Accident Investigation
An industry and union perspective on why accident and incident rates remain stubbornly high.
Remove the blinkers and broaden your horizons to find out why accidents still happen
 For decades, Australian industry has embraced many systems to minimise workplace accidents and incidents. Yet, despite the best intentions, there's been little reduction in the rate at which people are killed or injured at work.
The union movement claims that as many as 800,000 Australian workers are seriously injured every year, and the question is being posed as to whether the real cause is being overlooked. 'The reason deaths and injuries happen in workplaces is because we don't pay attention to the daily signals warning that the injury is about to happen.' That's the conclusion reached by the National Health and Safety Officer for the Australian Workers Union (AWU), Yossi Berger. It's a view that is shared by the ex NSW OHS Manager for the Australian Industry Group (AIG), Gary Wall, who doesn't think people are aware of the messages they are getting from the workplace. Gary Wall says this particularly applies to the failure to report 'near misses'. Finding out why near misses or small accidents occur is just as important as investigating big accidents, as it may prevent a more serious accident happening in the future. All companies are required by law to investigate accidents, no matter how small. According to Gary Wall, this failure to report is often due to a lack of training. 'In a lot of small to medium businesses, people from leading-hands up to production managers initially came from the factory floor. There seems to be a distinct lack of training in health and safety matters', he says, adding that if there is training it is 'fairly ad hoc and informal'.
Human behaviour
According to Yossi Berger, OHS systems in use today fail to take into account ordinary human behaviour, which is predictably unpredictable. 'You have to build human behaviour into any OHS system,' he says. OHS systems fail to take into account the state of mind of employees when they arrive at work. They might be fatigued, for instance.  Yossi Berger says that experts claim many accidents are the result of apathy and rare said to be caused by the failure or workers and supervisors to report potential accident problems they encounter. But the AWU expert says that the so-called 'apathy' is often brought about by workers and supervisors getting an apathetic response when they report such matters. 'They find that they try to make a difference for a very long time, but they've been belting their heads against a brick wall. Therefore, they give up and it looks like apathy.'
He claims that workers, in many cases, are scared of losing their jobs or facing retribution. 'There's feeling in many situations that if you open your mouth you will get (the worst) jobs for the rest of your life!' However, Gary Wall of AIG suggests that this attitude is negative and could be potentially destructive. He believes that, in general, managers have the health and welfare of their workers at heart. 'Often it is just that they are unaware of the requirements and how to address hazards.' OHS guidelines for accident and incident investigation and reporting put behaviour as one of four components listed as essential factors in the lead up to an accident. (The others are design, environmental and managerial/supervisory components.) Behavioural factors can result in exposure to hazards through, for example, misuse of safeguards, improper use of tools and equipment, ignoring cautionary notices, failure to wear personal protective equipment, horseplay or poor standards of housekeeping. The reasons behind disregard for accepted safe systems of work and safety practices, procedures or rules need to be examined. Such behaviour may indicate the need for improved communication, further training, supervision or modification of controls so they are move convenient, more comfortable or easier to use. According to Gary Wall, human behaviour doesn't necessarily need to be built in to an OHS system. He prefers 'a balanced approach' between the behavioural side and the management systems side. 'You need to have your systems in place, you need to set your boundaries by having those systems, policies and procedures in place as well as attacking the safety culture aspects,' he says. 'Safety culture couldn't exist without the comprehensive systems being in place.' But Gary Wall believes it is essential to get the workforce involved in setting up the systems and in their ongoing improvement. 'Just trying to change the behaviour of people won't work in the long term.' He says that people are only human and they will make mistakes. 'You can train them to understand the ramifications of judgement errors but at the end of the day they need to be involved in setting up the systems. It's basically on-the-job training in health and safety.' The AIG expert is dubious about the value of workplace committees which, he says, tend to get caught up in 'the nitpicking, housekeeping sorts of issue.'
Revolution
Yossi Berger is passionately committed to bringing about a 'revolution' in attitudes towards accidents and incidents in the workplace. He believes that companies have invested millions on OHS systems that are not working. As well, there's often a huge gap between having a system, on the one hand, and implementing the system, on the other. 'No one is asking why, with all these systems and culture changes, nothing much is different!' He says a paradigm change is essential if safety records in Australian workplaces are to improve. Companies, he says, are 'bankrupt' of ideas when it comes to finding solutions and their attention is shifting to 'safety behaviour', putting the onus squarely on the worker. 'The attitude is 'we trained them, we put them through various classes, we gave them standard operating procedures to follow, but they didn't comply. Therefore operator error is the cause!' Yossi Berger cites as an example the Royal Commission into the explosion at Esso's Longford plant where, in evidence to the Commission, Esso put some of the blame on two operators. He also highlights official statistics for the Longford accident, showing two dead and eight injured, and claims that the real toll is much higher. 'Tons of workers will be injured for the rest of their lives as a result of the explosion. And the effect on their private life and their family's lives are 'injuries' that never enter the statistics'. The committed union supporter puts his case forward strongly. 'Thumping' a hand on a table usually elicits a momentary startled response, yet by comparison many Longford workers could be upset for hours. The explosion has 'ripped through their souls''.
Ageing equipment and ageing people
OHS problems in some workplaces can be twofold - ageing machinery and an ageing workforce.  'People get so used to their own environment that they tend to put on the blinders and don't see the hazards,' according to Gary Wall. He says this can apply from employees up to managers. 'This can be an OHS management system issue or a workplace hazard issue that just hasn't been identified.'
Some things are fairly obvious. Gary Wall says he recently visited a manufacturer of concrete products where trowelling work was in progress. 'They were finishing off the cast products and had been doing it the same way for years. The workers were bending over from the waist to ground level, or kneeling down on a hard concrete floor to trowel away the excess concrete from moulds. When I suggested they could bring it to waist level by moving a couple of benches, they said they hadn't thought about that. Yet this was a serious manual handling injury waiting to happen.'
The supervisor's dilemma
Yossi Berger refers to what he calls 'the supervisor's dilemma'. This is brought about by what he sees as the tension between profit and productivity on one hand and looking after workers' interest on the other. 'A supervisor can be told by his boss that he really loves his workers, he really respects them deeply, they are the most important resource he has. But in the same breath he will tell the supervisor, 'If you don't get 273 cars off the production line today your job will be in jeopardy!' According to Yossi Berger, this can only be resolved by 'giving supervisors dignity'. A supervisor should be able to respond by saying that if the aim of 273 cars is to be met he'll need, say, two more staff. Supervisors often find themselves in 'humiliating' situations. For example, Yossi Berger quotes the example of a worker on a production line wanting to go to the toilet, but being asked by her co-workers to wait two hours because there was no one to replace her. Supervisors don't like being put in the position of appearing to 'harass' their mates either, but their jobs are on the line. As a result, they often develop what Yossi Berger refers to as 'detachable personalities', focussing on how many cars, how many tonnes, what movements, what chain etc.
Small business pressures
There is little argument that large companies are better placed to tackle OHS issue. 'They have the resources and the will to do it,' says Gary Wall. He says that many companies extend their employee development programs into the OSH field. 'These people tend to have better skills in OHS than in companies without an employee development structure.' Gary Wall believes that it is difficult for small business operators to keep pace with all the legislation and requirements, but at the end of the day OHS is a business benefit not a cost. 'If you have a safe place of work, you are going to have a productive and efficient workplace as well. If people don't have to worry about being injured when they go to work, they are going to be much more productive!'
Note: The article originally appeared in
CCH's Australian OHS magazine and is reproduced with the permission of CCH
Australia. 
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