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.