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Nature vs Nurture (Part 1) - The Tragedy of the Commons

Shelley Inkster - Friday, April 01, 2016
The Tragedy of the Commons


Whilst we will successfully thrust and parry technology against nature to counter many of the challenges we face, our limiting factor is ultimately population. Our growth and expectation of quality of life is unsustainable.

As we will eventually be forced to limit population, it would be reasonable to ask why a global strategic approach has not been developed before now.

As we look to the future, government scientific and economic policy should reflect an appreciation of both human and environmental resources in a holistic way.      

When appreciation for care of the planet first took major root during the 1960s and 1970s a number of prominent people publicised their ideas on the future of human-ecosystem relationships. One vocal proponent of these concepts was E.F. Schumacher (author of

Small is beautiful:  Economics as if people mattered’ and ‘Schumacher on Energy’) and when asked if he thought his ‘Buddhist economics’ would work in the west, he replied, “Why not? The west is just as much capable of common-sense as anybody else!”  (E F Schumacher was known for his sense of humour and optimism as well as his intellect and vision).

If we are, as E F Schumacher put forward as capable of common-sense, our focus needs to be concurrently slowing our rate of expansion and implementing sustainable, clean technologies to diffuse our impact.

Safety Alert - Faulty Grinding Discs

Shelley Inkster - Friday, April 01, 2016

On the 13/1/16, an employee at Ottoway Fabrications Whyalla facility reported a 125mm Flexovit grinding

disc had started to show signs of damage in normal use, he changed the disc out and continued

using another disc from the same box, again he noticed the new disc doing the same.


The employee brought the 2 discs to the HSE Department along with the box that the discs were sourced

from.  The discs showed clear indication that the mounting holes were off centre. Upon inspecting the box,

similar discs were found throughout to have the off centre mounting holes.


A stop work was called and all workers were informed of the problem and encouraged to inspect all discs

in their possession before recommencing work.


Actions moving forward:


All employees to inspect grinding discs prior to use and report all faults/defects to the Supervisor or

HSE Department immediately.


The supplier was notified of the defects and requested to investigate the issues.


Thank you to the team at Ottoway Fabrications for the Safety Alert.

WHS Toolbox Tips #1 (Part 9b) - Consultation is a 'Two Way Street'

Kevin Stretton - Tuesday, March 29, 2016

Consultation is a ‘Two Way Street’


The WHSR has a pivotal role in the consultative process and apart from mediation and representing their workgroup acts as a ‘technical interpreter’ between the employer and employee.


How do the roles of a WHSR combine hazard identification, risk assessment and consultation?


With an intimate knowledge WHSR’s already have a detailed understanding of specific hazards in their workplace and are able to communicate these to employees and the employer. Additionally, if the WHSR has a thorough understanding of risk assessment then they are in a unique position to communicate with employees how risk assessments are to be completed and the importance of ranking hazards for the significance of risk.


If an employer, employees and their WHSR’s do not have a common or shared understanding of these requirements workplace safety often becomes a ‘shotgun’ approach where complex hazards are perceived as too difficult to correct or eliminate.


Likewise, employers must ensure that WHSR’s have the respect of everyone and the resources to be able to complete their role, especially when educating others about specific workplace safety issues.

WHS Toolbox Tips #1 (Part 9a) - The Basis for a WHS Representative's Role

Kevin Stretton - Thursday, March 24, 2016

The basis for a WHS Representative’s role


The national model for work, health & safety (WHS) legislation requires that where elected WHS Representatives are involved in communication, consultation, participation between employers and employees, problem solving & promotion of WHS.


The objective to encourage employee representatives to become engaged or involved in the strategic continual improvement process of:-


       ·    Hazard identification

· Risk assessment

· Control which includes hazard elimination or risk reduction


Therefore it’s important to recognise that WHS Representatives play a pivotal role in the success of any short or longer term WHS improvements.


This and subsequent articles will progressively look at the responsibilities and roles of WHS Representatives.


The role of WHS Representatives (WHSR)


Hazard identification & risk assessment:-

The WHSR has a central role in facilitating & supporting the implementation of WHS in the workplace.


This can only occur if there is a common interpretation and understanding between employees and employers of hazard identification and risk assessment specific to the workplace.


Although many businesses and organisations have common hazards which provide opportunities for sharing knowledge, every business and organisation also have hazards specific or unique to their operations.


It is this uniqueness which requires WHS Representatives to be familiar with their work place and the interactions between infrastructure, methods or procedures and people. It is this quality that wherever possible requires the WHSR be elected from within their work group.

Toolbox Tips #1 (Part 8c) - The Concepts of Incident Causation

Kevin Stretton - Monday, March 21, 2016

Part 8c:           Common examples of sophisticated causation analysis models


Kepner Tregoe Causation Model


Stair – Step Model of Causation

International Journal of Engineering - Construction Accident Causal Models


Failure Modes Effects Analysis (FMEA)

Process Analysis Tool


Ishikawa Fishbone Diagram analysis tools-fishbone





We have seen how our thinking can be influenced by a wide range of social interpretations and how, in turn, our behaviours influence the way we approach incident investigation.


We can only hope to create a culture of continual improvement in the organisation if we change our thinking and assist others to not only follow but practice these improved skills.


The more people we encourage to adopt an analytical approach to systems design & improvement the faster will be the transition to a culture based on the prevention of error.



Toolbox Tips #1 (Part 8b) - The Concepts of Incident Causation

Kevin Stretton - Thursday, March 17, 2016

Part 8b:          Applying the new thinking


In most cases the ‘5 Why’ approach will suffice as an investigation model for many organisations.


The ‘5 Why’ approach simply requires that everyone participate in an exercise asking ‘Why’ questions at every step of the incident analysis. Upon reaching (b) in the timeline five ‘Why’ questions are asked for each of the observed symptoms.




An example:

1.    Injury:             


a.    An employee loses an eye. Why?


2.    Incident:


                  a.    The grinding wheel shattered and struck the employee’s face fracturing a cheek

                       bone which punctured the eye from behind. Why?


      3.    Symptomatic causes:


a.    They were only wearing safety glasses. Why?

b.    Employee was not wearing a face shield / visor. Why?

                  c.    Pieces of the grinding wheel displayed signs of furrowing. Why?


       4.    Management, Systems Control & Root Causes:


a.    There is no evidence that the employee had been informed, instructed or trained to use face visors as PPE. Why?

b.    There is no evidence that the employee had been informed, instructed or trained to inspect grinding wheels before using them. Why?

c.    No training system in place for employees other than tradespeople regarding pedestal grinder safety. Why?

d.    There is limited evidence to suggest occasional maintenance inspections & work included redressing of grinding wheels. Why?

e.    The hazard & housekeeping inspections lacked sufficient detail and were not specific to departmental hazards. Why?

 f.     There is no site wide approach to asset & preventative maintenance. Why?

                  g.    Employees, managers & supervisors are not appraised on safety performance or

                       the need to continually improve safety. Why?


    5.    Root Cause:


                 a.    Management has not been trained in the implementation and integration of safety

                      systems with normal operations.


Other investigation models can be used for complex incidents or when planning complex operations in order to avoid catastrophes.




Toolbox Tips #1 (Part 8a) - The Concepts of Incident Causation

Kevin Stretton - Monday, March 14, 2016

Summary of Part 7


In Part 7 we came to understand not only how human and social factors can influence our perceptions of incident causality we also determined that incident investigations can be a valuable tool for concentrating efforts on the continual improvement of management systems. 


Objectives of Part 8:


By combining an engineering & social approach, understand & apply the basic concepts of causality when:-

Designing management & work procedures [Safe / Standard Operating Procedures (SOP’s) or Work Instructions (WI’s)].

•    Completing an incident investigation.


So that through continual improvement and time, elimination of hazards & the prevention of error becomes the norm.


Part 8a:           Modern or recent incident investigation techniques


There are a variety of models available for incident investigation.

    Can you choose the one that is right for you &/or a variety of incident scenarios?

    Is there a ‘one size fits all’ model that can be used for everything like environmental, quality & safety incidents?


The answer to both these questions is yes, only if we redirect our thinking to the analysis & continual improvement of management systems because all systems direct & influence the way employees, executives, managers & supervisors operate.


This means focusing our techniques on (a) in the timeline and progressively working backwards through time to recall & trace the sequence of events.



This is the only way we can create a culture that is focused on prevention rather than reaction.


Thought about carefully this model can be applied to any incident, not just one involving employee illness or injury.


Some examples:

1.    Product or service recall following a customer’s complaint.

2.    A chemical spill that found its way into a natural water system.

3.    A financial error causing incorrect allocation of resources.

4.    A safety device which failed when being used by an employee under standard conditions.

       5.   Protective equipment being used incorrectly by an employee

Toolbox Tips #1 (Part 7b) - The Concepts of Incident Causation

Kevin Stretton - Friday, March 11, 2016


Traditional incident investigation


Traditionally and due to misconceptions of employees, executives, managers & supervisors, incident investigation was always focused on (b), (c) & (d) of the timeline.


This resulted in a focus on symptomatic causes.

Some common examples from incident investigation reports are:-


·         The employee failed to wear protective equipment.

·         The guard failed.

·         There were no guards in place and the employee lost their fingers in the machine.

·         Human error.


Issues & problems with this traditional approach are still linked with insufficient training


Deeper questions were rarely asked as a way of trying to understand management systems & the dynamism of workplaces.


·         Why was the employee not wearing their protective equipment?

·         Why did the guard fail?

·         Why were there no guards in place?

·         Why was there human error? For a good example of this often cited subjective statement & an ineffective initial investigation see - Air New Zealand Flight 901


Only management control & systems can:-


·      Train employees how to use & care for protective equipment (PPE).

·      Design machine guarding to be safe.

·      Create continual improvement in performance.


In Part 8 we start looking at how these concepts are linked with & can be used to understand incident investigation for the identification of root causes.

Toolbox Tips #1 (Part 7a) - The Concepts of Incident Causation

Kevin Stretton - Monday, March 07, 2016


Summary of Part 6


In Part 6 we came to understand how human and social factors can influence our perceptions of incident causality and as a result we are often only concerned with the immediate past rather than the chronology of incidents. 


Objectives of Part 7:


By combining an engineering & social approach, understand & apply the basic concepts of causality when:-

•   Designing management & work procedures [Safe / Standard Operating Procedures (SOP’s) or Work Instructions (WI’s)].

•   Completing an incident investigation.


So that through continual improvement and time, elimination of hazards & the prevention of error becomes the norm.


Part 7a:           Engineering interpretations of occupational incidents


1.    Lack of control in management systems:-

a.    All factors in a management system have relevance

b.    These need to be understood by the managers

c.    The word ‘control’ refers to the 4th function of professional management:

                                          i.    Planning

                                         ii.    Organisation

                                        iii.    Leading

                                       iv.    Controlling

2.    Basic & immediate causes (Aetiology):-

a.    Includes personal & social factors

b.    Lack of job knowledge (training)

c.    Physical or mental obstacles

d.    Inadequate work standards

e.    Inadequate maintenance of equipment

f.     Unsafe acts and conditions including unsafe engineering design

g.    Operating without authority

h.    Nullifying safety devices

i.      Poor housekeeping

3.    Incident = contact with the hazard which is an undesired event.

4.    Injury, damage or loss = physical illness, injury &/or property damage & loss whether instantaneous (acute) or delayed (chronic).


Bird, F; Management Guide to Loss Control, Institute Press, Atlanta


Heinrich et al, Industrial Accident Prevention; pages 25 - 28

The Changing Landscape of Risk and Risk Managment

Kevin Stretton - Friday, March 04, 2016

The Changing Landscape of Risk and Risk Management


If we could go back more than 15 years we would have found a business environment where mentioning the word ‘risk’ would have elicited word association responses such as banking, finance and insurances.


Over the past decade the business and risk environment has been changing rapidly and a much broader interpretation is now entering the vocabulary of boards, CEO’s, executives, managers and risk practitioners.


There are two major changes occurring in the current risk landscape, an increase in the number of risk categories and the potential size of risk that has to be managed. These rapid developments are now bringing risk to the forefront of all businesses, large, medium, multi-national and small.


This means that boards and executives now have to develop a refined focus on risk as well as translating strategy into action at middle management and employee levels. The focus on risk and the risk management process is accompanied by an emphasis on how it contributes to protecting the business and enhances value.


Without doubt this is an exciting new way of thinking as there is a reversal from ‘reactionary strategy’ to ‘prevention’ to ‘risk anticipation’ and those companies embracing the concept will be better prepared.


However, it will require a change in the way organisations encourage innovative thinking and the reporting of risk at various levels, especially at shareholders' meetings. Shareholders will want evidence on how well the organisation can adapt and cope with rapidly changing risk categories, environments & severities.


We’ve included some references for you to review and consider.


Forum for the Future


Managing how to learn 


Economics & culture