Wednesday, October 25, 2006

The problems with behavioural safety

I have just found this article by Nancy Lessin published at

Problems identified in this paper include:

* Focusing on worker behaviour tends to mean root causes of problems are not looked at closely enough. Production pressure is quoted as a common reason why employees do not behave as safely as they should;
* There is a tendency to place the burden of prevention on the worker, rather than developing technical solutions;
* Everyone makes mistakes, is at some time careless, complacent, overconfident, and stubborn. At times each of us becomes distracted, inattentive, bored and fatigued. BS seems to suggest this should not be the case, and that if people are more careful mistakes will not happen.
* BS tends to mean that any individual acting unsafely is subject to 'inquisitions.' This is not pleasant, so the result is incidents don't get reported.
* BS programmes can be used by management to justify actions that unions have identified in the past, and thus undermining the union.
* A 'systems approach' that emphasizes the identification and elimination of root causes of workplace injuries and illnesses: workplace health and safety hazards would be far more effective.

The paper quotes some examples of where unions and workers have fought back against BS. They include:
* Engaging in a campaign that includes educating and involving the membership, identifying allies, identifying leverage and employing escalating tactics.
* Workers all wearing anti-behavioural safety buttons (badges);
* Placing fluorescent stickers on hazards in the workplace to bring a focus back to hazards rather than workers' "unsafe behaviours";
* Making a sign for the union bulletin board that reads "It has been x days since we asked management to correct [a particular hazard] and they have still not fixed it" (and keeping the count going each day);
* Threatening to call OSHA in to inspect the workplace.
* The United Steelworkers of America developed buttons (badges) for locals going through such campaigns that have a large BS in the center, with a line drawn through it, and the words "Eliminate Hazards - Don't Blame Workers" around the outside.

I certainly don't agree with everything in this paper or the way the message is put over. However, I do also share some of the concerns and am convinced that a systems approach to improved health and safety would be more effective and likely to address process as well as personal safety, as well as health.

Andy Brazier

Thursday, October 19, 2006

Safety last

Article in the Guardian by David Brindle and Paul Lewis on 18 October 2006 link

Provide a summary of the recent debate about society becoming more risk averse. Includes some examples. The problem is, what is the solution?

Andy Brazier

Controlling risk associated with violence

An excellent set of responses to a question posted on an IOSH forum to a question related to protecting doctors from violent patients. Not much for me to say. I just want to record the link here for future reference.


Wednesday, October 18, 2006

Driver warning system

Article at CBC published 17 October 2006.

Ford Motor Co. testing a number of different systems that warn drivers when they stray off the lane on a road. Researchers studied drivers who had not slept for 23 hours and had each of the participants drive for three hours in a simulator.

Found that all systems were effective at improving reaction time, implying they would reduce likelihood of accidents. However, I wonder how much such devices will affect driver behaviour. Will people pay less attention when driving because they know there is a device that will warn them that they are straying. Will people drive for longer without a break or be less concerned about driving when they haven't slept?

Andy Brazier

Working under fire

Report by Robert Jaques 17 October 2006 published here

Military student medic were required to perform a thoracostomy (insertion of a tube into the chest cavity to permit fluid to drain) under virtual reality battle conditions.

Interesting findings
* The students' completion times showed that they could perform the surgery efficiently, but that the quality of their work suffered.
* Those who performed the procedure faster were more susceptible to the virtual sniper fire.
* The stress created by the simulated environment may have caused some students to engage in inappropriate and dangerous behaviour that would be likely to result in their being killed in a real combat situation.

Not sure how this would translate into a business setting, but I can imagine that during a major incident people are likely to act differently. We rarely get the chance to give our staff the opportunity to see what it will be like, and have no real idea of how they will react.

Andy Brazier

Friday, October 13, 2006

Employers not liable for unforseeable events

The HSE has recently lost a case at the court of appeal regarding a case where two employees of Hatton Traffic Management (HTM) died when taking part in road improvements on the A66 near Scotch Corner.

According to this website "HTM were providing traffic management services for contractors (L) who were resurfacing the A66. There were contraflow works, lit at each end by HTM’s mobile telescopic towers which were 9.1 metres tall. 20,000 volt electricity cables passed overhead, dipping to 7.5 metres above the ground. HTM had two employees on site, C and D, who took their day to day instructions from L. C and D were told to move one of the towers. They did not lower the tower under the cables (contrary, said HTM, to their training and to instructions on the tower) and the inevitable happened, with fatal consequences for both employees."

HTM were charged with failing to discharge their duty under s.2(1) of the Health and Safety at Work Act 1974, namely failing to ensure, so far as was reasonably practicable, the health, safety and welfare at work of all its employees. At a preparatory hearing, the judge ruled in favour of HTM on both points. The prosecution’s appeal was unsuccessful.

The HSE took it to appeal and lost. According to this website The implication is that this ruling demonstrates that "Employers cannot be found negligent on health and safety grounds when employees are acting outside their remit."

According to another website HTM's lawyer said after the case "If this argument had been upheld by the COA, Groch believes, it would have effectively removed of any real defence available to employers in the area of risk management. Insurance premiums would have also beeen affected as insurance companies would take action to protect themselves against substantial claims. Another disturbing implication would be that some employers may question the need to invest heavily in health and safety provisions if, in reality, they have no effective defence against criminal prosecution."

But this is unlikely to be the end of the case. HSE will probably take it to the House of Lords, and it does seem there is plenty to debate. I personally find it hard to say that with high voltage cable nearby that it was not foreseeable that workers may forget to lower the lights before moving them. Also, we all know people take shortcuts and we should consider this in our risk assessments.

A spokesman from Norwich Union made the following comments at this website. "In this case it seems that HTM argued they had taken all reasonably practicable steps to ensure the safety of the employees and had provided training and instruction, as required by law. But, they argued the sequence of events that occurred was not foreseeable.

"Some might consider this somewhat disingenuous, despite the ruling. If there is a shortcut - that will save a bit of time and perhaps enable an early tea break, a chance to have a few minutes in the cab out of the rain - then is it not the case that employees will find it?"

Andy Brazier

Wednesday, October 11, 2006

Human error caused Cyprus air crash

Reuters website 10 October 2006.

Crash in August 2005. The plane on a Larnaca-Prague flight flew on autopilot for two hours, its pilots slumped over the controls, before running out of fuel and ramming into a Greek hillside killing all 121 people on board.

The report blamed deficient technical checks on the ground, failure by the pilots to pick up on compression warnings and a series of other mistakes for the Cypriot Helios Airways Boeing 737-300 crash.

The compression system regulates the oxygen supply, which decreased as the aircraft gained altitude and rendered the pilots and passengers unconscious.

BBC webstite added more. Including:

* Pilots misread instruments regulating cabin pressure and misinterpreted a warning signal.
* Maintenance officials on the ground left pressure controls on an incorrect setting.
* Plane's manufacturers Boeing took "ineffective" measures in response to previous pressurisation incidents in the particular type of aircraft.
* Airline came in for criticism for "deficiencies" in its organisation
* The Cypriot regulatory authority was accused of "inadequate execution of its safety oversight responsibilities"

Andy Brazier

Eye strain from computer use

Article by Darryl E. Owens published 10 October 2006 on the Orlando Sentinal

Studies haven't found that long-term computer use produces permanent damage But some people do suffer from burning, watery, or dry eyes, or blurred or double vision during or after use.

There is no evidence that this is caused by radiation from the screen. However, the main causes appear to be decreased blinking during computer use and wearing improper or outdated eyeglass prescriptions.

Coloured tints and filters are not the solution. Instead properly adjust your office chair or positioning your computer monitor so that it is 20 to 25 inches from your eyes and slightly below eye level (a screen that is too high or too low will be hard for your eyes to work together). Also, adjust brightness and contrast.

Andy Brazier

The war on error

Article by David Learmount published 10 October 2006 on Flight website

Talks about a course titled 'Safety Stand-down' for experienced pilots run in US. Claims that the course "takes fully trained pilots well above and beyond what an advanced conventional or recurrent flying training programme provides. It challenges preconceptions, stimulates questions, and presents a pilot with a mirror in which his/her latent professional and personal vulnerabilities become fully visible. More than that, it renews a pilot’s respect for the multiple disciplines it takes to be a really good aviator."

Quotes Bob Agostino (Bombardier Business Aircraft director of operations): “Development of the human half of the man-machine equation has not kept pace with the technology developments in either formal training programmes nor in regulatory development.”

Also Dr Tony Kern (senior partner in Convergent Knowledge Solutions): "The challenge of human error will never be remedied by any traditional safety programme. Personal error must be slowly untangled in a private battle within each individual.”

Finally, researcher from University of Manchester: “The study of human error has grown dramatically in the last 20 years. We know why people make errors and how to prevent 90% of them, but no-one seems to care.”

Andy Brazier

Friday, October 06, 2006

Indian Air Force

According to article from Reuters on 5 October 2006 available here

"Out of nearly 800 MiG-21s that India's air force has acquired since 1963, 330 have crashed, mostly due to human error, according to official figures."

The Indian Air Force are buying new trainer jets to try and improve then safety record.

Andy Brazier

Thursday, October 05, 2006

IT reliability

Article by Borris Sadacca on 3 October 2006 available here

Mostly concerned with datacentres, and the reliance on reliable equipment and reliable power supply including Uninterruptible Power Supply (UPS). "It is clear that to achieve high availability in the datacentre, IT directors need to look not only at the applications and server infrastructure and service level agreements associated with the IT, but also at the non-IT infrastructure - the mech­anical, electrical and plumbing systems that keep the datacentre operational."

It points out that systems designed to be highly reliable are often brought down by human error. Examples quoted include:
* Staff may be needed to work after hours and are tired.
* A common problem is when maintenance staff do not follow procedures step by step, which happens especially with well-versed personnel.
* Systems components are replaced even though there are no signs of wear or failure. This creates an opportunity for inserting other failures.
* Invasive checks that require the removal of other components can introduce problems.

"So while technology and multiple levels of redundancy can limit the effect of failure, much of what keeps a datacentre going is down to the people. Many problems can be avoided simply by operating a two-person maintenance team."

Andy Brazier

Shift work

Article written by George Brogmus and Wayne Maynard 4 October 2006

Findings of a recently published Liberty Mutual Research Institute study modeling the impact of the components of long work hours on injuries and accidents:

* Work-related injuries increased 15.2 percent on afternoon shifts and 27.9 percent on the night shift relative to the morning shift.
* Injury risk increases nearly linearly after the eighth hour of a shift, with risk increasing 13 percent on a 10-hour shift and almost 30 percent on a 12-hour shift.
* As consecutive shifts increase, injury risk also increases, but at a higher rate for night shifts than for day shifts.
* Average risk for injury is 36 percent higher on the last night of a four-consecutive-night shift. Risk increases incrementally over each night on the job: 6 percent higher on the second night, 17 percent higher on the third night – culminating at 36 percent on the fourth night.
* Injury risk is 2 percent higher on the second morning/day shift, 7 percent higher on the third day and 17 percent higher on the fourth day than it is on the first shift.
* Injury risk also increases as time between breaks increases. The last 30 minutes of a 2-hour work period has twice the risk of injury as the 30 minutes immediately after the break.

Advice to minimise problems includes:
* Evaluate the combined effect of work scheduling factors rather than to just limit total work hours (i.e. time of day, breaks on shift).
* Establish maximum limits for days and nights worked per week, including overtime. Whenever possible, favor day/morning shifts over afternoon or night shifts.
* Consider adding hours to existing shifts or add an additional day of work to the project, and limit work to five or six consecutive shifts.
* Provide for frequent rest breaks. Hourly breaks generally are appropriate, but consider providing more frequent breaks for highly repetitive or strenuous work.
* Schedule work so every worker has at least two consecutive rest days and at least one of these days is Saturday or Sunday.
* Avoid scheduling several days of work followed by four- to seven-day mini-vacations.
* Keep consecutive nights shifts to a minimum – four nights maximum in a row should be worked before a couple of days off and schedule no more than 48 hours of night shiftwork per worker per week.
* Educate workers on the importance of getting enough good sleep. Suggest they use black-out drapes, turn off phones and pagers and use a fan or white noise to mask daytime noises. Regular exercise, diet and relaxation techniques also are effective strategies for coping with night work.
* Consider alternatives to adopting permanent night shifts. Most workers never fully adapt to night shiftwork, since they go back to a daytime schedule during days off.
* Avoid quick shift changes and adjust shift length to the workload.
* Take into account all aspects of workers' job and home lives when changing work schedules.
* Provide a minimum of 11 hours off between shifts and a minimum of 24 to 48 hours when rotating workers off the night shift.
* Change from the night and morning shifts should happen between 7 a.m and 9 a.m., as starting the morning shift too early often cuts down on evening sleep time.
* Forward shift rotation – going from a day to afternoon or afternoon to night or night to day shift – is more compatible with normal sleep patterns than backward shift rotation.

Andy Brazier