The lessons of Longford - Company Director

By Carl Luttig, managing director of OHS change management advisors ZEAL Consulting
(Article for the Australian Institute of Company Directors’ publication "Company Director")

The death of two men in the Esso Longford gas plant explosion last winter has brought into focus many of the hurdles still in the way of genuine understanding of workplace safety, particularly by those in positions of responsibility.

Unfortunately, the royal commission process used to shed light on the cause of the accident was not suited to greatly improving that broader knowledge.

Nor was the adversarial nature of the process conducive to creating a climate in which companies felt encouraged to step up their own workplace safety efforts.

Indeed it could be argued that the process inadvertently contributed to a tendency to treat safety as a legal issue rather than one of life or death. Blaming employees, some may have concluded, had become a far more acceptable option.

There is indeed evidence that, to many companies, the most glaring lesson from Longford was the urgency to tighten up their legal defence against charges arising from any major accident, instead of concentrating on preventing one from happening in the first place.

In one sense that is understandable, even unavoidable. Given the extent of the legal and financial ramifications of the Longford catastrophe, many companies’ initial response was always going to be on the defensive side.

However, this is not the sole explanation of such actions. In our experience, there is a wide-spread and persistent tendency to use a one-dimensional approach to workplace accidents. Too many companies still think in terms of singular causes, often regarding "human error" as a satisfactory conclusion. Blame also features prominently in their assessments.

As the royal commission evidence progressively unfolded in the public domain via the media, it was these rather simplistic concepts that occupied most of centre stage, rather than the complex, inter-related factors that constitute workplace safety, and indeed risk.

So what lessons might be learnt from a purely scientific inquiry into the causal links of a workplace disaster, devoid of legal motivations and constraints?

Before dealing with that question in some detail, it is worth lingering on some of the factors that have compounded the failure of the royal commission process so far to inspire more companies to tackle the complex safety issues.

First, we have the pending $1 billion class action against Esso.

The spectre of US-style litigation no doubt looms large, and justifiably so.

Such trepidation has a tendency to divert companies’ focus from proactive, creative problem solving toward adopting a predominantly defensive stance marshaled by lawyers rather than experts in the field of workplace safety.

However legal considerations are a major factor also in the way companies themselves inquire into workplace accidents. While proper scientific processes are usually used to analyse less severe accidents, the legal environment generated by catastrophic accidents invariably dictates the use of non-scientific processes, thus negating the search for multifactorial truth.

WorkCover’s new advertising campaign, stressing sanctions against employers who breach health and safety laws, may in some ways be viewed as feeding into this mindset.

The advertisements’ message is intended to cause corporate leaders to become personally more aware of the consequences of any failure on their part to meet legal responsibilities with regard to workplace safety.

It is a correct and urgent message for company directors and senior executives who traditionally have tended to treat workplace safety as a somewhat secondary issue.

Yet there is a danger that this message, together with the defensive climate flowing from the Longford experience, may be contributing to a situation where companies’ principal priority is to secure their legal position rather than actual accident prevention.

Whatever their motivation, ultimately the only real defence is a diligent, persistent and demonstrable endeavor to manage and reduce safety risks.

So what is the key to achieving a safe workplace?

The single most important factor, but one that goes largely unrecognised, is a company’s culture.

Most severe workplace accidents are linked to a combination of work culture related factors. Yet these considerations often are merely a silent subtext of the thousands of pages produced by non-specific legal processes..

The truth of the matter is that if you develop a "safe work culture", you are well on the way to improving safety.

The following conditions are essential for such a culture to thrive:

Purpose focused – a culture in which OH&S activity is clearly working within a context and with a strategic purpose, against which it can be assessed.

Risk based – efforts are directed toward the real risks and not just the compliance issues.

No blame – a culture that does not immediately seek to find a party at fault, but looks more broadly to the interactions between environmental, equipment, people and system factors that contributed to an accident, so as to find ways to improve.

Participation – a culture that encourages broad input into designing systems and work procedures, eventually from those who will eventually use the systems.

Ownership – a culture in which people feel "this is our OH&S system", not one imposed on them.

In such a workplace culture, emphasis on human failing is replaced by constructive efforts to put in place, maintain and continually improve policies, strategies, systems and behaviours that genuinely reduce risk, damage and cost.

Unquestionably, the first major step in that quest is to go beyond viewing incidents as isolated events with single causes, to seeing the broader patterns of interactions between multiple factors.

But as no man is an island, so any OH&S culture is subject to broader business imperatives. They include profitability, competitiveness and, at probably unprecedented levels, the creation of shareholder value.

So few of the companies we see have been able to integrate safety into these broader perspectives.

To meet their goals, many companies therefore focus almost entirely on reducing their lost time injury frequency rates. Little regard is given to the fact that a good LTIFR record does not necessarily mean a workplace is free of life-threatening safety risks.

The fact is there is only a tenuous connection between LTIFR performance and the likelihood of employees getting killed or disabled in workplace accidents.

In fact, you can have a good LTIFR record in a potential death trap!

Common incidents and catastrophic accidents are two totally different phenomena. The former we usually understand and know how to deal with. But the latter are unfamiliar and we struggle to find ways to overcome the risks.

Unfortunately, most companies still do not understand these differences. As a result, they fail to properly assess the serious safety risks inherent in the nature and design of their work places, let alone take the necessary preventive actions.

What is more, a good LTIFR record often gives companies a false sense of security with respect to the potential for high impact accidents.

The introduction of a two-tiered approach to workplace safety – that is one where minor damage and high impact damage, including fatalities, are subject to separate but integrated strategies – must be driven from the top. WorkCover’s new Major Hazard Unit is a step in the right direction. So indeed is the aforementioned advertising campaign aimed at sheeting home ultimate responsibility.

Senior management must accept responsibility for, and become more directly involved in, occupational health and safety because a major catastrophe can determine business viability itself.

And there is yet another cultural aspect to the equation: Organisational change.

Perpetual and all-pervasive, its impact on workplace safety is inestimable.

There are many examples where the effects of organisational change, including the extensive use of outsourced services, has significantly contributed to the circumstances leading to a major workplace accident.

In many companies, organisational change and outsourcing has blurred the lines of responsibility and created gaps in managerial responsibilities, particularly with respect to OH&S.

Of course, nobody wants those gaps to exist. But the fact is they do, and it is up to companies to ensure they are properly plugged.

So what are the lessons of Longford?

I believe that any process that does not address the broader issues outlined above is unlikely to contribute significantly to our knowledge of how to effectively reduce the risk of serious workplace accidents, or even catastrophes.

An adversarial legal process is not suited to the scientific approach needed to find these kind of answers.

Nor is its emphasis on pursuing the "guilty party" conducive to a climate in which companies will readily address the highly complex issues of work culture.

It is nevertheless to be hoped that corporate leaders will come to ignore the Longford headlines and instead focus on the commission’s sub-text. Because it is there that most of the really valuable lessons can be learnt.