Friday, June 20, 2008

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

Monday, June 16, 2008

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.


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.


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) ( 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.


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

Monday, June 09, 2008

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

Friday, June 06, 2008

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

Tuesday, June 03, 2008

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

Approaching Safety and Ergonomics Strategically

Article on the Occupational Hazards website 20 December 2005 by Robert Pater

Strategy entails both vision and action. Part of this is looking at what are already doing and what works and what does not. Which interventions are working and which are in the domain of diminishing returns? Which organizational forces currently block improvements and which are supporters? What are the current leadership strengths and limitations? But you need to go beyond what's been previously done if you want to see different results.

Keep in mind that how you initially look at a problem can funnel you into a limited set of solutions. For example, defining ergonomics as making work fit the worker limits intervention to engineering the environment to fix selected problems. But taking ergonomics literally means the science (-nomics) of work (from the Greek word 'ergon"), giving a more "strategic" definition as: improving the fit between people and their work (to improve safety, productivity and morale). This paradigm opens up three different approaches:

* Bringing work "closer" to people (through design, redesign, positioning, etc.);
* Bringing people "closer" to their work (through improving mental skills of attention control, risk assessment, judgment, team focus, etc., and physical skills of improved coordination, leverage, balance, flexibility, range of motion and more); and
* Bringing work closer to people as well as people closer to their work.

This last approach is most preferred. For example, it is more efficient, whenever possible, to take the stuck lid off a jar by twisting the bottom clockwise and the lid counterclockwise (rather than just holding the bottom stationery while working on the top).

There are limitations beyond initial costs. Ergonomics improvement can deteriorate into safety hazards (think of worn-down nonskid mats with curling-up edges); and might require workers to change. (in one place introducing recoilless rivet guns actually exacerbated those hand and arm injuries they was purchased to prevent - until riveters were trained how to gauge the different kinesthetic feel of setting the rivet with the new tool).

A strategic human factors approach relies on effective communication and training to motivate use of and to transfer new skills; requires a work force able to receive communication (are there language or other blockages?); necessitates time away from job tasks for training and reinforcement; can be logistically challenging for multiple sites (especially where facilities have few employees); and is not automatically in place for new hires. But it has the advantages of

* Improving situations where engineering solutions have been exhausted in difficult-to-control environments;
* Is portable to wherever people are - in multiple locations and environments, at work and at home; and
* Can boost involvement and morale while heightening worker abilities that transfer to other needed arenas.

Andy Brazier

The crash-proof car is coming

Article in The Times 11 May 2008 by Emma Smith

"Imagine a world in which parents could nonchalantly hand over their car keys to their teenage son, safe in the knowledge that the car would look after him. A future in which human error is eliminated by electronic systems capable of foreseeing smashes and taking preventative action; a world in which car crashes almost never happen."

I am always concerned when people say human error will be eliminated by some form of automation. Yes, the opportunity for some operator errors may be reduced, but what about maintenance errors and how does it affect operator behaviour?

In this case the proposal from Volvo is for a system that monitors what is going on around the car and applies the brakes to avoid collisions.

In fact the article goes on to quote Peter Rodger, chief examiner for the Institute of Advanced Motorists. "We have to be very careful not to ‘underload’ the driver. There is an issue in the airline industry that if the pilot is inadequately involved and something goes wrong, it takes them a long time to actively take over.

“There needs to be adequate involvement so the driver isn’t allowed to switch off in this way, so that they are ready to react if something goes wrong. We also need to be confident that these systems have the power to work in myriad real-life situations.”

Volvo refer to some interesting research they have made. They claim "about 50% of drivers don’t brake at all before a crash – perhaps because they are paralysed by fear or simply distracted. The other 50% may brake, but probably not as effectively as they could do."

Andy Brazier