Critical Incident Evaluation – Newcastle Shipping Fatality Essay

Forgers acknowledged that the incident occurred due to failures on their behalf to provide systems of work for the on-site transport of large items and to ores hazards to health and safety arising from the transport of such items (ANSWER 2000). Short-falls were present in Forgers commitment and policy, and planning of their GOSH management system which created active failures and latent conditions that would result in occurrence of the incident.

Recommendations to prevent a recurrence of this incident include: implementing training and instruction for workers, providing adequate equipment, and ensuring employee awareness and commitment to GOSH. Essay On January 19th 1998, Forgers Engineering Pity Ltd failed to ensure the safety of one f their employees, Malcolm Dennis Phillips, who drowned after the truck he was driving toppled off a floating dock into Newcastle Harbor (Workforce 2010). Forgers, as the employer of Phillips, hardheaded for breaching the Occupational Health and Safety Act 1983, Section 15(1).

Investigation into the incident showed failures on Forgers behalf to give necessary information, training and instruction and provide the adequate equipment to perform the task that contributed to the incident (ANSWER 2000). Short-falls in the GOSH management system, particularly in the areas f commitment and policy, and planning, can be identified as being the root cause behind the active failures and latent conditions that led to Phillips death.

There are many actions Forgers can take to reduce the likelihood of an incident like this reoccurring, such as implementing appropriate training and instruction. On the morning of the January 19th 1998, Malcolm Dennis Phillips drowned while carrying out his duties as a driver for Forgers Engineering Pity Ltd (ANSWER 2000). The task being performed was the movement of a large hopper bin from the floating dock to another location.

Originally the hopper was to be moved by an 8-9 tone tip truck but upon loading it onto the truck,employees deemed it unstable with not enough tie down points and instead decided to use a tabletop truck to be driven by Phillips ) It is reported that another driver tort the organization believed t task Phillips was to perform was unsafe and had refused to perform it (Mulled 1998). Phillips had barely moved the truck from its loading position on the access ramp to the floating dock before it became unstable and rolled into the harbor trapping Phillips in the cabin (Workforce 2010).

Investigations into the incident found that the tabletop truck used to carry the hopper could carry a payload of maximum keg, as was labeled on the truck (ANSWER 2000). The hopper being transported had a combined weight of keg (Workforce 2010), nearly a full tone above what the truck was labeled to carry. It was the found that the combination of the overweight hopper, the position on the tray of the truck of the hopper, the elevation of the weight of the load, and the loading platform angles were what led to the truck plummeting into the harbor (ANSWER 2000).

The unexpected death of Phillips can be described as a critical work incident. Workspaces (2013) define a critical incident as an event outside the range of normal experience which causes emotional or psychological trauma in people directly or indirectly exposed to incident. While the movement of hoppers around the dock site was not an unusual task for the workers at Forgers (ANSWER 2000), the death of an employees while performing that task was certainly outside the normal experience.

Forgers acknowledged that the incident caused trauma and provided counseling to those employees involved or affected by it (ANSWER 2000). Under the Occupational Health and Safety Act 1983, organizations are required to ensure the health, safety and welfare of their employees while at work. Organizations strive to achieve this by implementing protections to act as an intervention between possible victims and the local hazards involved in their workplace (Reason 1997).

Just as industries vary, so to do the meaner by which protection can be achieved (Reason 1997). Reason (1997) defines the various meaner of protection as ‘defenses’. Len an ideal world, the defenses organizations put in place would be flawless and prevent incidents from ever occurring. In reality however, incidents do occur, like the drowning of Phillips while at work for Forgers, which shows there are gaps in these defenses. A model popular in the GOSH profession to help describe how these incident occur is James Reasons ‘Swiss cheese’ model.

In this model, the defenses organizations put in place are represented by slices of Swiss cheese and the gaps in these defenses are represented by the ‘holes’ in the slices of cheese (Quintal, Bole &Lam 2010). The gaps in the defenses occur due to either active failures, which Quintal, Bole amp;Lam (2010) define as “the errors and violations of those at the human-system interface” (up. 1 55), or latent conditions which arise when designers, builders, managers and maintainers fail to anticipate all possible scenarios.

Reason (1997) distinguishes between the two by describing active failures as”usually having immediate and relatively shortlists effects” and “committed by those at the human- system interface” whereas latent conditions are able to “lay dormant… Until they interact with local circumstances to defeat the system’s defenses” and “are spawned in the upper echelons of the organization” (up. 1). Using this model,active failures and latent conditions can be identified in Forgers ‘defenestrate led to the incident that occurred on January 19th 1998 which cost Phillips his life.

An area that can be seen as a defensive layer in the model is decision makers. The decision of the employees working on the day of the incident to move the hopper using a flatbed truck rather than a tip truck is an example of an active failure, or ‘hole’, in this layer. The workers did not identify the flatbed truck as a hazard even though it was labeled to only carry a load of kegs but was loaded with kegs. The effect of this decision was almost immediate with the flatbed truck becoming unstable and toppling into the harbor once it was loaded with the hopper.

Another example of an active failure in the decision maker’s layer of defense was Phillips decision to drive the truck. While another employee had reportedly refused to drive the truck as he thought it to be unsafe (Mulled 1998), Phillips chose to take the risk in order to complete the task at hand. The ANSWER (2000) report stated that there had been some discussion of the stability of the load, but the decision was made to continue. A witness had stated that he had told Phillips he would “watch the load” and “if I scream at all, don’t ask questions, Just Jump out” (Workforce 2010, n. P. ).

The effect of this decision was immediate, with Phillips only having Just climbed in and started the truck before the incident occurred (Workforce 2010). A common layer of defense organizations put in place to protect possible victims is information and training. The most alarming latent condition that led to the incident occurring was the lack of information, training and instruction provided to the workers by Forgers which created a big ‘hole’ in that layer of defense. This latent condition went unnoticed previously as the movement of a full hopper, like the one involved in the incident, had never been required before (ANSWER 2000).

Interviews with employees involved in the incident revealed that no instruction or training had been received with regard to the movement of items such as the hopper bin (Workforce 2010). Another common layer of defense for organizations trying to protect possible victims is the provision of adequate equipment and maintenance. While reports from after the incident showed that the trucked used was in good working condition (ANSWER 000), the truck itself was not adequate to move the hopper safety.

The 8 tone tip truck originally intended for use to complete the task was replaced by the flatbed truck involved in the incident because it was deemed unstable and did not have enough tie down points (Workforce 2010). Neither of the trucks was adequate for the task and as a result, a ‘hole’ was created in the defensive layer. It was the rare combination of all the holes in the defensive layers lining up that created the accident trajectory which led to Phillips death. The holes in the identities layers themselves are not the root cause behind t incident, they are merely symptoms.

The root cause can be traced back to the short- falls in the GOSH management system (CHOOMS) in place, particularly in the areas of commitment and policy, and planning. When questioned about the system of work or standard operation procedure that was in place with regard to the movement of items such as the hopper involved in the incident, the Joint Managing Director of Forgers stated that “the established system of work is to employ qualified persons with suitable tickets to carry out the handling and transport of large items” (ANSWER 2000, n. P. ).

Essentially, it was Forgers policy to hire already trained workers and give only Job familiarization training (ANSWER 2000) rather than providing specific training for the work conducted by the company. Management “rely on the competency of the qualified person operating the machine or the equipment” (ANSWER 2000, n. P. ). This shows a lack of commitment by management to assign the appropriate resources to ensuring their workers are appropriately trained. This short-fall in policy led to workers performing a task they were not properly trained to do and contributed to the accident trajectory which led o the incident.

In order for organizations to prevent incidents from occurring they need to identify possible hazards/risks, assess them, and have a policy in place to control them (Quintal, Bole &Lam 2010). This evaluation comes under the CHOOMS principle of planning. The vehicular movement of hopper bins prior to the incident was not seen by Forgers as an unusual operation and as such, workers were not required to undertake any additional training outside of their qualification (ANSWER 2000).

Upon assessment, it was suggested that removing the contents of the hopper ND laying it in a different direction would have been safer, but no instruction, work method statement, or training were in place (ANSWER 2000). This shows a clear short- fall in Forgers CHOOMS in the area of planning. Had they identified the movement of hoppers as an unusual hazard, there would have been procedures in places for the appropriate handling and maybe the incident would not have occurred. There are many actions Forgers can take in order to prevent incidents like this fatality from happening again.

Most obviously, it is necessary for Forgers to review their CHOOMS and put into practice policies which ensure the appropriate training and instruction is given to workers performing potentially hazardous tasks. This would require a commitment of management to provide the appropriate resources, including money and training facilities, to ensure this can happen. Another action Forgers should take to prevent a repeat incident is to evaluate their current equipment and determine its appropriateness.

Had there been a more appropriate vehicle on site at the time, perhaps the workers would not have chosen the flatbed truck to perform the task and led to the incident. Should this evaluation mind that the current equipment was not adequate, financial commitment from management would be required as the purchasing to new capital equipment can be costly. The actions of the employees involved in the incident show a clear lack of awareness concerning health and safety at work.

Phillips decision to drive the truck despite being aware of its instability shows this lack of awareness. Action should be taken by Forgers to ensure its employees are not only aware of health and safety issues but also committed to achieving a safe work place. Forgers Engineering Pity Ltd failed to ensure the safety of Malcolm Dennis Phillips while he was at work. The short-falls in the GOSH management system were what led to the active failures and latent conditions that created the accident trajectory which resulted in Phillips death.


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