Working for MTR – Safety Governance Par Excellence

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During 2014/15 I was working in Hong Kong for MTR, one of the most respected companies in the world of Metro Operations and boasts a trip count in excess of 5 million per day on its ever expanding network.

With operations worldwide this was a “plum assignment” for me and rightly so since the operations department is world-class and the Safety Team there is second to none. In this assignment I was not fulfilling my usual role in project safety, but working in the Operations Team which is led by Dr Jacob Kam who is not only MTRs Director of Operations but also a respected safety professional in his own right and ex HSE in the UK. But this blog is not about him… This is about Safety Governance at corporate and company level and I mention Dr Kam mainly because he was so passionate about safety that meetings may have been delayed a little but they were never cancelled. There was one time when he was meeting with the board of MTR but still joined into our bi-weekly safety meeting (by video link from across Victoria Harbour). These meetings discussed the safety events and near misses from the previous two weeks and what actions had been taken and he wanted to be part of the meetings. This gave him that “helicopter view” of safety below him and thus enabling him to think strategic safety.

In addition to this the quarterly Safety Governance Meeting was not just a meeting it was “an event”. It was attended by all the other directors and a review of subordinate safety committees were reported to the meeting and analysed; once again giving rise to strategic safety thinking at corporate level.

If only other corporates and big companies gave that sort of attention to safety governance but alas most just pay lip service and try to do as little as possible or do just enough to please the requirements of their safety certification

Would you give a few hours every two weeks or three hours every three months to better your safety performance? 

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Working for MTR – Safety Governance Par Excellence

Upsetting the Balance – An Absence of Supervision and Experience

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Another from the annals of my work in a “developing country”. This time the result was one death, three “life changing injuries” and one scratched face.

Building an elevated railway using a “Launching Girder” is known to be hazardous work usually because of working at height and the precarious operation of moving the launching girder into its new position, which entails a little bit of physics and an appropriate amount of “counterweight”.

In this instance the launching girder was being pushed out to rest on top of the next pier cap when, instead, it plunged to the ground. So let’s look into why it fell so disastrously and left an indelible imprint on so many lives.

Firstly the work was not being done as planned or as described in the method statement and in a series of supplied drawings; in fact the “new” methodology bared no resemblance to what had been originally planned. (I should point out that this location was a one-off and not a regular type girder launch).

Secondly, even though this was an unusual situation, the experienced site manager left a less experienced operator in charge and the usual safety officer, highly experienced in these works, was away on leave and a junior safety officer replaced him. Now add to the mix the fact that the Consulting Engineer was also not on site at the time and so we have a classic accident situation developing… (Think here of the “Swiss Cheese Model” of Accident Causation)

As the Launching Girder was pushed out our inexperienced operator did not heed the calls to add more counterweight to the back of the equipment (given to him by some of his more experienced assistants). It was soon noticed that the launching girder had begun to take on a list to the front… Instead of retracting the Girder the operator decided that the best thing to do would be to ask four guys to climb onto the back of the Girder and try to counterbalance the weight by shifting some “sliding elements” towards the back end of the Girder.

Needless to say this was a futile effort and the very act of climbing onto the Girder was enough to further upset the balance and tip it towards the ground; the rest is history.

Now if that was not enough, the recovery of the fallen Launching Girder and replacing with a new one was no simple feat and took many hours, additional risks and money to complete. When we had finished the investigation we decided to look into what that lapse of supervision had cost the company… the amount was close to US$1 000 000 and a three month delay in construction. This calculation excluded the cost associated with my input which was not insignificant. This is a very large construction company and I am sure that they could cobble that sort of money together but what of their reputation… Not long after this they brought in some ex-pat safety people into their organisation (one who is a good friend of mine) realising that they needed to take control over safety.

So in the final analysis… make sure your people are competent and where something is out of the ordinary, ensure that adequate supervision is available.

Oh by the way the guy with the scratched face was a worker who happened to be walking past the site to get a cup of tea… not sure what went through his mind at the time!

Upsetting the Balance – An Absence of Supervision and Experience

First Aid Station Disaster

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Saturday Morning here… and I thought we might lighten the tone somewhat today.

Some time ago I was conducting an Inspection on a large Concrete Casting Yard in the “Developing Country” where I live and work… The last call of the day was to the First Aid Facility…

On arrival I saw their ambulance parked outside – ready for action – or was it? Being the “nosy type” I decided to check the availability of the ambulance and requested for it to be started. Here began the first problem since no one knew where the ignition key was! Ten minutes later, and after a lot of accusations being bandied about, someone came running up to us bearing the key in their hand…

Success however was soon thwarted by the flat battery on the ambulance… Really I am sure you will not believe me on this one… but it is the honest truth! Of course there were a lot of embarrassed people standing around (and a lot more intense accusations). And then to add insult to injury (pardon the pun) when I requested the daily check list for the vehicle I noted that it had been ticked all the way down the “OK” Column on the right hand side of the page. I threw my hands in the air, uttered a few expletives and continued with the inspection

Sadly more was to come and you will see from the photos above what a mess the place was inside and though not shown here the First Aider was sat reading a newspaper! My comment was “if I get injured here on this site please don’t bring me inside here – leave me in the dirt outside” (of course this was punctuated by even more four, six and eight letter oaths).

Now I am not sure what the baling wire, paint tin (with thinners), brush and gum boots are doing next to the gurney.. I can only presume from this that they had just finished a leg amputation and had yet to clean up!

Good news though… the following week the place was newly painted, absolutely spotless  and kitted out with some pretty impressive equipment and I wish I had those photos to share with you…

We often forget about First Aid during inspections and though it is not the first requirement to prevent injury – when an accident happens it is an essential part of ensuring the health of the injured person. Go look at your facility NOW and make sure it is Fit For Purpose

First Aid Station Disaster

Not the call of nature this time… but a quick nap!

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… On the evening of Sunday 5th January 2014 at approximately 21:50 a Dump Truck was being loaded with spoil from the Jet Grouting works at an Underground Station under construction. After a few loads from the JCB it was noticed that the Truck Drivers Assistant was inside of the load container of the dump truck and that he had been hit and had suffered head injuries…

That is the first paragraph from my interim accident report into a fatality I investigated a little while ago in my adopted “developing country” where I work. This was another one of those thoughtless moments which lead people to be killed on work sites around the world…

The story was as follows… One evening as a dump truck was on its way to our site to remove rubble, the drivers assistant decided that he was tired and decided to catch 40 winks in the load area of the dump truck (don’t ask why there!). He told the driver he was going to get some rest and climbed into the back of the truck, made a bed, took off his sandals, covered himself against the mosquitos and went to sleep. (if you are not too squeamish you may be able to see his sandals next to the plastic sheeting in the photo above)

When the truck arrived at site the truck driver reversed up to a JCB backhoe to be filled with the rubble, which consisted of different size pieces of broken concrete. During the loading operation the IP apparently staggered to his feet but then collapsed immediately. The loading was stopped (hey we are not so callous as to keep on loading OK) and first aid was given to the IP and he was shipped off to hospital; unfortunately he died a few days later from an embolism; likely to have been caused by the blow to the head.

So what the hell was going on here? The driver blamed the JCB Operator saying he didn’t tell him to start loading… OK I have to mention my opinion here… you back up a dump truck to a loader in my mind you don’t have to ask to get loaded!!

In fact what must have happened was that the driver forgot that his cab mate was sleeping in the back…

Now let’s just consider for a moment… what is running through someone’s mind when they make a bed in such a hazardous location; I guess the same thought as when someone uses a precarious places as a toilet. (See my earlier Blog)

Continue reading “Not the call of nature this time… but a quick nap!”

Not the call of nature this time… but a quick nap!

Not All Gloom and Doom – There are some Shining Examples

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Just the other day someone commented on my Facebook page that he wanted to cheer me up after he, mistakenly, deduced that I was “in the dumps” after he had read my last few blogs; but far from it I am in quite good spirits from a professional point of view.

In “developing countries” there are a few pockets of good safety practice which I come across from time to time and I am happy to share these with you as lessons to learn from and to strive to match or exceed.

One of the first things I look at on site is the general tidiness of the entrance area; which gives me a good indication of the site in general. Then as we get further into the inspection I look to see if good housekeeping is sustained throughout. My usual, and often vindicated, expectation is that as we progress through the site (and into those hidden corners where the contractor doesn’t expect me to visit) I see the standards tumble until it is not worth going on with the inspection any further… But there are exceptions and I exhibit those exceptions here, as photo evidence, of what can be achieved if there is a willingness to maintain standards… A friend provided me these photos of his work site where he is Manager and which was always impressive for the standards they maintained; not easy in a tunnelling works! Though you may not appreciate this fact, they were advancing at a rate of 25 Rings per day (about 35 – 40 metre) an amazing feat and more so because they were maintaining such great housekeeping standards…!

I am often reminded of the people’s concept that “we cannot expect high standards in developing countries” Well I totally reject that assertion…

We can and we should demand high standards of safety, or anything else, wherever we are… not to demand high standards is the same as capitulating to those attitudes of “don’t care”

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Photographs Courtesy: Mick Herbert-Jürgen – 2014©

Not All Gloom and Doom – There are some Shining Examples

Ergonomically Challenged or Lessons from an Apathetic Manager

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On a site inspection one day I came across this fella… he was cutting and threading pipes for services extensions on a TBM Tunneling job.

Let’s ignore the housekeeping for a moment… that was dealt with separately and maybe a subject for another day.

What really caught my attention was the fact that the pipe threading machine was simply plonked on the floor and the operator had to bend over to operate the machine… I have worked with this type of machine in my apprentice days and I know that even with the machine mounted on a bench at waist height they are pretty dangerous things. They turn very slowly and there is an enormous amount of torque. Of course the other danger, as with any other rotating machinery, is the possibility of getting your sleeve or shirt caught in the rotating chuck (on one infamous day in my apprentice days I ripped a pair of Wranglers – Don’t Ask…!).

Now aside from the fact that this work position cannot be comfortable it is also downright dangerous.

The study of the field of “Ergonomics” is all about making work tasks more comfortable / logical with an aim to make work safer (and of course also assists in productivity – “easier to work = more work output”). There is no doubt in my mind that this person’s supervisor and he himself has not considered to make this work easier and more comfortable… there is in fact a whole lot of apathy going on in this photo…

There is no care about the work location (i.e. the presence of the trip hazards) and no consideration to make the job easier… surely the lazy and apathetic would want to make the job easier?

This is just another example of a worker not thinking about his safety whilst he is working and a less than caring manager who is not in-tune with what is going on in the workplace.

If the managerial focus is simply on delivery then we can expect that there will be trouble ahead. In this instance this particular contract had already experienced a number of fatalities and little wonder if they are not thinking about safety (or ergonomics for that matter).

There is no excuse for indifferent or lazy management…!

Ergonomically Challenged or Lessons from an Apathetic Manager

Falling Cranes Bring Death and Regret

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Seeing a news item yesterday morning about a Tower Crane collapsing in Doha reminded me of a similar crane collapse I was called to investigate just over one year ago; a classic case of “sods law”.*

I had received a call at about 6:30am to be told that a crane had collapsed with one person dead and one person with “life changing injuries” (which turned out to be a trauma amputation of the leg). So with little choice I pulled on my boots and went to investigate.

In India usually the first persons to be called are the police who always attend and very often arbitrarily arrest the “main players” which in this instance happened to be the crane operator who had survived the accident with little other than a little emotional shock. When I arrived at the scene the crane was lying on its side with the boom bent and stretching across the hole (which was to eventually be an underground metro station). The photos will set the scene for you.

Essentially what had happened was that a large trenching grab machine was being dismantled and the 17 ton counterweight needed to be lifted onto a low bed for transport to the next worksite. Now in this large city there is a curfew on large / heavy vehicle movements after 6am so there was a rush to get the trailer loaded and off to the new site before the curfew came into effect. The operation had been held up somewhat due to the previous trailer becoming stuck in mud within the work site which had delayed the next trailer coming onto site to remove the counterweight.

Now you know “Sod’s Law” states that “when something can go wrong it will” and it did…

Firstly there was a change of Crane operator but not the Lifting Supervisor, who for some reason did not share the same shift hours as each other!

Secondly it is highly unlikely that the Crane Operator did any pre-start checks on the crane since there was this rush to load the counterweight onto the truck.

Thirdly there was seemingly no “plan” for this lifting operation and thus no calculation of the lifting radius nor the safe working load

Lastly we found the key for the Safe Working Load Indicator in the instrument and in the Off Position

These four points seemingly were contributory to the incident (not forgetting the rush everyone was in….) but the final blow of fate was the fact that two guys were standing having a chat on the other side of the excavation when the crane boom came down in that exact spot and the rest, as they say, is history.

I have only outlined briefly what went wrong in this tragic story, there is in fact much, much more; so many things which if advice had been followed, if supervisors and workers had been following the SSOW and Safety Practices already established the incident would not have happened.

In my mind are two enduring images… the horrific injuries to the deceased and, far more significant, the troubled and mournful look of the crane operator who was sitting in the back of the police van…

Stick to the Plan… nothing can bring back time or satisfy a wish that you had done it differently…

* A bit stuck between a rock and a hard place here… “sod” could be construed as an offensive word and if I use the alternative “Murphy’s Law” I might be accused of some sort of racism against the Irish

Falling Cranes Bring Death and Regret