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Safety, Culture and Risk. The Organisational Causes of Disasters
Hopkins, Andrew
ISBN: 1-921022-25-6 2005 172 pages CCH Australia
Bruce Hocking
Andrew Hopkins is one of Australia's foremost thinkers on workplace safety. He has been influential in drawing attention to failures by organisations, as distinct from failures by individuals, as the causes of major disasters in Australian mines and chemical plants. Therefore a new book from him is read with anticipation of providing further help in understanding the complexity of these events: he does not disappoint.
Safety, culture and risk is best approached as a collection of five essays rather than as chapters in a book. The foreword by James Reason, an internationally distinguished authority on accidents, sets the scene. Reason notes that technical or mechanical failures as causes of accidents have become uncommon, whereas human performance problems have come into greater prominence. These are sometimes described as ‘human error', but many investigations have shown that the workers immediately involved are not so much the instigators of bad events as the inheritors of an accident waiting to happen. Hopkins pursues this theme by looking for the ‘causes of the causes' in the two main essays.
The major essay examines the Glenbrook (NSW) train crash in which seven people died in 1999; a tragedy eerily foreshadowing the similarly fatal Waterfall train crash of 2003. Whilst the immediate cause of the Glenbrook crash was due to a train driver passing a failed red signal with the blessing of the signal operator, Hopkins doggedly identifies the series of failures in the rail organisation which led to this behaviour. These include: a preoccupation with endless rules for train drivers to follow and associated disempowerment to make sensible decisions; the disaggregation of the railways into separate companies, weakening any sense of cooperation between employees from different companies in achieving safety; a premium placed on ‘on time running' leading to a conflict with safety considerations; and a complacency about safety risks. There is an excellent flowchart which shows the complexity of interaction of these various forces leading to the accident.
A shorter essay examines the problems which arose from the ‘deseal/reseal' program for repairing the fuel tanks of F111 fighters in the RAAF. The solvents used in this program caused extensive neuro-psychological harm to many ground-crew and resulted in a major Board of Inquiry of which Hopkins was a member. The proximate causes of the injuries could be attributed to failure to use personal protective equipment; however the equipment sometimes dissolved in the solvents and was very difficult to wear in the space and heat inside the fuel tanks. Hopkins identifies several factors operating in the RAAF which contributed to the injuries. These included a lack of attention by medical personnel to complaints from the workers over many years; the priority placed on operational flying over the supporting logistics; the lack of authority for those involved with health and safety of ground crew compared to aircrew; and inadequate systems for reporting incidents in ground crew compared to aircrew. The point is well made that the same organisation can have a very good record for flight safety but a poor one regarding safety of other workers such as ground crew. The analysis of reasons for this imbalance is instructive. The key is the focus of senior management, which in turn depends on comprehensive safety reporting systems and organisational structures to effectively implement decisions about safety. These factors were present for flight safety but defective for the OHS of ground crew.
Two brief theoretical essays, one on ‘Quantitative Risk Assessment' and the other on ‘Risk Society' help round out the collection. Hopkins criticises the current fashion for quantitative risk assessment on several grounds including theoretical and practical difficulties in quantifying risk, as well as the concept of ‘acceptable risk', which begs the question: acceptable to whom? Workers, shareholders, train passengers? He favours the current legal approach to safety which involves the concept of reducing risk to ‘as low as reasonably achievable'. Although this is imprecise, and can give rise to uncertainty, I concur with Hopkins because it enables each situation to be judged on its merits and evolve with community expectations. The essay on ‘Risk Society' looks at why an increasing number of incidents provoke outrage in a modern society. Hopkins extends the ideas of the anthropologist Mary Douglas, who noted that many societies have sought to allocate blame for various misfortunes, using concepts such as witchcraft or acts of God, but these explanations have become unacceptable in modern secular, scientific societies, so legal responsibility and moral outrage have become substitutes. Unfortunately this potentially very interesting essay is too short.
The essay ‘Cultural Approaches to Safety', which links to the title of the book, is perhaps the least successful of the collection. It seeks to define organisational culture and its relationship to safety culture. However I found it meandering and comprised of truisms, such as culture is ‘the way we do things around here'. Adding the layer of jargon about culture doesn't improve understanding of the valid point that productivity and safety are heavily influenced by whatever gets consistent attention from the chief executive officer. This requires structures to be in place to provide timely information and to execute decisions about safety.
The book will be of interest to readers who want to learn from investigations of major accidents as well as having their horizons broadened regarding concepts of managing safety risk. The essays on the Glenbrook train crash and the RAAF ‘deseal/reseal' program would be useful reading for postgraduate students of occupational health and safety, and hopefully, some students of management. The book would be enhanced by a few photographs and diagrams of the major accidents described.
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