Viewpoint – Best-laid schemes
Keith Turney gives a first-person account of the effect a worker fatality – and the subsequent HSE prosecution – had on him and his company, and explains how the incident prompted the revitalisation of the safety culture within the already very safety-conscious business.
The company of which I am managing director, Central Highrise, is a successful and long-established steeplejack business based in Nottingham, with an exemplary safety record throughout its history of nearly a quarter of a century, and a string of safety awards to its name. But, three years ago, in March 2008, we got the call that every employer – certainly every employer in this industry – dreads.
It was from one of our sites, telling us that an employee had been killed in a fall from a gantry at Long Sutton Power Station. The team had been rust-proofing – a job that entailed removing sections of walkway within a gantry, lowering them through the gap, painting the bolts, and moving on to the next section. Carried out at a height of 30m, this was the sort of task we undertook on a daily basis. There was nothing unusual about it and it entailed relatively low risk.
Brian Collins, one of our longest-serving operatives, had, it appeared, removed the walkway section, stepped away to pick up his bosun’s chair without clipping on to the structure, and then stepped back into space. It was a moment’s inattention that had dreadful consequences.
When somebody is killed at work, most of the reports in the media give little more than the bald facts: someone has died in an accident, his employers are being investigated, or they have been fined, etc. Often, the business-owners are portrayed as profit-driven, uncaring, and cavalier about employee safety. Clearly, the effect on the employer is nothing compared to the loss felt by the victim’s family, but still – I had to identify Brian’s body, and my wife June – then our MD – had the task of informing Helen, Brian’s wife.
Brian had been a steeplejack for more than 30 years, and had worked for us for more than 20. We thought of him as a friend. How had such an experienced man made such an error? And had we, in some way contributed, to his death?
Central Highrise has been in operation since 1984, and I believe we have been a driving force in introducing improved safety standards to an industry that had been more prey than most to the ‘macho’ culture prevalent within construction in general. We were the first to introduce the second safety rope to back up the steeplejack’s rope and steeplejack ladder, eight years before it became compulsory. We have trained, trained and trained again our staff, becoming the first steeplejack business to gain the Investors in People accreditation.
Personally, I sit on the Safety Committee of the National Federation of Master Steeplejacks and Lightning Conductor Engineers, and PH/5 – the British Standards Committee advising on European work-at-height standard CEN/TC160. I am a fellow of RoSPA and have been involved in the drafting of BS2830 – Industrial Climbing Steeplejack Methods.
As a business, we have won 18 safety awards, including the RoSPA Gold Award eight years in a row, and I was presented with an Award for Distinguished Service. We were selected as a case study for the HSE’s ‘Revitalising Health and Safety Strategy’. In half a million team hours, and many millions of man hours, we have had only four notifiable incidents. The equipment we have supplied to the work teams has always been comprehensive and of the very highest quality.
Central Highrise is a very safe business. And yet. . .
Under the microscope
Following Brian’s death, we knew that we would be subject to an HSE investigation, and, of course, we undertook our own root-and-branch review of the procedures in place. We had undertaken a five-year review of safety in 2007, stress-testing the business processes. The HSE investigation was thorough, staff were invited to give their views. In general, we have no issues with the way the investigation was conducted, though the presumption of guilt that seems to pertain to any investigation was concerning.
If a serious accident occurs it means something has gone wrong. The employer is in a difficult position: if the method is correct, then either he has failed to provide the employee with the appropriate equipment or training, or, if all that is in place, he must have failed to supervise the work properly. This is an ‘augmented’ view of reality, at best.
That aside, we set about reforming the work and identifying any issues that might have contributed to the fall. In specific terms, we issued new guidance to work groups involved in removing grilles, and we identified some specifics related to use of the various types of lanyards we supply to the men.
At that time, we didn’t identify supervisory training as a substantial issue. We believed that SSSTS (Site Supervisor Safety Training Scheme) didn’t adequately relate to the issues faced by steeplejack gangs, as it is written around the needs of civil engineering. In fact, our review of the methodology and content of the SSSTS course suggested that it could actually work against us, because work at extreme height is not sufficiently covered.
Seventeen months later, after three in-house reviews and while HSE investigations were still continuing, we had a second accident. Without going into detail, one of our gangs was doing some extremely routine maintenance work, abseiling down a rock face to clear rubble. One of the men decided to abseil down the face without a hard hat, without using the second rope, and without using the panic grab device. The worker – an experienced man, who had recently completed individual rope refresher training (receiving a commendation) – fell and injured himself.
On one level, this was an act of individual stupidity, clearly against our protocols, and clearly dangerous. On another, it was, of course, a clear failure of supervision. The individual was dismissed, but the incident was added to the HSE investigation.
The investigation turned into a prosecution for procedural and documentary failings in the first – fatal – accident, and for supervisory failings in the second. To move things on, to minimise pain to Brian’s family, and, it has to be said, because we realised that there were issues to address, we pleaded guilty at the first available opportunity. The court case finally concluded earlier this year with a fine being imposed of £100,000.1 We ended up being featured in the local and national press and I was interviewed on television.
The second accident had made it crystal clear to us that we had a supervisory issue. We also realised that, in a strange way, our previously exceptional safety record and all our awards could be working against us. The issues boiled down to one word – complacency.
Naturally, I had considered complacency as an issue but the second incident threw into stark relief the fact that the ‘macho’ element in the industry had not gone away. In some ways, neither should it. The people attracted to steeplejacking often are because they are, for want of a better word, tough; they want the physical dimension of the job, a greater challenge than that provided by more straightforward construction work. The challenge for us is to respect an individual’s character while making sure it doesn’t become corrosive and dangerous to the worker, or the team.
Our staff were well-trained and well-equipped yet, on occasion, still cut corners. In order to win our awards, our staff were interviewed and were able to provide correct, clear answers to safety questions. However, Brian had not clipped his lanyard to the structure because it made the job slightly easier. In the second accident, the employee had abseiled down because it was easier than walking around.
Steeplejack work is undertaken in small, transient gangs. We have a contracts manager who randomly visits sites, but he can’t be there all the time. When Brian fell, he himself was the supervisor, so where does that leave us?
We needed to develop a system that moved beyond a foreman simply imposing rules on a team. We had to work to target the ‘Fourth Dimension’ – the ‘mind on the job’ – and so developed a Shared Mental Model of safe practice in the workplace. We did make some structural and practical improvements – for example, a new training matrix to emphasise supervision. (Incidentally, at Central Highrise, nobody with less than six years’ experience is considered for a supervisory role; it is critical that any individual in a supervisory position can command respect.)
All operatives underwent re-induction in safety skills based around a new core document, which we call ‘Conduct Pack’. A fellow director and I attended a seminar on behavioural safety, and felt that this was the key that would allow us to develop a different approach to site safe practice. Following that seminar I researched all available behavioural safety studies and programmes and rebuilt our systems with what we have termed a ‘mindset initiative’ woven into them.
Behavioural safety, which, in this context, meant that all operatives work together to collectively challenge unsafe behaviour, is the central plank of the new strategy. We have always achieved about twice the industry average in training hours but, over the last two years, we have intensified the process. Key to the system is a formalised ‘buddy’ system, under which safety is increased by an insistence on staff monitoring each other’s activities. The office has become a ‘remote buddy’ through the use of laptops, and all parties are equal partners in the delivery of safety. Workers are individual, independent units within the safety team and each takes responsibility for the others.
It is easier for a steeplejack to hit his thumb with a hammer and keep quiet about it than to turn to his mate and say: “I care about you.” We recognise the barriers to communication that exist and we have been radical in the way that we have delivered training and support – for example, we have brought in a theatre group to role-play safety situations and allow our staff to explore the ways in which they might challenge unsafe behaviour without it becoming confrontational.
New technology using notepad-type computers allows live signalling between base and the work teams, making sure any necessary variances to the job are properly documented, recorded and authorised. Our software also provides a trail, so we have chronological and auditable records. The notepads also contain all the job specifications (work packs). We increased our support staff to make sure we can fully support the teams out in the field.
As a business and as people, it is our responsibility to act in the very best interests of ourselves, our staff and, of course, our clients. We now know that we can operate a shared mental model at a high level through live signalling and a continually driven buddy system. We are confident that, as a business, we are now safer in operation than we have ever been. We are also aware that we could have introduced a narrow, tick-box process and been equally as ‘legally compliant’ – but without being as safe, efficient, or effective as we are today.
I worry that it is too easy to develop an augmented view of reality, where people both promote and hide behind ever-thickening piles of process documents that sometimes serve to do little other than disengage the workplace staff. These are the people that not only need to be persuaded by but also become advocates for the shared mental model, so that, together, we can add real value to safety.
Since originally putting this article together for SHP the author has further developed the concepts and ideas, and consolidated them into an online presentation, which explains more about the project and provides a lot more detail. The presentation can be accessed here.
Keith Turney is managing director of Central Highrise.
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