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Risk Management Code of Practice

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Introduction to WHS Codes of Practice

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Lessons Learned from a Theme Park Tragedy

In this 30-minute video, we learn lessons from an accident in 2016 that killed four people on the Thunder River Rapids Ride in Queensland. The coroner’s report was issued this year, and we go through the summary of that report. In it we find failings in WHS Duties, Due Diligence, risk management, and failures to eliminate or minimize risks So Far As is Reasonably Practicable (SFARP). We do not ‘name and shame’, rather we focus on where we can find guidance to do better.

Lessons Learned from a Theme Park Tragedy

Transcript: Lessons Learned from a Theme Park Tragedy

Introduction

Hello, everyone, and welcome to the Safety Artisan: purveyors of fine safety engineering training videos and other resources. I’m Simon and I’m your host and today we’re going to be doing something slightly different. So, there’re no PowerPoint slides. Instead, I’m going to be reading from a coroner’s report from a well-known accident here in Australia and we’re going to be learning some lessons in the context of WHS workplace health and safety law.

Disclaimer

Now, I’d just like to reassure you before we start that I won’t be mentioning the names of the deceased. I won’t be sharing any images of them. And I’m not even going to mention the firm that owned the theme park because this is not about bashing people when they’re down. It’s about us as a community learning lessons when things go wrong in order to fix the problem, not the blame. So that’s what I’d like to emphasize here.

Coroner’s Report

So, I’m just going to I’m just turning to the summary of the coroner’s report. Basically, the coroner was examining the deaths of four people back in 2016 on what was called the Thunder River Rapids Ride. Or TRRR or TR3 for short because it’s a bit of a mouthful. This was a water ride, as the name implies, and what went wrong was the water level dropped. Rafts, these circular rafts that went down the rapids, went down the chute, got stuck. Another raft came up behind the stuck raft and went into it. One of the rafts tipped over. These raft seat six people in a circular configuration. You may have seen them. They’re in – different versions of this ride are in lots of theme parks. But out of the six, unfortunately, the only two escaped before people were killed, tragically. So that’s the background. That happened in October 2016, I think it was. The coroner’s report came out a few months ago, and I’ve been wanting to talk about it for some time because it really does illustrate very well a number of issues where WHS can help us do the right thing.

So, first of all, I’m looking at the first paragraph in the summary, the coroner starts off; the design and construction of the TRRR at the conveyor and unload area posed a significant risk to the health and safety of patrons. Notice that the coroner says the design and construction. Most people think that WHS only applies to workplaces and people managing workplaces, but it does a lot more than that. Sections 22 through 26 of the Act talk about the duties of designers, manufacturers, importers, suppliers and then people who commissioned, install, et cetera. So, WHS supplies duties on a wide range of businesses and undertakings and designers and constructors are key. There are two of them. Now, it’s worth noting that there was no importer here. The theme park, although the TRRR ride was similar to a ride available commercially elsewhere, for some reason, they chose to design and build their own version in Queensland. Don’t know why. Anyway, that doesn’t really matter now. So, there was no importer, but otherwise, even if you didn’t design and construct the thing, if you imported it, the same duties still apply to you.

Risks and Hazards

So, the coroner then goes on to talk about risks and hazards and says each of these obvious hazards posed a risk to the safety of patrons on the ride and would have been easily identifiable to a competent person had one ever been commissioned to conduct a risk and hazard assessment of the ride. So, what the coroner is saying there is, “No effective risk assessment has been done”. Now, that is clearly contrary to the risk management code of practice under WHS and also, of course, that the definition of SFARP, so far as reasonably practicable, basically is a risk assessment or risk management process. So, if you’ve not done effective risk management, you can’t say that you’ve eliminated or minimized risks SFARP, which is another legal requirement. So, a double whammy there.

Then moving on. “Had noticed been taken of lessons learned from the preceding incidents, which were all of a very similar nature …” and then he goes on. Basically, that’s the back end of a sentence where he says, you didn’t do this, you had incidents on the ride, which are very similar in the past, and you didn’t learn from them. And again, with respect to reducing risks SFARP, Section 18 in the WHS Act, which talks about the definition of reasonably practicable, which is the core of SFARP, talks about what ought to have been known at the time. So, when you’re doing a risk assessment or maybe you’re reassessing risk after a modification and this ride was heavily modified several times or after an incident, you need to take account of the available information. And the owners of TRRR the operators clearly didn’t do that. So, another big failing.

Scant and Ad Hoc Records

The coroner goes on to note that records available with respect to the modifications to the ride are scant and ad hoc. And again, there’s a section in the WHS risk management code of practice about keeping records. It’s not that onerous. I mean, the COP is pretty simple but they didn’t meet the requirement of the code of practice. So, bad news again.

And then finally, I’ve got to the bottom of page one. So, the coroner then notes the maintenance tasks undertaken on the ride whilst done so regularly and diligently by the staff, seemed to have been based upon historical checklists which were rarely reviewed despite the age of the device or changes to the applicable Australian standards. Now, this is interesting. So, this is contravening a different section of the WHS Act. In Section 27, it talks about the duties of officers and effectively that sort of company directors, senior managers. Officers are supposed to exercise due diligence. In the act, due diligence is fairly simple- It’s six bullet points, but one of them is that the officers have to sort of keep up to date on what’s going on in their operation. They have to provide up to date and effective safety information for their staff. They’re also supposed to keep up with what’s going on in safety regulation that’s applicable to their operation. So, I reckon in that one statement from the coroner then there’s probably three breaches of due diligence there to start with.

The Hierarchy of Controls

We’ve reached the bottom of page one – let’s carry on. The coroner then goes on to talk about risk controls that were or were not present and says, “in accordance with the hierarchy of controls, plant and engineering measures should have been considered as solutions to identified hazards”. So in WHS regulations and it’s repeated in the risk code of practice, there’s a thing called the hierarchy of controls. Basically, it says that some types of risk controls are more effective than others and therefore they come at the top of the list, whereas others are less effective and should be considered last.

So, top of the list is, “Can you eliminate the hazard?” If not, can you substitute the hazardous thing for something else that’s less hazardous- or with something else that is less hazardous, I should say? Can you put in engineering solutions or controls to control hazard? And then finally, at the bottom of my list is admin procedures for people to follow and then personal protective equipment for workers, for example. We’ll talk about this more later, but the top end of the hierarchy had just not been considered or not effectively anyway.

So, the coroner then goes on to say, “raft’s coming together on the ride was a well-known risk, highlighted by the incident in 2001 and again in 2004”. Now actually it says 2004, I think that might be a typo. Elsewhere, it says 2014, but certainly, there were two significant incidents that were similar to the accident that actually killed four people. And it was acknowledged that various corrective measures could be undertaken to, quote, “adequately control the risk of raft collision”. However, a number of these suggestions were not implemented on the ride. Now, given that they’ve demonstrated the ability to kill multiple people on the ride with a raft collision, it’s going to be a very, very difficult thing to justify not implementing controls. So, given the seriousness of the potential risk, to say that a control is feasible is practicable, but then to say “We’re not going to do it. It’s not reasonable”. That’s going to be very, very difficult to argue and I would suggest it’s almost a certainty that not all reasonably practicable controls were implemented, which means the risk is not SFARP, which is a legal requirement.

Further on, we come back to document management, which was poor with no formal risk register in place. So, no evidence of a proper risk assessment. Members of the department did not conduct any holistic risk assessments of rides with the general view that another department was responsible. So, the fact that risk assessment wasn’t done- That’s a failing. The fact that senior management didn’t knock heads together and say “This has to be done. Make it happen”- That’s also another failing. That’s a failing of due diligence, I suspect. So, we’ve got a couple more problems there.

Then, later on, the coroner talks about necessary engineering oversight of high-risk plant not being done. Now, under WHS act definitions, amusement rides are counted as high-risk plant, presumably because of the number of serious accidents that have happened with them over the years. The managers of the TRRR didn’t meet their obligations with respect to high-risk plants. So, there are some things that are optional for common garden stuff is mandatory for high-risk plants and those obligations were not met it seems.

Due Diligence

And then in just the next paragraph, we reinforce this due diligence issue. Only a scant amount of knowledge was held by those in management positions, including the general manager of engineering, as to the design modifications and passed notable incidents on the ride. One of the requirements of due diligence is that senior management must have a knowledge of their operations, a knowledge of the hazards and risks associated with the operations. So for the engineering manager to be ignorant about modifications and risks associated with the ride, I think is a clear failure of due diligence.

Still talking about engineering, the coroner notes “it is significant that the general manager had no knowledge of past incidents involving rafts coming together on the ride”. Again, due diligence. If things have happened those need to be investigated and learned from and then you need to apply fresh controls if that’s required. And again, this is a requirement. So, this shows a lack of due diligence. It’s also a requirement in the risk management code of practice to look at things when new knowledge is gained. So, a couple more failures there.

Now, it said that the operators of the ride were well aware that when one pump failed, and there were two, the ride was no longer able to operate with the water level dropping dramatically, stranding the rafts on the steel support railings. And of course, that’s how the accident happened. Regardless, there was no formal means by which to monitor the water level of the ride or audible alarm to advise one of the pumps had ceased to operate. So, a water level monitor? Well, we’re talking potentially about a float, which is a pretty simple thing. There’s one in every cistern, in every toilet in Australia. Maybe the one for the ride would have to be a bit more sophisticated than that- A bit industrial grade but basically the same principle. And no alarm to advise the operators that this pump had failed, even though it was known that this would have a serious effect on the operation of the ride. So, there’re multiple problems here. I suspect you’ll be able to find regulations that require these things. Certainly, if you looked at the code of practice on plant design because this counts as industrial plants, it’s a high-risk plant, so you would expect very high standards of engineering controls on high-risk plants and these were missing. More on that later.

Reasonably Practicable Controls Lacking

In a similar vein, the coroner says “a basic automated detection system for the water level would have been inexpensive and may have prevented the incident from occurring”. So basically, the coroner is saying this control mechanism would have been cheap so it’s certainly reasonably practicable. If you’ve got a cheap control that will prevent a serious injury or a death, then how on earth are you going to argue that it’s not reasonable to implement it? The onus is on us to implement all reasonably practical controls.

And then similarly, the lack of a single emergency stop on the ride, which was capable of initiating a complete shutdown of all the mechanisms, was also inadequate. And that’s another requirement from the code of practice on plant design, which refers back to WHS regulations. So, another breach there.

Human Factors Aspects

We then move on to a section where it talks about operators, operators’ account of the incident, and other human factors. I’m probably going to ask my friend Peter Bender, who is a Human Factors specialist, to come and do a session on this and look at this in some more detail, because there are rich pickings in this section and I’m just going to skim the surface here because we haven’t got time to do more. And the coroner says “it’s clear that these 38 signals and checks to be undertaken by the ride operators was excessive, particularly given that the failure to carry out any one could potentially be a factor which would contribute to a serious incident”. So clearly, 38 signals and checks distributed between two ride operators, because there was no one operator in control of the whole ride – that’s a human factors nightmare for a start – but clearly, the work designed for the ride was poor. There is good guidance available from Safe Work Australia on good work design so there’s really no excuse for this kind of lapse.

And then the coroner goes on to say, reinforcing this point about the ride couldn’t be safely controlled by a human operator. The lack of engineering controls on a ride of this nature is unjustifiable. Again, reinforcing the point that risk was not SFARP because not all reasonably practicable controls had been implemented. Particularly controls at the higher end of the hierarchy of controls. So, a serious failing there.  

(Now, I’ve got something that I’m going to skip, actually, but – It’s a heck of a comment, but it’s not actually relevant to WHS.)

Training and Competence

We’re moving on to training and competence. Those responsible for managing the ride whilst following the process and procedure in place – and I’m glad to see you from a human practice point of view that the coroner is not just trying to blame the last person that touched it. He’s making a point of saying the operators did all the right stuff. Nevertheless, they were largely not qualified to perform the work for which they were charged. The process and procedures that they were following seemed to have been created by unknown persons. Because of the poor record-keeping, presumably who it is safe to assume lacked the necessary expertise. And I think the coroner is making a reasonable assumption there, given the multiple failings that we’ve seen are in risk management, in due diligence, in record-keeping, in the knowledge of key people, et cetera, et cetera. It seems that the practice at the park was simply to accept what had always been done in terms of policy and procedure. And despite changes to safety standards and practices happening over time, because this is an old ride, only limited and largely reactionary consideration was ever given to making changes, including training, providing to staff. So, reactionary -bad word. We’re supposed to predict risk and prevent harm happening. So, multiple failures on due diligence here and on staff training, providing adequate staff training, providing adequate procedures, et cetera.

The coroner goes on to say, “regardless of the training provided at the park, it would never have been sufficient to overcome the poor design of the ride. The lack of automation and engineering controls”. So, again, the hierarchy of controls was not applied, relatively cheap, engineering controls not used, placing an undue burden on the operator. Sadly, this is all too common and in many applications. This is one of the reasons they are not naming the ride operators or trying to shame them because I’ve seen this happen in so many different places. It wouldn’t be fair to single these people out.

A History of ‘Incident-free Operation’?

Now we have a curious, a curious little statement in paragraph 1040. The coroner says “submissions are made that there was a 30-year history of incident-free operation of the ride”. So, what it looks like is that the ride operators, management, trying to tell the coroner that they never had an incident on the ride in 30 years, which sounds pretty impressive, doesn’t it, at face value. But of course, the coroner already knew or discovered later on that there had been incidents on the ride. In fact, there have been two incidents that were very similar to the fatal accident.

Now, on the surface, this looks bad, doesn’t it? It looks like the ride management was trying to mislead the coroner. I don’t actually think that’s the case because I’ve seen so many organizations do poor incident reporting, poor incident recording, and poor learning from experience from incidents, that it doesn’t surprise me that the senior management was not aware of incidents on their ride. Unfortunately, it’s partly human nature.

Nobody likes to dwell on their failures or think about nasty things happening, and nobody likes to go to the boss saying we need to shut down a moneymaking ride. (Don’t forget, this was a very popular ride.) We need to shut down a moneymaking ride in order to spend more money-making modifications to make it safer. And then management turns around and says, “Well, nobody’s been hurt. So, what’s the problem?” And again, I’ve seen this attitude again and again, even on people operating much more sophisticated and much more dangerous equipment than this. So, whilst this really does look bad- the optics are not good, as they like to say. I don’t think there’s actually a conspiracy going on here. I think it’s just stupid mistakes because it’s so common. Moving on.

Standards and the Regulator

Now the coroner goes on to talk about standards not being followed, particularly when standards get updated over time. Bearing in mind this ride was 30 years old. The coroner states “it is essential that any difference in these standards are recognized and steps taken to ensure any shortfalls with a device manufactured internationally is managed”. Now, this is a little bit of an aside, because as I’ve mentioned before, the TRRR was actually designed and manufactured in Australia. Albeit not to any standards that we would recognize these days. But most rides were not and this highlights duties of importers. So, if you import something from abroad, you need to make sure that it complies with Australian requirements. That’s a requirement, that’s a duty under WHS law. We’ll come back to this in just a moment.

We’ll skip that one because we’ve done training and competency to death. So, following on about the international standards, the coroner also has a crack at the Queensland regulator, who I won’t name, and says “the regulator draws my attention to the difficulties arising when we’re requiring all amusement devices to comply with Australian standards. This difficulty is brought about by the fact that most amusement devices are designed and manufactured overseas, predominantly based on European standards”.

Now, in the rest of the report, the coroner has a good old crack at the regulator. (I’m sorry, if you’re Irish, a crack means a bit of fun. I’m not talking about a bit of fun.) The regulators, the coroner sticks the boot into the regulator for being pretty useless. And sadly, that’s no surprise in Australia. So basically, the regulator said, “Oh, it’s all too difficult!” And you think, “Well, it’s your job, actually, so why haven’t you done it properly?” But being a little bit more practical, if you work in an industry where a lot of stuff is imported and let’s face it, that’s pretty common in Australia, you’ve got two choices. You can either try and change Australian standards so that they align better to the standards of the kit where you’re getting the stuff from in your industry, or maybe the regulators could say, “Okay, this is a common problem across the industry. We will provide some guidance that tells you how to make that transition from the international standards to Australian standards and what we as the regulator consider acceptable and not acceptable”. And then that really helps the industry to do the right thing and to be consistent in terms of operation and enforcement. So, the regulator is letting their people who they regulate know this is the standard that is required of you, this is what you have to do. And that’s really the job of a good regulator.

So, the fact that the regulator in this particular case just hadn’t bothered to do so over a period of some decades, it would seem, doesn’t really say a lot for the professionalism of the regulator. And I’m not surprised that the coroners decided to have a go at them.

In Summary

So, we’ve been through just over 20 comments, I think. I mean, I actually had 24/25 in total, but I skipped a few because they were a bit repetitive and it’s interesting to note that there were two major comments on failure to conduct designer duties and that kind of thing. Seven on risk management, four on SFARP, although of course, all the risk management ones also affects SFARP, and five on due diligence.

So, there are almost 20 significant breaches there and I wasn’t even really trying to pick up everything the coroner said. And bearing in mind, I was only reading from the summary. I didn’t bother reading the whole report because it’s pages and pages and pages. And the lesson that we can draw from all of this is not to bash the people who make mistakes but to learn lessons for ourselves. How could we do better? And I think the lesson is everything that we need to do has been clearly set out in the WHS Act, in the WHS regulations. Then there are codes of practice that give us guidance in particular areas and our general responsibilities and these codes of practice also guide us on what should be considered, SFARP, for certain hazards and risks. Then there’s also some fantastic guidance, documentation and information available from Safe Work Australia. On, for example, human factors and good work design and so on and so forth.

So, there’s lots of really good, really readable information out there and it’s all free. It’s all available on that wonderful thing we call the Internet. So, there really is no excuse for making basic mistakes like this and killing people. It’s not that difficult. And a lot of the safety requirements are not that onerous. You don’t have to be a rocket scientist to read them and understand them. A lot of the requirements are basic, structured, common sense. So, the lesson from this awful accident is it doesn’t have to be this way. We can do much better than that quite easily and if we don’t and something goes wrong, then the law will be after us.

It will be interesting to see – I believe that WorkSafe Queensland is now investigating to see whether they’re going to bring any prosecutions that should be said. The police investigated and didn’t bring any prosecutions against individuals. I don’t know if Queensland has a corporate manslaughter act. I wouldn’t think so based on the fact that they’ve not prosecuted anybody. Now, you don’t need to find an individual guilty of gross negligence, manslaughter for WHS to take effect. So, I suspect that in due course, we will see the operators of the theme park probably cop a significant fine [after note: they did], and maybe some of their directors and senior managers will be going to jail [after note: they did not]. That’s how serious these and how numerous these breaches are. You really don’t need to dig very deep to see what’s gone wrong and to see that legal obligations have not been met.

For More …

Anyway, that’s it for this session. I hope you’ll join me again soon. On your screen, you should be seeing some options for following us on our YouTube channel and the link to the Web site to find more information. So, all that remains for me to say is thanks very much for watching and I’ll look forward to talking to you again soon. Goodbye.

There’s more!

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Foreword to all Codes of Practice

This post covers the Foreword to all Codes of Practice. In the 30-minute video, we introduce Australian WHS Codes of Practice (CoP). We cover: What they are and how to use them; their Limitations; we List (Federal) codes; provide Further commentary; and where to get more information. This session is a useful prerequisite to all the other sessions on CoP.

In particular, we explain the threefold significance of the statements found in the foreword.

Foreword to all Codes of Practice

This Code of Practice on how to manage work health and safety risks is an approved code of practice under section 274 of the Work Health and Safety Act (the WHS Act).

An approved code of practice is a practical guide to achieving the standards of health, safety and welfare required under the WHS Act and the Work Health and Safety Regulations (the WHS Regulations).

A code of practice applies to anyone who has a duty of care in the circumstances described in the code. In most cases, following an approved code of practice would achieve compliance with the health and safety duties in the WHS Act, in relation to the subject matter of the code. Like regulations, codes of practice deal with particular issues and do not cover all hazards or risks that may arise. The health and safety duties require duty holders to consider all risks associated with work, not only those for which regulations and codes of practice exist.

Codes of practice are admissible in court proceedings under the WHS Act and Regulations. Courts may regard a code of practice as evidence of what is known about a hazard, risk or control and may rely on the code in determining what is reasonably practicable in the circumstances to which the code relates.

Compliance with the WHS Act and Regulations may be achieved by following another method, such as a technical or an industry standard, if it provides an equivalent or higher standard of work health and safety than the code.

An inspector may refer to an approved code of practice when issuing an improvement or prohibition notice. 

This Code of Practice has been developed by Safe Work Australia as a model code of practice under the Council of Australian Governments’ Inter-Governmental Agreement for Regulatory and Operational Reform in Occupational Health and Safety for adoption by the Commonwealth, state and territory governments.

A draft of this Code of Practice was released for public consultation on 7 December 2010 and was endorsed by the Workplace Relations Ministers’ Council on 10 August 2011.

Scope and Application

This Code provides practical guidance for persons who have duties under the WHS Act and Regulations to manage risks to health and safety. The duty is placed on persons conducting a business or undertaking, including employers, self-employed, principal contractors, persons with management or control of a workplace, designers, manufacturers, importers and suppliers of plant, substances or structures that are used for work.

This Code applies to all types of work and all workplaces covered by the WHS Act. Other approved codes of practice should be referenced for guidance on managing the risk of specific hazards.

How to use this Code of Practice

In providing guidance, the word ‘should’ is used in this Code to indicate a recommended course of action, while ‘may’ is used to indicate an optional course of action.

This Code also includes various references to sections of the WHS Act and to regulations which set out the legal requirements. These references are not exhaustive. The words ‘must’, ‘requires’ or ‘mandatory’ indicate that a legal requirement exists and must be complied with.

Use the Latest Version

Image from https://www.legislation.gov.au/Details/F2016L00414 taken on 30 Aug 2020.

Copyright

The “text in quotes” was copied from the Federal Register of Legislation (https://www.legislation.gov.au/Details/F2016L00414) on 30 Aug 2020. It is reproduced under the terms of the CC 4.0 Licence – see here for full details.

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Transcript: Introduction to Codes of Practice

This is the Transcript for Codes of Practice. In the 30-minute video, we introduce Australian WHS Codes of Practice (CoP). We cover: What they are and how to use them; their Limitations; we List (Federal) codes; provide Further commentary; and Where to get more information. This session is a useful prerequisite to all the other sessions on CoP.

Transcript: Introduction to Codes of Practice

Hello and welcome to the Safety Artisan, where you will find professional, pragmatic and impartial teaching and resources on all thing’s safety. I’m Simon and today is the 16th of August 2020. Welcome to the show.

Introduction

So, today we’re going to be talking about Codes of Practice. In fact, we’re going to be introducing Codes of Practice and the whole concept of what they are and what they do.

Topics for this Session

What we’re going to cover is what Codes of Practice are and how to use them – several slides on that; a brief word on their limitations; a list of federal codes of practice – and I’ll explain why I’m emphasizing it’s the list of federal ones; some further commentary and where to get more information. So, all useful stuff I hope.

CoP are Guidance

So, Codes of Practice come in the work, health and safety hierarchy below the act and regulations. So, at the top you’ve got the WHS Act, then you’ve got the WTS regulations, which the act calls up. And then you’ve got the Codes of Practice, which also the act calls up. We’ll see that in a moment. And what Codes of Practice do are they provide practical guidance on how to achieve the standards of work, health and safety required under the WHS act and regulations, and some effective ways to identify and manage risks. So, they’re guidance but as we’ll see in a moment, they’re much more than guidance. So, as I said, the Codes of Practice are called up by the act and they’re approved and signed off by the relevant minister. So, they are a legislative instrument.

Now, a quick footnote. These words, by the way, are in the introduction to every Code of Practice. There’s a little note here that says we’re required to consider all risks associated with work, not just for those risks that have associated codes of practice. So, we can’t hide behind that. We’ve got to think about everything. There are codes of practice for several things, but not everything. Not by a long way.

Guidance We Should Follow

Now, there are three reasons why Codes of Practice are a bit more than just guidance. So, first of all, they are admissible in court proceedings. Secondly, they are evidence of what is known about a hazard, risk, risk assessment, risk control. And thirdly, courts may rely, or regulators may rely, on Codes of Practice to determine what is reasonably practicable in the circumstances to which the code applies. So, what’s the significance of that?

So first of all, the issue about being admissible. If you’re unfortunate enough to go to court and be accused of failing under WHS law, then you will be able to appeal to a Code of Practice in your defence and say, “I complied with the Code of Practice”. They are admissible in court proceedings. However, beyond that, all bets are off. It’s the court that decides what is anadmissible defence, and that means lawyers decide, not engineers. Now, given that you’re in court and the incident has already happened a lot of the engineering stuff that we do about predicting the probability of things is no longer relevant. The accident has happened. Somebody has got hurt. All these probability arguments are dust in the wake of an accident. So, Codes of Practice are a reliable defence.

Secondly, the bit about evidence of what is known is significant, because when we’re talking about what is reasonably practicable, the definition of reasonably practicable in Section 18 of the WHS act talks about what it is reasonable or what should have been known when people were anticipating the risk and managing it. Now, given that Codes of Practice were published back in 2012, there’s no excuse for not having read them. So, they’re pre –existing, they’re clearly relevant, the law has said that they’re admissible in court. We should have read them, and we should have acted upon them. And there’ll be no wriggling out of that. So, if we haven’t done something that CoP guided us to do, we’re going to look very vulnerable in court.  Or in the whatever court of judgment we’re up against, whether it be public opinion or trial by media or whatever it is.

And thirdly, some CoP can be used to help determine what is SOFARP. So in some circumstances, if you’re dealing with a risk that’s described a CoP, CoP is applicable. Then if you followed everything in CoP, then you might be able to claim that just doing that means that you’ve managed the risk SOFARP. Why is that important? Because the only way we are legally allowed to expose people to risk is if we have eliminated or minimized that risk so far as is reasonably practicable, SOFARP. That is the key test, the acid test, of “Have we met our risk management obligations? “And CoP are useful, maybe crucial, in two different ways for determining what is SOFARP. So yes, they’re guidance but it’s guidance that we ignore at our peril.

Standards & Good Practice

So, moving on. Codes of Practice recognize, and I reemphasize this is in the introduction to every code of practice, they’re not the only way of doing things. There isn’t a CoP for everything under the sun. So, codes recognize that you can achieve compliance with WHS obligations by using another method as long as it provides an equivalent or higher standard of work, health and safety than the code. It’s important to recognize that Codes of Practice are basic. They apply to every business and undertaking in Australia potentially. So, if you’re doing something more sophisticated, then probably CoP on their own are not enough. They’re not good enough.

And in my day job as a consultant, that’s the kind of stuff we do. We do planes, trains and automobiles. We do ships and submarines. We do nuclear. We do infrastructure. We do all kinds of complex stuff for which there are standards and recognized good practice which go way beyond the requirements of basic Codes of Practice. And many I would say, probably most, technical and industry safety standards and practices are more demanding than Codes of Practice. So, if you’re following an industry or technical standard that says “Here’s a risk management process”, then it’s likely that that will be far more detailed than the requirements that are in Codes of Practice.

And just a little note to say that for those of us who love numbers and quantitative safety analysis, what this statement about equivalent or higher standards of health and safety is talking about  –We want requirements that are more demanding and more rigorous or more detailed than CoP. Not that the end –result in the predicted probability of something happening is better than what you would get with CoP because nobody knows what you would get with CoP. That calculation hasn’t been done. So, don’t go down the rabbit hole of thinking “I’ve got a quantitatively demonstrate that what we’re doing is better than CoP.” You haven’t. It’s all about demonstrating the input requirements are more demanding rather than the output because that’s never been done for CoP. So, you’ve got no benchmark to measure against in output terms.

Primacy of WHS & Regs

A quick point to note that Codes of Practice, they are only guidance. They do refer to relevant WHS act and regulations, the hard obligations, and we should not be relying solely on codes in place of what it says in the WHS Act or the regulations. So, we need to remember that codes are not a substitute for the act or the regs. Rather they are a useful introduction. WHS ACT and regulations are actually surprisingly clear and easy to read. But even so, there are 600 regulations. There are hundreds of sections of the WHS act. It’s a big read and not all of it is going to be relevant to every business, by a long way. So, if you see a CoP that clearly applies to something that you’re doing, start with the cop. It will lead you into the relevant parts of WHS act and regulations. If you don’t know them, have a read around in there around the stuff that – you’ve been given the pointer in the CoP, follow it up.

But also, CoP do represent a minimum level of knowledge that you should have. Again, start with CoP, don’t stop with them. So, go on a bit. Look at the authoritative information in the act and the regs and then see if there’s anything else that you need to do or need to consider. The CoP will get you started.

And then finally, it’s a reference for determining SOFARP. You won’t see anything other than the definition of reasonably practicable in the Act. You won’t see any practical guidance in the Act or the regulations on how to achieve SOFARP. Whereas CoP does give you a narrative that you can follow and understand and maybe even paraphrase if you need to in some safety documentation. So, they are useful for that. There’s also guidance on reasonably practicable, but we’ll come to that at the end.

Detailed Requirements

It’s worth mentioning that there are some detailed requirements in codes. Now, when I did this, I think I was looking at the risk management Code of Practice, which will go through later in another session. But in this example, there are this many requirements. So, every CoP has the statement “The words ‘must’, ‘requires’, or ‘mandatory’ indicate a legal requirement exists that must be complied with.” So, if you see ‘must’, ‘requires’, or ‘mandatory’, you’ve got to do it. And in this example CoP that I was looking at, there are 35 ‘must’s, 39 ‘required’ or ‘requirement’ – that kind of wording – and three instances of ‘mandatory’. Now, bearing in mind the sentence that introduces those things contains two instances of ‘must’ and one of ‘requires’ and one of ‘mandatory’. So, straight away you can ignore those four instances. But clearly, there are lots of instances here of ‘must’ and ‘require’ and a couple of ‘mandatory’.

Then we’ve got the word ‘should’ is used in this code to indicate a recommended course of action, while ‘may’ is used to indicate an optional course of action. So, the way I would suggest interpreting that and this is just my personal opinion – I have never seen any good guidance on this. If it says ‘recommended’, then personally I would do it unless I can justify there’s a good reason for not doing it. And if it said ‘optional’, then I would consider it. But I might discard it if I felt it wasn’t helpful or I felt there was a better way to do it. So, that would be my personal interpretation of how to approach those words. So, ‘recommended’ – do it unless you can justify not doing it. ‘Optional’ – Consider it, but you don’t have to do it.

And in this particular one, we’ve got 43 instances of ‘should’ and 82 of ‘may’. So, there’s a lot of detailed information in each CoP in order to consider. So, read them carefully and comply with them where you have to work and that will repay you. So, a positive way to look at it, CoP are there to help you. They’re there to make life easy for you. Read them, follow them. The negative way to look at them is, ”I don’t need to do all this says in CoP because it’s only guidance”. You can have that attitude if you want. If you’re in the dock or in the witness box in court, that’s not going to be a good look. Let’s move on.

Limitations of CoP

So, I’ve talked CoP up quite a lot; as you can tell, I’m a fan because I like anything that helps us do the job, but they do have limitations. I’ve said before that there’s a limited number of them and they’re pretty basic. First of all, it’s worth noting that there are two really generic Codes of Practice. First of all, there’s the one on risk management. And then secondly, there’s the one on communication, consultation and cooperation. And I’ll be doing sessions on both of those. Now, those apply to pretty much everything we do in the safety world. So, it’s essential that you read them no matter what you’re doing and comply with them where you have to.

Then there are other codes of practice that apply to specific activities or hazards, and some of them are very, very specific, like getting rid of asbestos, or welding, or spray painting – or whatever it might be – shock blasting. Those have clearly got a very narrow focus. So, you will know if you’re doing that stuff. So, if you are doing welding and clearly you need to read the welding CoP. If welding isn’t part of your business or undertaking, you can forget it.

However, overall, there are less than 25 Codes of Practice. I can’t be more precise for reasons that we will come to in a moment. So, there’s a relatively small number of CoP and they don’t cover complex things. They’re not going to help you design a super –duper widget or some software or anything like that. It’s not going to help you do anything complicated. Also, Codes of Practice tend to focus on the workplace, which is understandable. They’re not much help when it comes to design trade –offs. They’re great for the sort of foundational stuff. Yes, we have to do all of this stuff regardless. When you get to questions of, “How much is enough?” Sometimes in safety, we say, “How much margin do I need?” “How many layers of protection do I need?” “Have I done enough?” CoP aren’t going to be a lot of use helping you with that kind of determination but you do need to have made sure you’ve done everything CoP first and then start thinking about those trade –offs, would be my advice. You’re less likely to go wrong that way. So, start with your firm basis of what you have to do to comply and then think “What else could I do?”

List of CoP (Federal) #1

Now for information, you’ve got three slides here where we’ve got a list of the Codes of Practice that apply at the federal or Commonwealth level of government in Australia. So, at the top highlighted I’ve already mentioned the ‘how’ to manage WHS risks and the consultation, cooperation, and coordination codes. Then we get into stuff like abrasive, blasting, confined spaces, construction and demolition and excavation, first aid. So, quite a range of stuff, covered.

List of CoP (Federal) #2

Hazardous manual tasks – so basically human beings carrying and moving stuff. Managing and controlling asbestos, and removing it. Then we’ve got a couple on hazardous chemicals on this page, electrical risks, managing noise, preventing hearing loss, and stevedoring. There you go. So, if you’re into stevedoring, then this CoP is for you. The highlighted ones we’re going to cover in later sessions.

List of CoP (Federal) #3

Then we’ve got managing risk of Plant in the workplace. There was going to be a Code of Practice for the design of Plant, but that never saw the light of day so we’ve only got guidance on that. We’ve got falls, environment, work environment, and facilities. We’ve got another one on safety data sheets for another one on hazardous chemicals, preventing falls in housing – I guess because that’s very common accident – safe design of structures, spray painting and powder coating, and welding processes. So, those are the list of – I think it’s 24 – Codes of Practice are applied by Comcare, the federal regulator.

Commentary #1

Now, I’m being explicit about which regulator and which set of CoP, because they vary around Australia. Basically, the background was the model Codes of Practice were developed by Safe Work Australia, which is a national body. But those model Codes of Practice do not apply. Safe Work Australia is not a regulator. Codes of Practice are implemented or enforced by the federal government and by most states and territories. And it says with variations for a reason. Not all states and territories impose all codes of practice. For example, I live in South Australia and if you go and look at the WorkSafe South Australia website or Safe Work – whatever it’s called – you will see that there’s a couple of CoP that for some reason we don’t enforce in South Australia. Why? I do not know. But you do need to think about these things depending on where you’re operating.

It’s also worth saying that WHS is not implemented in every state in Australia. Western Australia currently have plans to implement WHS, but as of 2020 but I don’t believe they’ve done so yet. Hopefully, it’s coming soon. And Victoria, for some unknown reason, have decided they’re just not going to play ball with everybody else. They’ve got no plans to implement WHS that I can find online. They’re still using their old OHS legislation. It’s not a universal picture in Australia, thanks to our rather silly version of government that we have here in Australia – forget I said that. So, if it’s a Commonwealth workplace and we apply the federal version of WHS and Codes of Practice. Otherwise, we use state or territory versions and you need to see the local regulator’s Web page to find out what is applied where. And the definition of a Commonwealth workplace is in the WHS Act, but also go and have a look at the Comcare website to see who Comcare police. Because there are some nationalised industries that count as a Commonwealth workplace and it can get a bit messy.

So, sometimes you may have to ask for advice from the regulator but go and see what they say. Don’t rely on what consultants say or what you’ve heard on the grapevine. Go and see what the regulator actually says and make sure it’s the right regulator for where you’re operating.

Commentary #2

What’s to come? I’m going to do a session on the risk management Code of Practice, and I’m also, associated with that, going to do a session on the guidance on what is reasonably practicable. Now that’s guidance, it’s not a Code of Practice. But again, it’s been published so we need to be aware of it and it’s also very simple and very helpful. I would strongly recommend looking at that guidance if you’re struggling with SFARP for what it means, it’s very good. I’ll be talking about that soon. Also, I’m going to do a session on tolerability of risk, because you remember when I said “CoP aren’t much good for helping you do trade–offs in design” and that kind of thing. They’re really only good for simple stuff and compliance. Well, what you need to understand to deal with the more sophisticated problems is the concept of tolerability of risk. That’ll help us do those things. So, I’m going to do a session on that.

I’m also going to do a session on consultation, cooperation, and coordination, because, as I said before, that’s universally applicable. If we’re doing anything at a workplace, or with stuff that’s going to a workplace, that we need to be aware of what’s in that code. And then I’m also going to do sessions on plant, structures and substances (or hazardous chemicals) because those are the absolute bread and butter of the WHS Act. If you look at the duties of designers, manufacturers, importers, suppliers, and installers, et cetera, you will find requirements on plant, substances and structures all the way through those clauses in the WHS Act. Those three things are key so we’re going to be talking about that.

Now, I mentioned before that there was going to be a Code of Practice on plant design, but it never made it. It’s just guidance. So, we’ll have a look at that if we can as well – Copyright permitting. And then I want to look at electrical risks because I think the electrical risks code is very useful. Both for electrical risks, but it’s also a useful teaching vehicle for designers and manufacturers to understand their obligations, especially if you operate abroad and you want to know, or if you’re importing stuff “Well, how do I know that my kit can be safely used in Australia?” So, if you can’t do the things that the electrical risk CoP requires in the workplace if your piece of kit won’t support that, then it’s going to be difficult for your customers to comply. So, probably there’s a hint there that if you want to sell your stuff successfully, here’s what you need to be aware of. And then that applies not just to electrical, I think it’s a good vehicle for understanding how CoP can help us with our upstream obligations, even though CoP applies to a workplace. That session will really be about the imaginative use of Code of Practice in order to help designers and manufacturers, etc.

And then I want to also talk about noise Code of Practice, because noise brings in the concept of exposure standards. Now, generally, Codes of Practice don’t quote many standards. They’re certainly not mandatory, but noise is one of those areas where you have to have standards to say, “this is how we’re going to measure the noise”. This is the exposure standard. So, you’re not allowed to expose people to more than this. That brings in some very important concepts about health monitoring and exposure to certain things. Again, it’ll be useful if you’re managing noise but I think that session will be useful to anybody who wants to understand how exposure standards work and the requirements for monitoring exposure of workers to certain things. Not just noise, but chemicals as well. We will be covering a lot of that in the session(s) on HAZCHEM.

Copyright & Attribution

I just want to mention that everything in quotes/in italics is downloaded from the Federal Register of Legislation, and I’ve gone to the federal legislation because I’m allowed to reproduce it under the license, under which it’s published. So, the middle paragraph there – I’m required to point that out that I sourced it from the Federal Register of legislation, the website on that date. And for the latest information, you should always go to the website to double–check that the version that you’re looking at is still in force and is still relevant. And then for more information on the terms of the license, you can go and see my page at the www.SafetyArtisan.com because I go through everything that’s required and you can check for yourself in detail.

For More…

Also, on the website, there’s a lot more lessons and resources, some of them free, some of them you have to pay to access, but they’re all there at www.safetyartisan.com. Also, there’s the Safety Artisan page at www.patreon.com/SafetyArtisan where you will see the paid videos. And also, I’ve got a channel on YouTube where the free videos are all there. So, please go to the Safety Artisan channel on YouTube and subscribe and you will automatically get a notification when a new free video pops up.

End

And that brings me to the end of the presentation, so thanks very much for listening. I’m just going to stop sharing that now. It just remains for me to say thank you very much for tuning in and I look forward to sharing some more useful information on Codes of Practice with you in the next session in about a month’s time. Cheers now, everybody. Goodbye.

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Transcript: Lessons Learned from a Fatal Accident

In this 30-minute video, we learn lessons from an accident in 2016 that killed four people on the Thunder River Rapids Ride in Queensland. The coroner’s report was issued this year, and we go through the summary of that report. In it we find failings in WHS Duties, Due Diligence, risk management, and failures to eliminate or minimize risks So Far As is Reasonably Practicable (SFARP). We do not ‘name and shame’, rather we focus on where we can find guidance to do better.

Transcript: Lessons Learned from a Theme Park Tragedy

Introduction

Hello, everyone, and welcome to the Safety Artisan: purveyors of fine safety engineering training videos and other resources. I’m Simon and I’m your host and today we’re going to be doing something slightly different. So, there’re no PowerPoint slides. Instead, I’m going to be reading from a coroner’s report from a well-known accident here in Australia and we’re going to be learning some lessons in the context of WHS workplace health and safety law.

Disclaimer

Now, I’d just like to reassure you before we start that I won’t be mentioning the names of the deceased. I won’t be sharing any images of them. And I’m not even going to mention the firm that owned the theme park because this is not about bashing people when they’re down. It’s about us as a community learning lessons when things go wrong in order to fix the problem, not the blame. So that’s what I’d like to emphasize here.

The Coroner’s Report

So, I’m just turning to the summary of the coroner’s report. Basically, the coroner was examining the deaths of four people back in 2016 on what was called the Thunder River Rapids Ride. Or TRRR or TR3 for short because it’s a bit of a mouthful. This was a water ride, as the name implies, and what went wrong was the water level dropped. Rafts, these circular rafts that went down the rapids, went down the chute, got stuck. Another raft came up behind the stuck raft and went into it. One of the rafts tipped over.

These rafts seat six people in a circular configuration. You may have seen them. They’re in – different versions of this ride are in lots of theme parks.

But out of the six, unfortunately, the only two escaped and four people were killed, tragically. So that’s the background. That happened in October 2016, I think it was. The coroner’s report came out a few months ago, and I’ve been wanting to talk about it for some time because it really does illustrate very well a number of issues where WHS can help us do the right thing.

WHS duties

So, first of all, I’m looking at the first paragraph in the summary, the coroner starts off; the design and construction of the TRRR at the conveyor and unload area posed a significant risk to the health and safety of patrons. Notice that the coroner says the design and construction. Most people think that WHS only applies to workplaces and people managing workplaces, but it does a lot more than that. Sections 22 through 26 of the Act talk about the duties of designers, manufacturers, importers, suppliers and then people who commissioned, install, et cetera.

So, WHS supplies duties on a wide range of businesses and undertakings and designers and constructors are key. Now, it’s worth noting that there was no importer here. The theme park, although the TRRR ride was similar to a ride available commercially elsewhere, for some reason, they chose to design and build their own version in Queensland. Don’t know why. Anyway, that doesn’t really matter now. So, there was no importer, but otherwise, even if you didn’t design and construct the thing, if you imported it, the same duties still apply to you.

No effective risk assessment

So, the coroner then goes on to talk about risks and hazards and says each of these obvious hazards posed a risk to the safety of patrons on the ride and would have been easily identifiable to a competent person had one ever been commissioned to conduct a risk and hazard assessment of the ride. So, what the coroner is saying there is, “No effective risk assessment has been done”. Now, that is clearly contrary to the risk management code of practice under WHS and also, of course, that the definition of SFARP, so far as reasonably practicable, basically is a risk assessment or risk management process. So, if you’ve not done effective risk management, you can’t say that you’ve eliminated or minimized risks SFARP, which is another legal requirement. So, a double whammy there.

Then moving on. “Had noticed been taken of lessons learned from the preceding incidents, which were all of a very similar nature …” and then he goes on. Basically, that’s the back end of a sentence where he says, you didn’t do this, you had incidents on the ride, which are very similar in the past, and you didn’t learn from them. And again, with respect to reducing risks SFARP, Section 18 in the WHS Act, which talks about the definition of reasonably practicable, which is the core of SFARP, talks about what ought to have been known at the time. So, when you’re doing a risk assessment or maybe you’re reassessing risk after a modification and this ride was heavily modified several times or after an incident, you need to take account of the available information. And the owners of TRRR the operators clearly didn’t do that. So, another big failing.

The coroner goes on to note that records available with respect to the modifications to the ride are scant and ad hoc. And again, there’s a section in the WHS risk management code of practice about keeping records. It’s not that onerous. I mean, the COP is pretty simple but they didn’t meet the requirement of the code of practice. So, bad news again.

due diligence

And then finally, I’ve got to the bottom of page one. So, the coroner then notes the maintenance tasks undertaken on the ride whilst done so regularly and diligently by the staff, seemed to have been based upon historical checklists which were rarely reviewed despite the age of the device or changes to the applicable Australian standards.

Now, this is interesting. So, this is contravening a different section of the WHS Act. In Section 27, it talks about the duties of officers and effectively that sort of company directors, senior managers. Officers are supposed to exercise due diligence. In the act, due diligence is fairly simple- It’s six bullet points, but one of them is that the officers have to sort of keep up to date on what’s going on in their operation. They have to provide up to date and effective safety information for their staff. They’re also supposed to keep up with what’s going on in safety regulation that’s applicable to their operation. So, I reckon in that one statement from the coroner then there’s probably three breaches of due diligence there to start with.

risk controls lacking

We’ve reached the bottom of page one- Let’s carry on. The coroner then goes on to talk about risk controls that were or were not present and says, “in accordance with the hierarchy of controls, plant and engineering measures should have been considered as solutions to identified hazards”. So in WHS regulations and it’s repeated in the risk code of practice, there’s a thing called the hierarchy of controls. Basically, it says that some types of risk controls are more effective than others and therefore they come at the top of the list, whereas others are less effective and should be considered last.

So, top of the list is, “Can you eliminate the hazard?” If not, can you substitute the hazardous thing for something else that’s less hazardous- or with something else that is less hazardous, I should say? Can you put in engineering solutions or controls to control hazard? And then finally, at the bottom of my list is admin procedures for people to follow and then personal protective equipment for workers, for example. We’ll talk about this more later, but the top end of the hierarchy had just not been considered or not effectively anyway.

a predictable risk

So, the coroner then goes on to say, “raft’s coming together on the ride was a well-known risk, highlighted by the incident in 2001 and again in 2004”. Now actually it says 2004, I think that might be a typo. Elsewhere, it says 2014, but certainly, there were two significant incidents that were similar to the accident that actually killed four people. And it was acknowledged that various corrective measures could be undertaken to, quote, “adequately control the risk of raft collision”. However, a number of these suggestions were not implemented on the ride.

Now, given that they’ve demonstrated the ability to kill multiple people on the ride with a raft collision, it’s going to be a very, very difficult thing to justify not implementing controls. So, given the seriousness of the potential risk, to say that a control is feasible is practicable, but then to say “We’re not going to do it. It’s not reasonable”. That’s going to be very, very difficult to argue and I would suggest it’s almost a certainty that not all reasonably practicable controls were implemented, which means the risk is not SFARP, which is a legal requirement.

Further on, we come back to document management, which was poor with no formal risk register in place. So, no evidence of a proper risk assessment. Members of the department did not conduct any holistic risk assessments of rides with the general view that another department was responsible. So, the fact that risk assessment wasn’t done- That’s a failing. The fact that senior management didn’t knock heads together and say “This has to be done. Make it happen”- That’s also another failing. That’s a failing of due diligence, I suspect. So, we’ve got a couple more problems there.

high-risk plant

Then, later on, the coroner talks about necessary engineering oversight of high-risk plant not being done. Now, under WHS act definitions, amusement rides are counted as high-risk plant, presumably because of the number of serious accidents that have happened with them over the years. The managers of the TRRR didn’t meet their obligations with respect to high-risk plants. So, there are some things that are optional for common garden stuff is mandatory for high-risk plants and those obligations were not met it seems.

And then in just the next paragraph, we reinforce this due diligence issue. Only a scant amount of knowledge was held by those in management positions, including the general manager of engineering, as to the design modifications and passed notable incidents on the ride. One of the requirements of due diligence is that senior management must have a knowledge of their operations, a knowledge of the hazards and risks associated with the operations. So for the engineering manager to be ignorant about modifications and risks associated with the ride, I think is a clear failure of due diligence.

Still talking about engineering, the coroner notes “it is significant that the general manager had no knowledge of past incidents involving rafts coming together on the ride”. Again, due diligence. If things have happened those need to be investigated and learned from and then you need to apply fresh controls if that’s required. And again, this is a requirement. So, this shows a lack of due diligence. It’s also a requirement in the risk management code of practice to look at things when new knowledge is gained. So, a couple more failures there.

no water-level detection, alarm or emergency stop

Now, it said that the operators of the ride were well aware that when one pump failed, and there were two, the ride was no longer able to operate with the water level dropping dramatically, stranding the rafts on the steel support railings. And of course, that’s how the accident happened.

Regardless, there was no formal means by which to monitor the water level of the ride or audible alarm to advise one of the pumps had ceased to operate. So, a water level monitor? Well, we’re talking potentially about a float, which is a pretty simple thing. There’s one in every cistern, in every toilet in Australia. Maybe the one for the ride would have to be a bit more sophisticated than that- A bit industrial grade but basically the same principle.

And no alarm to advise the operators that this pump had failed, even though it was known that this would have a serious effect on the operation of the ride. So, there’re multiple problems here. I suspect you’ll be able to find regulations that require these things. Certainly, if you looked at the code of practice on plant design because this counts as industrial plants, it’s a high-risk plant, so you would expect very high standards of engineering controls on high-risk plants and these were missing. More on that later.

In a similar vein, the coroner says “a basic automated detection system for the water level would have been inexpensive and may have prevented the incident from occurring”. So basically, the coroner is saying this control mechanism would have been cheap so it’s certainly reasonably practicable. If you’ve got a cheap control that will prevent a serious injury or a death, then how on earth are you going to argue that it’s not reasonable to implement it? The onus is on us to implement all reasonably practical controls.

And then similarly, the lack of a single emergency stop on the ride, which was capable of initiating a complete shutdown of all the mechanisms, was also inadequate. And that’s another requirement from the code of practice on plant design, which refers back to WHS regulations. So, another breach there.

human factors

We then move on to a section where it talks about operators, operators’ account of the incident, and other human factors. I’m probably going to ask my friend Peter Bender, who is a Human Factors specialist, to come and do a session on this and look at this in some more detail, because there are rich pickings in this section and I’m just going to skim the surface here because we haven’t got time to do more. And the coroner says “it’s clear that these 38 signals and checks to be undertaken by the ride operators were excessive, particularly given that the failure to carry out anyone could potentially be a factor which would contribute to a serious incident”. So clearly, 38 signals and checks distributed between two ride operators, because there was no one operator in control of the whole ride- that’s a human factors nightmare for a start- but clearly, the work designed for the ride was poor. There is good guidance available from Safe Work Australia on good work design so there’s really no excuse for this kind of lapse.

And then the coroner goes on to say, reinforcing this point about the ride couldn’t be safely controlled by a human operator. The lack of engineering controls on a ride of this nature is unjustifiable. Again, reinforcing the point that risk was not SFARP because not all reasonably practicable controls had been implemented. Particularly controls at the higher end of the hierarchy of controls. So, a serious failing there.  

(Now, I’ve got something that I’m going to skip, actually, but – It’s a heck of a comment, but it’s not actually relevant to WHS.)

training and competence

We’re moving on to training and competence. Those responsible for managing the ride whilst following the process and procedure in place – and I’m glad to see you from a human practice point of view that the coroner is not just trying to blame the last person that touched it. He’s making a point of saying the operators did all the right stuff. Nevertheless, they were largely not qualified to perform the work for which they were charged.

The process and procedures that they were following seemed to have been created by unknown persons. Because of the poor record-keeping, presumably who it is safe to assume lacked the necessary expertise. And I think the coroner is making a reasonable assumption there, given the multiple failings that we’ve seen are in risk management, in due diligence, in record-keeping, in the knowledge of key people, et cetera, et cetera.

It seems that the practice at the park was simply to accept what had always been done in terms of policy and procedure. And despite changes to safety standards and practices happening over time, because this is an old ride, only limited and largely reactionary consideration was ever given to making changes, including training, providing to staff. So, reactionary -bad word. We’re supposed to predict risk and prevent harm happening. So, multiple failures on due diligence here and on staff training, providing adequate staff training, providing adequate procedures, et cetera.

The coroner goes on to say, “regardless of the training provided at the park, it would never have been sufficient to overcome the poor design of the ride. The lack of automation and engineering controls”. So, again, the hierarchy of controls was not applied, relatively cheap, engineering controls not used, placing an undue burden on the operator. Sadly, this is all too common and in many applications. This is one of the reasons they are not naming the ride operators or trying to shame them because I’ve seen this happen in so many different places. It wouldn’t be fair to single these people out.

‘incident free’ operations?

Now we have a curious, a curious little statement in paragraph 1040. The coroner says “submissions are made that there was a 30-year history of incident-free operation of the ride”. So, what it looks like is that the ride operators, management, trying to tell the coroner that they never had an incident on the ride in 30 years, which sounds pretty impressive, doesn’t it, at face value. But of course, the coroner already knew or discovered later on that there had been incidents on the ride. In fact, there have been two incidents that were very similar to the fatal accident.

Now, on the surface, this looks bad, doesn’t it? It looks like the ride management were trying to mislead the coroner. I don’t actually think that’s the case because I’ve seen that many organizations do poor incident reporting, poor incident recording, and poor learning from experience from incidents that it doesn’t surprise me that the senior management were not aware of incidents on their ride. Unfortunately, it’s partly human nature. Nobody likes to dwell on their failures or think about nasty things happening, and nobody likes to go to the boss saying we need to shut down a moneymaking ride. Don’t forget, this was a very popular ride. We need to shut down a moneymaking ride in order to spend more money-making modifications to make it safer. And then management turns around and say, “Well, nobody’s been hurt. So, what’s the problem?”

And again, I’ve seen this attitude again and again, even on people operating much more sophisticated and much more dangerous equipment than this. So, whilst this really does look bad- the optics are not good, as they like to say. I don’t think there’s actually a conspiracy going on here. I think it’s just stupid mistakes because it’s so common. Moving on.

standards

Now the coroner goes on to talk about standards not being followed, particularly when standards get updated over time. Bearing in mind this ride was 30 years old. The coroner states “it is essential that any difference in these standards are recognized and steps taken to ensure any shortfalls with a device manufactured internationally is managed”. Now, this is a little bit of an aside, because as I’ve mentioned before, the TRRR was actually designed and manufactured in Australia. Albeit not to any standards that we would recognize these days. But most rides were not and this highlights duties of importers. So, if you import something from abroad, you need to make sure that it complies with Australian requirements. That’s a requirement, that’s a duty under WHS law. We’ll come back to this in just a moment.

(We’ll skip that [comment] because we’ve done training and competency to death.)

the role of the regulator

So, following on about the international standards, the coroner also has a crack at the Queensland regulator, who I won’t name, and says “the regulator draws my attention to the difficulties arising when we’re requiring all amusement devices to comply with Australian standards. This difficulty is brought about by the fact that most amusement devices are designed and manufactured overseas, predominantly based on European standards”. Now, in the rest of the report, the coroner has a good old crack at the regulator. (If you’re Irish, a crack means a bit of fun. I’m not talking about a bit of fun.)

The coroner sticks the boot into the regulator for being pretty useless. And sadly, that’s no surprise in Australia. So basically, the regulator said, “Oh, it’s all too difficult!” And you think, “Well, it’s your job, actually, so why haven’t you done it properly?”

But being a little bit more practical, if you work in an industry where a lot of stuff is imported and let’s face it, that’s pretty common in Australia, you’ve got two choices. You can either try and change Australian standards so that they align better to the standards of the kit where you’re getting the stuff from in your industry, or maybe the regulators say could say, “Okay, this is a common problem across the industry. We will provide some guidance that tells you how to make that transition from the international standards to Australian standards and what we as the regulator consider acceptable and not acceptable”. And then that really helps the industry to do the right thing and to be consistent in terms of operation and enforcement.

So, the regulator is letting the people who they regulate know this is the standard that is required of you, this is what you have to do. And that’s really the job of a good regulator. So, the fact that the regulator in this particular case just hadn’t bothered to do so over a period of some decades, it would seem, doesn’t really say a lot for the professionalism of the regulator. And I’m not surprised that the coroners decided to have a go at them.

Summary

So, we’ve been through just over 20 comments, I think. I mean, I actually had 24/25 in total, but I skipped a few because they were a bit repetitive and it’s interesting to note that there were two major comments on failure to conduct designer duties and that kind of thing. Seven on risk management, four on SFARP, although of course, all the risk management ones also affects SFARP, and five on due diligence. So, there’re almost 20 significant breaches there and I wasn’t even really trying to pick up everything the coroner said. And bearing in mind, I was only reading from the summary. I didn’t bother reading the whole report because it’s pages and pages and pages.

And the lesson that we can draw from all of this friends, is not to bash the people who make mistakes, but to learn lessons for ourselves. How could we do better? And I think the lesson is everything that we need to do has been clearly set out in the WHS Act, in the WHS regulations. Then there’re codes of practice that give us guidance in particular areas and our general responsibilities and these codes of practice also guide us on to what could should be considered, SFARP, for certain hazards and risks. Then there’s also some fantastic guidance, documentation and information available from Safe Work Australia. On, for example, human factors and good work design and so on and so forth.

So, there’s lots of really good, really readable information out there and it’s all free. It’s all available on that wonderful thing we call the Internet. So, there really is no excuse for making basic mistakes like this and killing people. It’s not that difficult. And a lot of the safety requirements are not that onerous. You don’t have to be a rocket scientist to read them and understand them. A lot of the requirements are basic, structured, common sense. So, the lesson from this awful accident is it doesn’t have to be this way. We can do much better than that quite easily and if we don’t and something goes wrong, then the law will be after us.

looking ahead

It will be interesting to see – I believe that the WorkSafe Queensland are now investigating to see whether they’re going to bring any prosecutions. It should be said that the police investigated and didn’t bring any prosecutions against individuals. I don’t know if Queensland has a corporate manslaughter act. I wouldn’t think so based on the fact that they’ve not prosecuted anybody, but you don’t need to find an individual guilty of gross negligence, manslaughter for four WHS to take effect. So, I suspect that in due course, we will see the operators of the theme park probably cop a significant fine and maybe some of their directors and senior managers will be going to jail. That’s how serious these and how numerous these breaches are. You really don’t need to dig very deep to see what’s gone wrong and to see the legal obligations have not been met.

Since this video was recorded the TRRR owners have been charged with three offences under WHS law.

For More …

Anyway, that’s it for this session. I hope you’ll join me again soon. On your screen, you should be seeing some options for following us on our YouTube channel and the link to the Web site to find more information. So, all that remains for me to say is thanks very much for watching and I’ll look forward to talking to you again soon. Goodbye.

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Lessons Learned from a Fatal Accident

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Guide to WHS

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Introduction to Australian Work Health and Safety

This short video Introduction to Australian Work Health and Safety looks at Australian legislation that is relevant to System Safety. Thus, it is of interest to system, functional and design safety practitioners.  It looks at the three classes of ‘upstream’ safety duties of designers, that also apply to manufacturers, importers, suppliers those who install/commission plant substances and structures. 

 

Introduction to Australian Work Health: so What?

Many people think the WHS Act only applies to the management of safety in a work place. They’re wrong – it does much more than that. In this short presentation, I am going to show you why the WHS Act is relevant to those with ‘upstream’ safety responsibilities such as designers.

Topics

  • The primary duty of care;
  • Safety duties of designers (Section 21); and
  • Similar duties apply to others, such as:
    • Manufacturers (Section 23);
    • Importers (Section 24);
    • Suppliers (Section 25);
    • Those installing, constructing or commissioning (Section 26);
    • Officers (Section 27); and
    • Workers (Section 28).

There’s more!

The full-length ‘Guide to WHS’ video is here.

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