Published Online 12/12/20.
Observations on Zero Harm, and the Management of Health & Safety in Construction
For those who have arrived here naturally via Part One, questions were also raised for the Health & Safety review panel regarding the Safety Differently article’s criticisms of the Health & Safety profession. Following deliberations, and whilst sympathetic to the anger the criticisms caused, the consensus was that they should be left to the relevant safety Institutes to address, save for the following.
In the Safety Differently article, John Green was dismissive of ‘zero harm’ initiatives in general, and his employer’s (Mission Zero) in particular. Indeed, we find an allied attack on ‘zero’ ‘by the numbers’ in a study by Sherratt & Dainty (2017), to whom we now turn.
The Sherratt & Dainty Study
From UK accident data for the periods 2011-12 to 2014-15, Sherratt & Dainty (2017) selected 9 construction companies that appeared to have ‘signed up’ for ‘zero harm’ (referred to below as the ‘zero group’), and 11 that had not (referred to below as the ‘non zero group’). Those companies were selected due to their position in the top 20 UK construction companies by way of turnover (note, no company was named in the article). As for decisions on which companies were, or were not, ‘signed up’ to ‘zero’, they were based on Sherratt & Dainty’s ‘assessment’ of company web sites. From their assessments, they appear, at first sight, to have identified companies that had adopted and mobilised any form of ‘zero harm’ to their sites. However, that is not the case. Despite which, Dekker (2017) believes they “have done pretty much everything possible to control or check the influence of confounds, and still conduct a real-world study”. Indeed, he sees it as “a unique and important contribution”. We find, however, such praise impossible to support upon analysis of what they did; and, more importantly, what they did not do.
In short, they found four fatalities and 214 Major/specified injuries in the ‘zero group’; and, no fatalities and 135 Major/specified injuries in the ‘non zero group’. Following adjustments to account for volume of work by way of turnover, they found 7 Fatal or Major/Specified injuries per £billion turnover for the ‘zero group’; and, 6 Major/Specified injuries per £billion turnover for the ‘non zero group’. As a result, they offer…
“you are marginally more likely to have a major/specified accident whilst working on a large construction site operated by a contractor mobilising any form of Zero safety, than if you are working on a site without it. Zero, for construction on large UK sites, actually means a greater risk of injury (or death) in practice” (note; it will shortly be seen that they are in no position to suggest that this “actually means a greater risk of injury (or death) in practice”).
Zero Harm: In Policy or In Practice?
According to our analysis, the three Laing O’Rourke fatalities should have been amongst their data, and LoR should have been one of the 20. However, they have been assigned to the ‘zero group’. Whilst the LoR Board were ‘signed up’ to Mission Zero, a reasonable assessment of evidence available at the time should have raised doubts about its existence in practice on many sites. If their data and findings had been kept under proper review (post study), the publicly available evidence should have led them to adjust their ‘findings’. Instead, that now falls to us in the interests of risk and safety management, generally and Internationally.
To consider if LoR actually adopted and mobilised ‘zero harm’ to their sites, we can start at pp. 20-21. of the Safety Differently article. There, we read about the safety director of a major contractor who said his organisation’s “version of zero harm was a form of window dressing for clients, while it concentrates on what it sees as the major risks”. Similarly, and despite rejecting mission zero, John Green informed the magazine that “the rules and processes around fatal and severe risks will not be tampered with”. Clearly, he did not believe that any component of mission zero played a part in their fatal accidents (indeed, with what follows shortly below, any such claim may be difficult to defend). Similarly, the ‘window dresser’ makes it clear that zero harm, for them, is distinct from major risk control. Added to which, we know that Sherratt & Dainty were unable to conduct any of the practical operations necessary (e.g. multiple, organisation wide, site visits, audits, inspections, etc., for multiple organisations) to identify and remove any such organisation from the equation (or, vice versa). Therefore, their phrase “mobilising any form of zero” is misleading, they do not know what the actual conditions, practices and culture were on any site. They do, however, know that ‘zero harm’ can be implemented appropriately (Sherratt & Dainty 2017), and that it can also be ‘implemented’ inappropriately (Zwetsloot et al 2017: Dekker 2014). Consequently, the means by which the zero and non zero groups were determined has ignored, hence, incorporated, critically confounding data. Contrary, then, to Dekker, it is difficult to see how ignoring (i.e. leaving in place) such matters equates to doing everything possible to control or check them.
In addition, we know that ‘zero harm’, first and foremost, requires companies to be managing the entirety of their health and safety risks, appropriately (Pillay 2014). Since Sherratt & Dainty sought to assess ‘zero harm’ relative to major and fatal accident rates, they really needed, if their study was to have any point at all, evidence of the practical management of the latter’s risks. Their failure there left them uninformed. For example, on p.21. of the article, John Green made it clear that LoR needed to put more effort into the control of “severe and fatal risks”. Similarly, our ‘window dresser’ made it clear that some organisations do not see zero harm as part and parcel of major risk control. Consequently, Sherratt & Dainty do not know what part, if any, zero harm played. In fact, they had no way of differentiating between zero harm initiatives, and regulatory non-compliance. Indeed, with what now follows, they may have ignored (not controlled or checked) the latter, only to confuse it with the former.
Health and Safety Management on the Fatal Accident Sites
Regarding health & safety management on the fatal accident sites, John Green told the magazine that the “projects weren’t ones we were getting more worried about. They were performing well on safety. The history of events and fatalities is that they always come as a surprise”. To make such a statement, Green must have seen a great deal of evidence that all was not well on other sites; but, how unwell must they have been if, in comparison, the fatal accident sites, whilst worrying, were deemed to be performing well on safety?
First, we know that Laco’s Coroner raised questions about the ‘pace’ of any responses, and the failure of improvements to have wide ranging, consistent effect. Writing to the LoR MD in October 2015, the Senior Coroner advised that “there is a risk that future deaths will occur unless action is taken” (Hassell, 2015). However, would it have needed a Coroner to advise the Board of that if ‘zero harm’, and effective health & safety management, was an organisational reality? Wouldn’t such advice, and the action to remedy across the business, have come two years earlier (i.e. 8 months before the next fatality)? Indeed, how the potential and probability of future high risk events was being assessed is, given Green’s comment about lack of warnings from a triangle, a mystery.
Tragically, Laco (died 6/11/13) was followed 8 months later by Griffiths (died 8/7/14) and very soon after by Reddish (died 2/10/14). After the criminal case involving Griffiths, the HSE Inspector, having already highlighted a lack of supervision, said the company “did nothing to address the trend of these workers carrying out tasks they weren’t trained or authorised for…..This case should act as a reminder of the dangers of using workplace transport without proper planning, management or monitoring of the risks involved” (source, Construction Manager).
In respect of Reddish, the HSE Inspector in his case said the “death could easily have been prevented, if the companies [i.e. Explore Manufacturing and Select Plant, both owned by LoR] had acted following previous warnings to identify and manage the risks involved, maintain the equipment, and put a safe system of work in place.” For the Judge, shortfalls at Explore were “symptomatic” of the way the company operated, and he attributed the death to the failure by both companies to provide either “a safe place or system of work” (Source, Nottingham Post). As for Mrs Reddish, she described her son’s death, not ‘as a surprise’, but as an “accident waiting to happen”, in which he was thrown over three, freestanding concrete panels from a working platform. He landed on the ground but, an 11 ton panel continued to topple and, “causing a domino effect”, all three fell on to him. Having heard there were more panels in the factory than could be coped with, the Court also heard that the deceased was fearful of working alone (Source, Nottingham Post). In fact, concerns had been raised on the shop floor, but there was no evidence of “a lax safety culture” according to John Green; which begs the question, ‘who was communicating what, to who, how and when’? Commenting after the case, Green offered that “significant lessons have been learned” (source, Nottinghamshire Post). However, that was puzzling to some given that the ‘significant lessons’ related to basic health & safety management failures, of an obvious and observable nature. It is, then, difficult to understand why the LoR Board were not being made immediately aware of failures; not least, in Reddish’s case, since they owned the company he worked for, were a supplier to them, and a consumer of their products. Commendably, they acknowledged all shortfalls, and entered early guilty pleas. As a result, fines in Reddish’s case were reduced from £2M and £1.8M, to £1.3M and £1.2M respectively. Nonetheless, and with all due respect to the Board, it would be somewhat unrealistic for anyone to suggest that health & safety risks were being effectively managed for them. Furthermore, Green’s statement that the fatal accident sites were not the ones they “were getting more worried about” indicates a wider set of known, more serious problems. Indeed, guilty pleas, four convictions and a Coroner’s report indicate that many, vital aspects of health & safety management were unknowingly failing; hence, Green declared that the fatalities came as surprises.
In a Complex, Dynamic, Resource-constrained, Goal-conflicted World, Risk and Safety Management Requires Science, and a Commonsense Approach
Before concluding on Sherratt & Dainty, we might note that John Green had access to, and knowledge of, the same information the Courts, Coroners and HSE investigators obtained. In addition, he had a wealth of information regarding the more worrying sites. Despite which, the official magazine (as it was at the time) of the International Institute of Risk and Safety Management, promotes Safety Differently to the membership, as opposed to safety properly. Indeed, ‘promotion’ is largely facilitated by criticism of ‘zero harm’ that, clear from the above in Green’s case, there is no basis for. In addition, the article’s inset review of Dekker’s book made some revealing statements. Worst of which for some, it said Safety Differently, largely heavy-going, is not about safety at work, and ‘evidence’ (e.g. from aviation and obstetrics) does not always translate easily to workplaces such as construction sites! Whilst readers and organisations will, of course, make their own decisions, decisions must be properly informed. Interventions such as Safety Differently, with no scientific basis, are known to do more harm than good; not least, they make systems brittle (Nemeth 2008). Furthermore, Amalberti (2001), upon whom Safety Differently rests in the context here, was actually puzzling over how certain systems might go beyond 10-6. To put 10-6 into perspective, that would mean that a passenger, taking a random flight a day, could fly for 2,739 years before dying in a commercial, airline accident (Barnett & Wang). Indeed, if we recall Dekker et al’s (2008) reference to 10-7 in Pt.1., the passenger could fly daily, according to them, for 19,000 years before dying. First, and whilst we might assume that the ultra-safe model of aviation is the ideal, Vincent & Amalberti (2016) warn that it could be unfeasible in other settings, and even inappropriate. Second, they further warn that such a model of safety is “only workable with very specific conditions and strong constraints on risky activity.” Consequently, the vast majority of organisations, which includes, not least, every large, construction and engineering company on the planet according to Amalberti, might be guided by him. According to Amalberti (2001), organisations that are close to being ultra-safe, got there via the “commonsense approach”.
Zero Paradoxes or Falsidical Paradoxes?
Returning to Sherratt & Dainty (2017); their belief that they found a ‘zero paradox’ in respect of zero harm in construction, cannot be supported. Indeed, we find no basis whatsoever for Dekker’s (2017) belief that they had “…done pretty much everything possible to control or check the influence of confounds”. On the contrary, for that to be the case, there would be three fatalities in the ‘non-zero group’, and one in the ‘zero group’; along with explanation why. If LoR are not amongst the data, that should have been identified and explained. As things stand, and with just a minimal application of scientific rigour, we find an organisation (i.e. Laing O’Rourke) to be in the wrong group. In consequence, and whilst they rightly urged caution in respect of their findings, Sherratt & Dainty’s data needs reviewing, and their conclusions need revising and re-wording. In addition, we were surprised to see Dekker (2017) attempting to take support from both Sherratt & Dainty and Saloniemi & Oksanen during his own attack on zero harm. Aside our views on the latter as expressed in Part 1., the paradox (i.e. more non-fatal accidents = less fatal accidents, and vice versa) that appeared visible to them at a National level, is not visible in Sherratt & Dainty’s sample. In fact, and regardless of which figures are looked at (i.e. their originals, or our corrected ones), they are impossible to reconcile with Saloniemi & Oksanen. Perhaps, once again, some are attempting to have their (cheese) cake, and eat it.
No level of suffering is acceptable. An organisation wide commitment to a suitably defined ‘Zero’ is the only way to approach things; off the back, of course, of on-going, effective, health & safety management. Hundreds of thousands of statistically, inevitable industrial deaths occur each year. Efforts to reduce those numbers are hampered by ‘studies’ that fail to address critical confounds. Hopefully, Parts 1. and 2. here will assist organisations to understand what is actually causing the problems that, seemingly out of the blue, result in funerals, and early guilty pleas. As for Dekker’s (2017) belief that Sherratt & Dainty have conducted a unique and important real-world study, he might be looking at science, the World and safety, differently.
Amalberti, R. (2001). “The Paradoxes of Almost Totally Safe Transportation Systems”. Safety Science, 37. 109-126.
Amalberti, R. (2002). Revisiting Safety and Human Factors Paradigms to Meet the Safety Challenges of Ultra Complex and Safe Systems. In Eds, Wilpert, B. and Falhbruch, B. System Safety: Challenges and Pitfalls of Intervention. Emerald Group Publishing Ltd, Bingley, UK. 265-76.
Arnold, R. (2009). “A Qualitative Comparitive Analysis of SOAM and STAMP in ATM Occurrence Investigation”. Under Supervision of Professor Sydney Dekker. Lund University, Sweden.
Barber, T.X. (1976). Pitfalls in Human Research. Ten Pivotal Points. Pergamon, Oxford, England.
Barker, J.A. (1993). Paradigms: The Business of Discovering the Future. Reprint ed. Harper Business, NY.
Barnett, A. & Wang, A. (2000) “Passenger-mortality Risk Estimates Provide Perspectives About Airline safety”. Flight Safety Digest, April 2000.
Christen, M., & Franklin, L. R. (2002). “The concept of Emergence in Complexity Science: Finding Coherence between Theory and Practice”. Proceedings of the Complex Systems Summer School, 4.
Cook, R. I. (1998). “How Complex Systems Fail”. CrT.
Corning, P.A. (2002). “The Re-emergence of Emergence: A Venerable Concept in Search of a Theory”. Wiley Periodicals, Inc. Vol 7, No. 6.
Davies, J., Ross, A., Wallace, B. and Wright, L. (2003). Safety Management: A Qualitative Systems Approach. London, Taylor and Francis.
Dekker, S. & Woods, D. (1999). In eds Dekker, S. & Hollnagel, E. Coping with Computers in the Cockpit. Ashgate Publishing. Oxon, UK.
Dekker, S.W.A (2001). “The Re-Invention of Human Error”. Tech Report 2002-01. Lund University School of Aviation.
Dekker, S. (2002). The Field Guide to Human Error Investigations. Aldershot, Ashgate.
Dekker, S., Hollnagel, E., Woods, R. & Cook, D. (2008). “Resilience Engineering: New Directions for Measuring and Maintaining Safety in Complex Systems”. Final Report. Lund School of Aviation. Nov. 2008. Online version.
Dekker, S. (2014). “The Bureaucratization of Safety”. Safety Science, 70, (2014) 348-357.
Dekker, S. (2015). Safety Differently. Human Factors for a New Era. 2nd Ed. CRC Press, Fl.
Dekker. S.W.A., Long, R. & Wybod, J-l. (2016). “Zero Vision and a Western Salvation Narrative”. Safety Science, 88, 219-223.
Dekker, S. (2017). “Zero Commitment: Commentary on Zwetsloop et al., and Sherratt and Dainty”. Policy and Practice in Health and Safety. 15, 2. 2017.
Goldstein, J. (1999). “Emergence as a Construct. History and Issues”. March, 1999, 1. Emergence.
GRA Inc (1997) “Safety Reports: Aviation Safety Data Accessibility Study Index: A Report On Issues Related To Public Interest In Aviation Safety Data”. A report prepared for the Office of
System Safety, Federal Aviation Administration.
Hassell (2015). Coroners Report to Prevent Future Deaths.
Heinrich, H.W. (1941). Industrial Accident Prevention: A Scientific Approach. 2nd Edition. New York, McGraw-Hill.
Hollnagel, E. (2008). Investigation as an Impediment to Learning. In eds Hollnagel, E., Nemeth, C. and Dekker, S. Remaining Sensitive to the Possibility of Failure. Ashgate. Aldershot, UK.
Hollnagel (2014). Safety-I and Safety-II: The Past and Future of Safety Management. CRC Press, Fl.
Hollnagel, E., Wears, R..L. & Braithwaite, J. (2015). From Safety-I to Safety-II: A White Paper. The Resilient Health Care Net: Published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia.
Kuhn, T.S. (1970). The Structure of Scientific Revolutions. 2nd Edition. The University of Chicago Press. USA.
Lundberg, J., Rollenhagen, C. & Hollnagel, E. (2009). “What-You-Look-For-Is-What-You-Find – The Consequences of Underlying Accident Models”. Safety Science. 47(10), 2009, 1297-1311.
Nemeth, C.P. (2008). In Ed Nemeth (2008). Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace. CRC Press. Hampshire, England.
Petersen, D. (1971). Techniques of Safety Management. New York, McGraw-Hill.
Pillay, M. (2014). “Taking Stock of Zero Harm: A Review of Contemporary Health and Safety Management in Construction”. In eds, Aulin, R., & Ek, Å. Lund University. Proc. CIB W099 Achieving Sustainable Construction Health and Safety, Lund, Sweden, 2-3 June 2014, pp. 70-80.
Reason, J. (1990). Human Error. Cambridge University Press. Cambridge. UK.
Reason, J. (1990b). “The Contribution of Latent Human Failures to the Breakdown of Complex Systems”. Phil. Trans. R. Soc. Lond. B. 327. 475-484. (1990).
Reason, J., Hollnagel, E., & Paries, J. (2006). “Revisiting the Swiss Cheese Model of Accidents”. Eurocontrol. Project Safbuild. EEC Note No. 13/06.
Reason, J. (2008). The Human Contribution. Unsafe Acts, Accidents and Heroic Recoveries. Ashgate Publishing, Farnham. UK.
Reason, J. (2016). Organizational Accidents Revisited. CRC Press, Fl.
Saloniemi, A. and Oksanen, H. (1998). “Accidents and Fatal Accidents – Some Paradoxes”. Safety Science. 29, 59-66.
Sherratt, F. & Dainty, A.R.J. (2017). “UK Construction Safety: A Zero Paradox?”. Policy and Practice in Health & Safety. TandF online.
Vincent, C. & Amalberti, R. (2016). Safer Healthcare: Strategies for the Real World. Springer Open.
Weinert, F. (2009). Copernicus, Darwin & Freud: Revolutions in the History and Philosophy of Science. Blackwell, Oxford, UK.
Woods, D.D., Dekker, S., Cook, R., Johannesen, L. and Sarter, N. (2010). Behind Human Error. 2nd Ed. Taylor & Francis.
Wright, L.B. & van der Schaaf, T.W. (2004) “Accident versus near-miss causation: A critical review of the literature, an empirical test in the UK railway domain and their implications for other sectors”.
Young, M.S., Shorrock, S.T., Faulkner, J.P.E. and Braithwaite, G.R. (2004). “Who Moved My (Swiss) Cheese? The (r)evolution of Human Factors in Transport Safety Investigation”. ISASI 2004.
Zwetsloot, G. (2017). Vision Zero: Promising Perspectives and Implementation Failures. A Commentary on the Papers by Sherratt & Dainty, and Dekker”. Policy and Practice in Health and Safety. 15, 2. 2017.
Zwetsloot, G., Leka, S. & Kines, P. (2017). “Vision Zero: From Accident Prevention to the Promotion of Health, Safety and Well-being at Work”. Policy and Practice in Health and Safety. 15, 2. 2017.
Regarding Major Injuries.
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995. SI No. 3163.
Regarding Specified Injuries (actually referred to in the Regulations as ‘Non-fatal Injuries’).
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. SI No. 1471.
Our core business is industrial accident investigation and we have a wealth of varied experience in that field.
Designed for those with an involvement in the accident investigation process, the reading areas consider a range of subjects from the perspective of the accident investigator.