if I were to be arguing such a case I would have thought road accidents or even work related health issues would have been far more interesting to investigate as both do kill far more people than workplace accidents.

I think the argument the report is trying to make is that more HSE inspectors are required so that more accidents can be investigated and more companies prosecuted. But there is no attempt to show that falling numbers of inspectors has actually resulted in more accidents.

Also, I think the authors feel that prosecuting more companies will inevitably improve safety. I am not sure this is the case. I believe our aim in safety is to learn from accidents. Any suggestion of a prosecution immediately creates an adversarial situation. Hence, rather than sharing information and learning the company has to construct a defence, which will almost always reduce the information that is made available.

I'd say the article is interesting and could create a good debate. But I personally, do not agree with the general theme.

Andy Brazier

Overzealous health and safety consultants

Select Committee on Work and Pensions Third Report examines the interpretation of health and safety legislation. It is available at parliament website and was published 2 April 2008.

Paragraph 75 reads as follows:

"A number of witnesses suggested that a key issue for employers was that the risk assessment process was often over-burdensome and it was argued that this could be exacerbated by the approach of some health and safety consultants and advisers. Mr Richard Jones, Policy and Technical Director at IOSH, the professional body that represents health and safety consultants, explained that IOSH has had informal discussions with HSE and was told that inspectors had raised concerns about the credibility of the evidence used by some consultants to form the basis of risk assessments. [74] Lord McKenzie of Luton, Parliamentary Under Secretary of State at DWP also acknowledged this was an issue saying, "I think it is certainly a fact that this happens and there is a lot of evidence and information to suggest that it does."

I am sure it is true there are some consultants out there who are overzealous, but that sounds like scapegoating to me. The most overzealous people I come across are inhouse advisors who quote regulations and fail to provide any practical advice. Consultants only get paid when they deliver, so I really don't believe this is the root cause of the problem. It seems to me that clients get what they ask for, and often consultants are given little scope to drive improvement.

Andy Brazier

Judith Hackitt - Closing remarks at Major Hazards conference

Judith is HSE Chair. She was talking at the end of HSE’s major hazards conference on 29 April 2008 at the QUII centre, London. This conference was attended by senior managers from a number of large companies. I believe it was partly in response to the BP Texas city accident.

Judith's key messages are shown below. They are available from the HSE website:

1. Process Safety cannot be managed or led from the comfort of the Boardroom. Real leaders have to demonstrate their commitment by walking the talk – which means going out and seeing for themselves. All too often senior managers and directors are far too detached from the reality of what is actually taking place on the ground.
2. If the people on your Board don’t know about/understand process safety, then they must learn. We cannot assume that Board members understand the concept. This is not something which can be delegated. You are responsible and you must lead, and to lead you must understand.
3. This is not about glossy volumes of procedures and management systems - it’s about listening to the people at the coalface who really know what’s going on. Procedures which look wonderful but are not being followed in practice are no use. Whatever system is in place has to be geared to ensuring safe operation – not to creating good impressions – whether that be for the senior management of the organisation or indeed your regulators.
4. We have heard also that every Board needs to consider what the real vulnerabilities are and address them – and they also need to know that it is OK to seek help and advice from others – that’s also part of real, honest leadership.

We’ve heard about the importance of consistency – leadership credibility takes a long time to build but an instant to lose with one inconsistent decision – “production comes before safety, just this once” simply will not do – the whole culture will be destroyed.

Errors in Medicine Administration: How Can They Be Minimised?

Article on Red Orbit website 14 June 2008 by By Venkatraman, Ramya Durai, Rajaraman

Errors in medicine administration can be lethal. Neontal, patients receiving chemotherapy and confused elderly patients who are receiving more than five medicines seem to be most vulnerable.

The route of administration and dosage of medicines are of vital importance. Common causes of errors in medicine administration include:

* inattention
* haste
* medicine labelling error
* communication failure
* fatigue (Abeysekera et al 2005).

The Department of Health's document An Organisation with a Memory (DH 2000) reports that 850,000 adverse events may occur each year in the NHS costing more than Pounds 2bn.

To reduce the risk of error, medicines should be prepared for only one patient at a time. Intravenous (IV) medicines should not be prepared at the same time as medicines to be administered via other routes (for example, nasogastric (NG), oral or intrathecal). All medicines whether they are administered via NG or IV should always be clearly labelled with the patient's details including name of the medicine, the dose and the route of administration to avoid confusion. To reduce errors, high risk medicines should be checked with a second qualified person and signed on the prescription chart. This second person should check that it is the correct medicine, the correct dose, the correct frequency, the correct route of administration and the correct patient.


A Spoonful of Sugar (Audit Commission 2001) discussed medicine management in NHS hospitals. The Audit Commission suggests:
* Induction and training of junior doctors regarding medication prescribing and error reporting.
* A focus on near misses to avoid repetition.
* The use of computer technology for avoiding errors from illegible prescribing.
* The integration of clinical pharmacists into clinical teams.

Recommendations from An Organisation with a Memory (DH 2000)*
* Avoiding the use of unsafe abbreviations.
* Reducing polypharmacy.
* Periodic medication reviews.
* Inclusion of the indication for all medications.
* Reading out the prescription and explaining the need to patients.


Electronic prescription systems ('e-prescribing') are a new concept that may help to avoid administering wrong medicines and wrong doses.

Errors in medicine administration can be minimised by applying a systematic approach to administration. Safe administration requires that the correct patient is identified against the prescription (noting allergies and sensitivities), checking the dose with BNF or a pharmacist when there is any doubt, double checking the medications with another qualified staff member together with regular education of staff about the importance of reporting all near misses and adverse events.

Case 1 Route of administration error

A 16 year-old boy presented with polytrauma including a pelvic fracture. A nurse gave soluble paracetamol (1 gram) intravenously by error instead of the nasogastric route. Fortunately, the patient recovered after a few hours without any intervention.

Factors

The temporary (bank) staff member was tired. The registrant was unfamiliar with medicines handling and administration. The patient and family were informed fully about the incident, and the bank staff member was cautioned. A decision was made to ensure that all qualified bank staff had undertaken appropriate medicines management training and were competent to administer medicines within that clinical setting.

Case 2 Dosage error

A ventilated 27 week-old premature baby suddenly deteriorated. On examination the baby was found to be inadequately sedated and was trying to take breaths against the ventilator. The ventilator was set to volume control rather than pressure control.

Factors

Under stress, the nurse did not label the medications, even though she had completed an IV study day. All nurses and non- nursing qualified staff should receive training and complete competencies before administering any medicines by any route. Wherever possible two registered staff should check medicines for intravenous administration - one of whom should also be the registrant who administers the medication (NMC 2007). After this incident, the nurse was cautioned. The nurse and her colleague who countersigned the CD register had to undergo further training on IV medicine administration and successfully complete their drug administration competency (administration under supervision) and medicine calculations before they were allowed to administer medicines without supervision.

Case 3 Error in frequency of administration

A 30 year-old female, who underwent fixation of a fractured toe with a K-wire, vomited twice in the postoperative period. She had received two doses of cyclizine 50mg at eight hour intervals as recommended in the Special Product Characteristics (SPC) (www.medicines.org.uk). The nurse on the night shift gave a third dose of cyclizine, one hour after the second dose, without looking at the time of the previous dose.

Factors

Even though the staff member was fully trained, tiredness and stress caused her to make an error. The staff member was cautioned.

Article concludes by saying "Errors con be minimised by applying a systematic approach to administration." Interesting to note the case studies all talk about "cautioning" staff and retraining. I am not sure this shows any systems were improved.

Andy Brazier

Red Faced Council Got Its Sums Wrong

Article in the Press and Journal on 10 June 2008 by Jamie Bachan.

Aberdeenshire Council have had to apologise after it released figures in response to a freedom of information request were dramatically wide of the mark. When asked to provide details of the amount spent on agency and temporary workers in the last financial year they came up with a figure of just over £27.3million.

The actual figure was £4,036,922. The council said "This was down to human error where the cumulative figures for each month were added together, rather than individual monthly figures."

This sounds like another spreadsheet error, which is ironic as I only posted an article on this very subject about a week ago.

On receiving the first figure the GMB union, who asked for the information, descirbed it as a “horrific abuse of the public purse.” I wonder how many times the incorrect figure will be quoted in years to come by people looking for evidence of overspending by doing a quick search of the internet.

Andy Brazier

Lewis Hamilton's pit lane crash

The incidents is summarised on the BBC website

Canadian Grandprix on 8 May 2008. The safety car had been sent on the the circuit following a crash. Several cars used this as an opportunity to get new tyres and fill with fuel by going to the pits. When going to rejoin the race Hamilton crashed into the back of Kimi Raikkonen who was stopped at a red light. Both cars were too badly damaged to continue.

Hamilton clearly made an error. He didn't see the red light and didn't realise the cars in front had stopped until it was too late. But my question is why did he make the error.

I noticed on the TV highlights that a car also went into the back of Hamilton, showing others made the same mistake. This leads me to wonder whether the lights are located correctly. The drivers in front can see them but people behind can't. Clearly Hamilton did not crash on purpose as he was having a great race. The crash allowed Kubica to win and take Hamilton's spot as number 1 in the rankings.

Of course Hamilton is punished and everyone says he is stupid. No ones asks why two people made such a fundamental error, so it will happen again.

Andy Brazier

Workers’ safety fears at Fawley refinery

Article from the The Southern Daily Echo on 3 May 2008 by Peter Law. It has sparked quite a lively debate on the newspaper's website. The HSE report that prompted the article is also available.

Excerpts from the article are shown below.

"Anxious staff at the giant Fawley oil refinery have revealed their fears of a major accident at the plant in a shocking new report obtained by the Daily Echo. The workers highlight the refinery's ageing infrastructure and lack of maintenance among their major concerns. Other staff at the complex - the largest of its kind in Britain - also admit under-reporting minor incidents, accidents and near-misses for fear of losing their cash bonuses received for their safety record, says the document."

This all comes from a report by inspectors from the Health and Safety Executive (HSE) in which they conclude they "had never encountered such a prominent and pervasive blame culture at any other refining and chemical complex in the country. Of particular concern was the extremely high numbers of staff stating that they would not be surprised if a major incident were to occur in the near future,"

In a statement the company said "Esso and ExxonMobil Chemical at Fawley strongly reject any claims that the Fawley site is unsafe. Fawley is the safest refinery in the UK for both personal safety and process safety, according to the latest figures from UKPIA (UK Petroleum Industries Association)." Also, "We take the safety of our people and of the local community extremely seriously. We have rigorous safety procedures in place and are regularly inspected by the Health and Safety Executive as to the safety of our plant and processes."

The HSE's Human Factors Inspection Report was the result of a two-day audit held with about 78 employees on January 8 and 9 and a feedback meeting on January 29.

The report also claims that although people were encouraged to report accidents or incidents, it seemed some staff were under-reporting because their bonuses were linked to safety. "Since the reward scheme is linked to safety eg lack of incident, it appears to have provided individuals with an incentive to cover up and not report minor incidents, accidents and near-misses as otherwise they (and their team) will be blamed for an incident and lose safety bonuses."

"As minor incidents/accidents are not being reported, the site may be missing precursors to something significant.

"The prevailing view is that when something goes wrong, the search is on for someone (and their supervisor) to blame, the fact that systems may be at fault appears not to feature. Worker's wide-ranging complaints also ranged from lack of morale to inadequate staffing levels, endemic overtime and ad hoc training. A fire, which occurred late last year, was put partially down to fatigue as a result of excessive working hours.

The report claims the organisation's blame culture stops some employees from raising issues and taking on additional responsibilities or overtime.

"Some participants felt uncomfortable raising issues, even with managers higher than the shift leader, but others felt that the culture is such that people don't want to raise problems and there would be repercussions if they did," the report states.

Senior staff expressed concern that trainees were not being given sufficient time to consolidate their training and that they may not have enough experience of the plant to deal with emergency situations.

There was a view that staffing levels were adequate on paper but in practice areas were badly staffed. This was partially attributed to stress-related sickness absence brought about by overtime, fatigue and the blame culture.

"There was a general lack-lustre feeling amongst staff, a lack of motivation compounded by fatigue and lethargy. Employees are beginning not to care about their roles or jobs being down to the required standard," the report states.

"The inspectors concluded that significant work needed to be undertaken to achieve full compliance with legal duties."

Andy Brazier

Unacceptable error

Article on This is Total Essex 4 June 2008

This website seems to be related to the local newspaper, so I guess that explains the slightly bizarre reporting.

Apparently when Brentwood Borough Council implemented a new computer system they managed to take council tax payments five days early, affecting 21,000 people "leaving many in the red, short of cash and with the prospect of hefty bank charges looming."

The article calls this a "shocking revelation" that "is just unacceptable" and "was a mistake which quite simply should never have occurred in the first place." It says the council has put this down to human error and it has "promised to refund any charges incurred."

What is bizarre is the article goes on to say that if a resident paid their task bill five days late they would probably be "hit them with a substantial fine and the threat of legal action." Which I doubt completely.

The article suggests the council "should launch an extensive investigation into this appalling error, take the appropriate action to ensure it never happens again, and do everything in its power to regain the trust of those residents affected." I would guess the council has already done this, and has promised to pay refunds.

All I can guess is the un-named reporter has never made an error, and if he/she did would look simply sweep it under the carpet, which he/she seems to have assumed the council have done.

Andy Brazier

The Spreadsheet Love Affair

Article on ZDNet 3 June 2008 by Dennis Howlett.

Dennis discusses the errors that occur in spreadsheets and how it is very difficult to detect them. It is suggested that 95% of spreadsheets have errors. This is because the error per cell is a "few percent" and so for any large spreadsheet at least one error is inevitable.

He says examples of the consequences of spreadsheet errors range from "a mortgage provider that overpaid some $270 million for a debt book, through to energy futures overpaid by $9 billion down to the $2 million a month interest calculation error."

Dennis' view is that "the spreadsheet was never designed for the sophisticated uses to which companies continue to put it. At best it is a development envronment that is rarely documented because users are not trained as developers. The net result is that when things go wrong, errors are notoriously difficult to find. What’s more, there seems to be a fundamental lack of awareness around the extent of spreadsheet error."

He questions why companies continue to use spreadsheets given the risk, but then seems to answer this by saying "the spreadsheet is seen as convenient in a way that other applications are not and that the learning curve is sufficiently shallow for anyone to pick up the basics and do something useful. It’s also cheap, often pre-installed on user machines at low cost in bulk deals."

What I don't understand is what Dennis is proposing as an alternative.

Andy Brazier

What do ergonomists do?

Article entitled "Ergonomists: Light relief for desk-bound employees" in The Independent Career Planning Section on 22 May 2008 by Caroline Roberts.

Suzanne Heape, an ergonomist with experience in a wide variety of consultancy work, is quoted. She "relishes the problem-solving aspect of her career, and also enjoys helping people."

"In workplace assessments, you spend time watching people at their desks or at manual work stations, looking at their posture, adjusting equipment and assessing the general environment, such as heating and lighting."

"Collaborating with workers in other professions can be challenging, because some lack awareness of the importance of ergonomics."

Liz Butterworth, a principal ergonomist with consultancy Human Engineering, is also quoted. "Almost every major accident has some element of human error involved, so the emphasis is on supporting people in the tasks that they do and reducing the chances of them making mistakes," she says. "We help establish the requirements and ensure they are captured by the people doing the design."

"To be a successful ergonomist, you need to be methodical, and good at listening to people and gathering information. Communication skills are also important, because you must be able to convey complex information in a way that clients can understand."

Andy Brazier