Organisational `Safety Stressors` and Organisational `Safety Stressors` and their Relationship to Severe Accidents their Relationship to Severe Accidents and Incidents Occurring within the UK and Incidents Occurring within the UK
Construction Industry.Construction Industry.
Robin Chaplin ; Bovis Lend Lease UK Robin Chaplin ; Bovis Lend Lease UK EHS DirectorEHS Director
The UK Construction IndustryThe UK Construction Industry
UK Industry overall saw 59 deaths (2005/6)UK Industry overall saw 59 deaths (2005/6) Highly dissociated and diverse operationsHighly dissociated and diverse operations Traditional workforce Traditional workforce Recognised industry requires improvement Recognised industry requires improvement
(Egan)(Egan) MCG £20 billion annum of workMCG £20 billion annum of work Major companies performance significantly better Major companies performance significantly better
than smaller construction companies than smaller construction companies Nil fatalities 2005/6 in Major Contractors GroupNil fatalities 2005/6 in Major Contractors Group Majors seeking significant improvement and new Majors seeking significant improvement and new
approaches.approaches.
Milton Keynes Scaffold Collapse Milton Keynes Scaffold Collapse
Worthing Crane CollapseWorthing Crane Collapse
The StudyThe Study
Review to establish key factors Review to establish key factors `underpinning` serious accidents`underpinning` serious accidents
Aim to address circumstances and Aim to address circumstances and understand `stressors` if presentunderstand `stressors` if present
Key `root factor` analysis processKey `root factor` analysis process Conducted by `expert panel` in a team Conducted by `expert panel` in a team
review review Review of 100 `events` drawn from MCG Review of 100 `events` drawn from MCG
companies and also other UK majorscompanies and also other UK majors
Expert Panel -Process of evaluationExpert Panel -Process of evaluation
100`events` to which full background 100`events` to which full background provided.provided.
Against the background to each `event`, Against the background to each `event`, the reviewers were asked tothe reviewers were asked to• Consider in the light of the investigation which Consider in the light of the investigation which
factors were considered present factors were considered present • Which of these factors are viewed as being of Which of these factors are viewed as being of
the major contributors to the incident or the major contributors to the incident or accident occurrence?accident occurrence?
Mark only after collegiate agreement with Mark only after collegiate agreement with other members of the panel.other members of the panel.
Range of serious `events` coveredRange of serious `events` covered
EVENT ,(Accident & Incident )CATEGORIES
Falls from height34%
Plant and machinery interaction
27%
Falling material21%
Equipment failure11%
Electrical issues
7% Falls from height
Plant and machineryinteraction
Falling material
Equipment failure
Electrical issues
Factors considered within panel review of Factors considered within panel review of ‘organisational factors and stressors‘ attributable to ‘organisational factors and stressors‘ attributable to
accident and incident events.accident and incident events. PHASE 1. PLANNING CONSIDERATIONS:PHASE 1. PLANNING CONSIDERATIONS:
• PLANNING TIMEPLANNING TIME• DESIGN CONSIDERATIONSDESIGN CONSIDERATIONS• BUDGETBUDGET• TIME CONSTRAINTSTIME CONSTRAINTS
PHASE 2. DECISION MAKINGPHASE 2. DECISION MAKING• DESIGNDESIGN• PROCESSESPROCESSES::
PHASE 3. EXECUTIONPHASE 3. EXECUTION• ORGANISATION AND RESOURCESORGANISATION AND RESOURCES• CABABILITIES OF SITE MANAGEMENT TEAMCABABILITIES OF SITE MANAGEMENT TEAM• TECHNICAL ISSUESTECHNICAL ISSUES
Expansion of Considered PointsExpansion of Considered Points
PHASE 1. PLANNING CONSIDERATIONS:PHASE 1. PLANNING CONSIDERATIONS:
- PLANNING TIME- PLANNING TIME• Lack of Forward Planning Time for overall operational Lack of Forward Planning Time for overall operational
deploymentdeployment• Lack of Forward Planning Time for selected operationsLack of Forward Planning Time for selected operations
- DESIGN CONSIDERATIONS- DESIGN CONSIDERATIONS• Aspects of design of the Construction phaseAspects of design of the Construction phase• Late designLate design
- BUDGET- BUDGET• Budget pressures (client generated)Budget pressures (client generated)• Budget pressures (self generated)Budget pressures (self generated)
- TIME CONSTRAINTS- TIME CONSTRAINTS• Time based pressure (self generated)Time based pressure (self generated)• Time based pressure (client generated)Time based pressure (client generated)
Decision making and PlanningDecision making and Planning
Percentage attribution of relevance to `event` - DECISION MAKING & PLANNING
0 10 20 30 40 50 60
PLANNING
Lack of Forward Planning Time
Aspects of design
Budget pressures
time based pressure
DECISION MAKING
support for decision making
decision processes
CA
TE
GO
RY
% ATTRIBUTION
Organisation and Resource, Team IssuesOrganisation and Resource, Team Issues
Percentage attribution towards `event` CATEGORIES - ORGANISATION & RESOURCES
;TEAM ISSUES
0 10 20 30 40 50 60 70
ORGANISATION &RESOURCES
Unsuitable organisation
Unsuitable location
Inadequate resources
Attention to procedure
TEAM ISSUES
Team organisational ability
Capability or knowledge base
Organisational stressors
Inadequate communication
CA
TE
GO
RY
% ATTRIBUTION
Production mattersProduction matters
Percentage attribution towards `event`- PRODUCTION MATTERS;PERSONAL &
TECHNICAL ISSUES.
0 10 20 30 40 50 60 70
PRODUCTION MATTERS
Intrinsic production pressure
PERSONAL ISSUES
Personal Behaviour
Personal Competence
Personal Condition & Pressures
TECHNICAL ISSUES
Unforseen technical Failure
CA
TE
GO
RY
% ATTRIBUTION
Data Evaluation : ConclusionsData Evaluation : Conclusions Highest attribution is given to failure to pay `attention to Highest attribution is given to failure to pay `attention to
procedure`procedure` Organisational `stressors` and internal production pressures Organisational `stressors` and internal production pressures
are attributed high concern.are attributed high concern.
Personal behaviour and competence are also rated significant Personal behaviour and competence are also rated significant contribution.contribution.
Technical issues are attributed minimal attributionTechnical issues are attributed minimal attribution Team communication, organisational ability and related facets Team communication, organisational ability and related facets
of `on site` team work are a most relevant issue within of `on site` team work are a most relevant issue within construction site management, and this indirectly linked to construction site management, and this indirectly linked to organisational pressure.organisational pressure.
Less relevance attributed to construction budget pressure, Less relevance attributed to construction budget pressure, although time based pressures still are identified in the although time based pressures still are identified in the analysis.analysis.
From the data there is an overall conclusion that aspects of From the data there is an overall conclusion that aspects of accidents and incidents evaluated are attributable in part to accidents and incidents evaluated are attributable in part to direct or indirect persistent stressorsdirect or indirect persistent stressors
Construction :Some Traditional Construction :Some Traditional Workplace ConcernsWorkplace Concerns
ORGANISATIONORGANISATION• Poorly organised job or short lead timePoorly organised job or short lead time• Client pressures to completeClient pressures to complete• Difficult build or design arrangementsDifficult build or design arrangements
PEOPLEPEOPLE• InexperienceInexperience• Intercommunication and relationshipsIntercommunication and relationships• `bad apples``bad apples`• ChangeChange
SUPPLY CHAINSUPPLY CHAIN• Inappropriate deployment by sub-contactorInappropriate deployment by sub-contactor• Poor attitudesPoor attitudes
Business State Transition Model Business State Transition Model after Sundstrum after Sundstrum & Hollnagel (2005)& Hollnagel (2005)
Resilience Engineering is Required !!!Resilience Engineering is Required !!! Implement processes which identify any degradation in practiceImplement processes which identify any degradation in practice Symptoms will be creation of non-compliant practices which are Symptoms will be creation of non-compliant practices which are
replacing Safe practices replacing Safe practices
Evaluation should go beyond `standard` auditing and Evaluation should go beyond `standard` auditing and inspection and aim to ‘predict uncertainty arising‘inspection and aim to ‘predict uncertainty arising‘
It is clear `stressors` plays a part in predicting deterioration of It is clear `stressors` plays a part in predicting deterioration of management controlmanagement control
A second stage of a resilience process should be the competent A second stage of a resilience process should be the competent mobilisation of resource to mitigate and manage a situation in mobilisation of resource to mitigate and manage a situation in developing crisisdeveloping crisis
In effect ‘pessimistic impact analysis‘ is required to evaluate In effect ‘pessimistic impact analysis‘ is required to evaluate production operationsproduction operations
A Red Amber Green Traffic Light process with suitable formal A Red Amber Green Traffic Light process with suitable formal
high level intervention is an effective processhigh level intervention is an effective process
Site SafetyReview
General site visit
Review output as
usual
REDImmediate
PhoneCall
Immediate summary( 24hrs)
Meeting within 24hrs
on site
AMBERRAG Report
(see e.g. enc)( 24hrs)
Review within 3
working days
GREENNo further
action
Site assignedR, A or G
Month endR.A.G. list
Board Review
DURINGMONTH WITHIN 7 days
R.A.G. Procedure
5/11/02
Final Conclusions and Proposed Industry ActionFinal Conclusions and Proposed Industry Action
A significant number of `high potential` and A significant number of `high potential` and tragically fatal accidents recorded over the last tragically fatal accidents recorded over the last ten years within the data from the UK ten years within the data from the UK construction sector construction sector have involved indirect or have involved indirect or direct workplace stressorsdirect workplace stressors
It should be recognised as a It should be recognised as a vital part of the vital part of the strategystrategy for accident and incident prevention for accident and incident prevention
Action should be directed at the `live evaluation`, Action should be directed at the `live evaluation`, recognition and maintenance of organisational recognition and maintenance of organisational resilienceresilience factors in the management of safety factors in the management of safety within a construction business environment.within a construction business environment.