Management Factors in Safety Cases

Management Factors in Safety Cases Introduction to Management Factors Historically, risk and safety analyses started by looking at mechanical equipment failure, over time the analyses have evolved to progress through assessment of electrical components, software systems and now an increasing number of analysts are now attempting to address the risks from humans interacting with the system. Lagging behind is any attempt to consider the risks posed by management, particularly senior managers, and judging by the results and recommendations, these risks can outweigh those from component failure. The policies and strategies that they make and the cultures created by them, by design or by default predispose accidents to occur – they are just waiting to happen [Redmill 2006]. The management team, board of directors, or whatever they are actually labelled as, has a controlling position over the culture of the organisation and the systems within it – including safety. In many countries, this group is legally obliged to be responsible for the safety systems of the organisation. However, all too often they fall into making incorrect inferences about their safety systems: 1) Nothing has happened so far in my system ═> The system is safe. This then leads on to a worse inference; 2) The system is safe ═> Nothing will happen in my system. Statement ‘2)’ is the basic rule of inference of safety engineering, however, the ongoing list of disasters in the world demonstrates that the conclusion of ‘2)’ may never be achieved [Sträter 2005]. The real inference that should be targeted is: 3) The system is safe enough ═> Nothing intolerable will happen in my system. Only managers and governors can direct an organisation to achieve and demonstrate this relationship. The organisation may just be a team of six working on a simple project – or it may be a multi-national company employing thousands. The managers may be the whole board of Directors or it may just be the local team-leader. Every level of manager has the responsibility to achieve ‘3)’, if not legally, then at least morally. The major error that comes from believing 1) and 2),

is not doing anything to improve the safety system. Although it must be noted that being tolerable does not guarantee freedom from accidents. The Managers Caused the Accident A great many of the accidents and disasters around the world that have been used as case studies over the years have cited significant contributions from the management chain e.g. Herald of Free Enterprise, Piper Alpha, Challenger and Bhopal. This text is not going to repeat previous discussions on these topics, rather, it will concentrate on areas where management contributions to accidents happen far more often. Historical Incidents [BSC 2005-06] The manager of a UK haulage firm was jailed for manslaughter for three years after one of his drivers had knowingly and with the complicity of the manager, killed a cyclist in August 2003. The driver was also jailed for four years for dangerous driving. Two other persons were each jailed for nine months for helping to destroy tachograph documents (12/05). A company Director who put profit before safety by ignoring health and safety prohibition notices has been jailed for nine months. A worker fell 12 feet to the ground in an accident after being struck by an excavator machine. During the accident investigation additional safety risks were identified and a prohibition notice was served. This was seen to have been allowed to be continually breached throughout November and December 2004 (01/06). A construction firm owner who showed ‘total contempt’ for the safety of his workforce has been jailed for 18 months after a worker was killed when a telehandler toppled over. The employee was working from a ‘home-made’ basket raised up 25 feet in the air to work on a barn roof in February 2004. The telehandler had defective breaks, missing ballast and had not been serviced for more that two years. The basket had a guardrail that was too low and a gate that opened outwards. The findings also indicated that the firm had not carried out an appropriate risk assessment of the task (03/06). These incidents are not simply caused by the single person at the ‘sharp-end’ of these companies. In the first incident, multiple employees of the company all received gaol sentences (this would have effectively wiped the company out). The continual breach of a prohibition notice does not happen because of one worker – it is permitted because the whole management structure allows it to happen. It is the owner of any firm, who is responsible for carrying out risk assessments and preventing un-safe acts. A home-made basket on unserviced equipment is something a management review should reject immediately. The final statistics make an interesting and tragic summary – three fatalities, 120 months of gaol sentences and all occurring within six months of each other. Out of interest, compare these with the statistics of the three high-fine accidents noted at the end of chapter 12. There were 23 fatalities, £42 million in fines, with six years between them. In the two UK cases, there were no personal convictions

for the offences, this has further enhanced the need for reform of the law on corporate responsibility in the UK. The US Chemical Safety and Hazard Investigation Board are still investigating the Texas City explosion. Managers and the Law NOTE: I am a professional engineer, not a lawyer, and this text has not been prepared by a lawyer, so if you have any legal doubt about the content of your safety case, please consult one. Many of the prosecutions that come to court are seeking to punish negligence, either by an individual or by a corporation as a whole. In countries which have a legal basis built on the concept of common law, the law tests four concepts for negligence to be proven: Causation, Foreseeability, Preventability and Reasonableness [Anderson 2006].