Another coroner’s report critical about written instructions/JSAs and the like; as they often seem to be.
For one, why bother developing instructions etc. if you don’t get people to read them, train them in work practices, or even have the instructions on site for reference?
Safety in this context isn’t a numerical statistical risk, but rather a “carefully considered analysis of the work to be performed”.
Moreover, some state safety inspectors following the fatal accident were “critical of the work method statement as not properly defining the job being done and was silent in relation to a number of matters”.
That is, safety is about work.
i.e. Consulting and cooperating, planning, implementing and verifying safe methods of work, considering the specific work task, and unique conditions and constraints at play in the environment, rather than generic hazard lists and non-contextual controls.
Indeed, the coroner noted that that work method statements and JSAs were “inadequate to describe how the work was performed and the associated safety considerations” and that the work plans “did not identify the particular aspects of the work, nor the particular safety considerations which applied to those processes”.
Source: Coroners Court of Victoria. (2010). Finding into death with inquest. PRICE, GREGORY (#2390/01).
Report link: https://www.coronerscourt.vic.gov.au/sites/default/files/2018-12/gregoryprice_239001.pdf
SafetyInsights.org 
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