Can a focus on compliance distract us from managing risk? Perhaps, according to a coronial investigation.
Described in this coroner’s report was the drowning of an Operations Supervisor at an organics facility during a flash flood event. Regrettably, the supervisor was caught in an overflowing leachate drain.
Some findings in this report were that:
- “industry standards relating to the design of drains, sewers and like systems tend to be focussed on questions of efficiency rather than safety” and there’s a “general lack of appreciation of the safety risks relating to drainage”
- If rules are to be relied upon, then “management needs to give precise directions to people as to what they are to do in such situations and the people have to be given the means to comply”
- In this case, the company had given an instruction not to enter water beyond gumboot depth but had not “clarified (a) the full range and magnitude of the potential risks if the rule was disobeyed nor (b) resolved the conflict between the rules that applied in this situation”
- However, “mere directions may be insufficient if the reasons for the directions are insufficiently clear or are not understood by the recipients of the directions”
- Moreover, while not entering water deeper than gumboots seems simple on the surface, these policies “did not meet every exigency”
- That is, no flood was expected. There appeared to be a condition where the existing rules didn’t interact or play together nicely, given there were few design options to eliminate risk of water
- The coroner notes the “common human experience that safety warnings … can become so routine that they lose impact”
- And that, “We tire of being in a state of vigilance against dangers that rarely materialise”, resulting in procedures becoming a “tick-a-box” exercise
- The coroner also warns that “Workplace safety managers can become so concentrated on compliance with rules and regulations that the reason for those rules and regulations and checklists can be forgotten”
An apt quote from James Reason is provided, arguing for a preoccupation with failure.
Source: Coroners Court NSW (2016) Inquest into the death of Paul Smith.
Link: https://coroners.nsw.gov.au/documents/findings/2016/Smith%20findings%2008%2004%2016.pdf
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