CEO & board not receiving clear information on effectiveness of critical controls – Maritime NZ case

Fourth post from the Maritime NZ case where the CEO (Gibson) was charged under a failure to exercise due diligence for a work fatality (Ports of Auckland Limited (POAL).

Some extracts on critical risks and controls: (** Post 2 in comments)

· “As Mr Kahler succinctly put it, “gravity is generally [the] most common killer of people and suspended loads precedes all legislation, it’s been with us for a hundred years of data recording”

· “POAL relied on a number of controls to manage the risk of handling overhead loads including gangway briefings, the use of the hazard board, lasher training, lash leading hand training, supervisor shift visits and walkabouts, and toolbox meetings”

· “I note, however, the absence of evidence of any “hard” or technical controls, for example, the placement of physical barriers or signage preventing access to areas where a crane was working on a ship. I consider it relevant that such additional controls were able to be put in place within a very short space of time following Mr Kalati’s death”

· “It is clear that the introduction of lash platforms was a significant positive development in the management of this critical risk. It was a hard or technological control. This evidence is, however, a double-edged sword: while the introduction of the lash platforms speaks positively to Mr Gibson’s desire to address risk and promote worker safety, it is also a matter of concern that the risk only appears to have been recognised and addressed after Mr Gibson personally observed the way the work was being undertaken”

· “There is no indication in the evidence that POAL had identified the risk and the need for the associated control in any systemic way”

· “the Executive would engage in what was described as a monthly “deep dive” into each one of the seven critical risks. Mr Gibson, General Managers and the Senior Manager of Health & Safety would review a critical risk and a Critical Risk Report would be produced and presented to the Board”

· “Mr Kahler said that the paper presented to the Board on this critical risk was: …not a report that reflects current actual behaviours of lashing crews or any other crews. It is a descriptive document of how handling loads is managed in the business”

· Such a report is expected to “reflect the results of audits, observations and engagement processes that would assure the CEO and the Board that handling loads was happening effectively. There are no lead indicators mentioned in the document”

· “It appears to be a guidance document. It does not describe the overall Critical Risk Owner or describe Critical Controls and the Control Owners appropriately. It has no measures with respect to verification by nominated roles of Critical Controls. This document does not allow a senior leader, such as the CEO, to gain insight as to what the actual compliances with associated controls are”

· “It is the CEO’s responsibility to ensure the Critical Risk programme develops into a robust system of sustainable Critical Controls that focus on reducing the fatality risk”

· “Mr Kahler referred to these documents as reflecting “health and safety immaturity”

· “… what I am not seeing in any of this is how you get the confidence at the CEO and Board level that what is happening, that we’ve got our critical risks effectively managed

· “The reports demonstrate that senior management or the Board were not gaining insight into work as done in relation to the critical risk of handling loads”

· “In relation to Health and Safety Performance reports, the audit report noted the lack of commentary in the reports regarding the effectiveness of critical controls for critical risks”

· “The critical risk of handling suspended loads was not addressed again in Board minutes until after Mr Kalati’s death”