Another coroner’s inquest which had some interesting findings around a tragic workplace death. This related to heat-related cardiac arrest, relating to a likely +40 degree Celsius day.
First, I like how the coroner’s frequently call out hindsight bias, and its effects in post-event clarity, that being “the potential to look at circumstances in retrospect and to criticize the decision-making of those who were only able to view events in prospect”.
The coroner was strongly critical of the reliance on the use of worker-led risk controls, like the buddy system, or responding to the climatic conditions themselves.
The coroner noted that these approaches “abrogates the responsibility of worker care to the workers themselves … [and this] abrogation of responsibility for worker care to untrained workers is unacceptable”.
It’s also observed that this buddy system existed in documented process only, not used in practice. What we’d call a fantasy plan.
That is, a fantasy plan is some safety artefact or process that allays concerns about a risk, even though it doesn’t reflect reality.
I see fantasy controls like the buddy system, task rotation, and self-assessments used a lot in fatigue management programs, sometimes it seems as a band-aid to patch up hazardous scheduling.
Moreover, the proposed controls were weak and ineffective around climatic conditions, including the lack of monitoring of actual conditions.
And while there was some thresholds in place for when work should be discontinued, these seemed to have been the result of “work condition negotiations” rather than based in health and safety and risk management.
Source: Hutton, J. (2016). Qld Coroner’s Court. Inquest into the death of Glenn Richard, NEWPORT.
Link: https://www.coronerscourt.qld.gov.au/__data/assets/pdf_file/0007/465046/cif-newport-gr-20160420.pdf
SafetyInsights.org 
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