2017 Visions Conference Presentation Presented by Geoff Dell

1. 45 Years since Robens…
and not much has changed!!
Associate Professor Geoff Dell
PhD, MAppSci (OHS), Grad Dip OHM, CFSIA

2. An accidental career….

3. SIXTY YEARS OF JET OPERATIONS BY AUSTRALIA’S AIRLINES
NO FATAL ACCIDENTS | CIRCA 1.5 BILLION PASSENGERS CARRIED | CIRCA 15 MILLION FLIGHTS

4. CQU FORENSIC INVESTIGATION TEACHING LABORATORY,
BUNDABERG, 2017

5. 1. In 2000-01, 8% ($4.0 billion) of total allocated health
expenditure was spent on persons who experienced injuries
in the home, recreation etc).1
2. The annual cost of accidents on Australian roads totals $17
billion dollars a year representing 2.3% of GDP!.2
3. In 2012-13, the cost of work-related injuries and illness was
estimated as $61.8 billion dollars or 5.9% of GDP.3
ACCIDENTS AND DISEASE AT EPIDEMIC PROPORTIONS
1. Australian Institute of Health and Welfare (2004), AIHW Disease Expenditure Database, October 2004. Cited in ABS (2006) Injury
in Australia: A Snapshot, 2004-05, Australian Bureau of Statistics, Canberra
2. Connelly L. & Supangan R. (2006), The economic costs of road traffic crashes: Australia, states and territories, Accident Analysis
& Prevention, Vol 38, Issue 6, PP1087-1093, Elsevier
3. Safe Work Australia (2015), The cost of work related injury & illness for Australian Employers, Workers and the Community:
2012-2013, www.safeworkaustralia.gov.au.

6. 4. Total annual costs of all rail related incidents in 1999
estimated at $196 million
5. In 2003/4 the total cost of all aircraft accidents and incidents
was estimated at $114 million
6. The 2004-05 NHS indicated that:
– 18% of the population (3.6 million persons) had sustained a recent
injury (in the previous four weeks).
– Of all employed persons aged 15 years and over, 7% had received an
injury while working for income in the four weeks prior to interview
Citations: 4. BITRE 2003, Rail Accident Costs in Australia, Bureau of Infrastructure, Transport and Regional Economics, Canberra,
https://bitre.gov.au/publications/2003/report_108.aspx
5. BITRE 2006, Cost of Aviation Accidents and Incidents, Bureau of Infrastructure, Transport and Regional Economics,
Canberra, https://bitre.gov.au/publications/2003/report_113.aspx
6. SIPP (2004), The Draft National Injury Prevention Plan: 2004 Onwards, Strategic Injury Prevention Partnership
Canberra. Cited in ABS (2006) Injury in Australia: A Snapshot, 2004-05, Australian Bureau of Statistics, Canberra
ACCIDENTS AND DISEASE AT EPIDEMIC PROPORTIONS

7. TOTAL ANNUAL COST OF ACCIDENTAL TRAUMA
AND DISEASE IS CIRCA:
$80 BILLION
or circa
8% of GDP
There is clearly a need for more research and
development of new and more effective
interventions
ACCIDENTS AND INJURIES AT EPIDEMIC PROPORTIONS

9. 45 years of “Modern” approaches to OHS prevention
• Lord Robens (1972)
• The Common Law “Duty of Care” taken up
progressively in Australia from mid 1980s
• Risk based decision-making
• “Blame” culture shifts to “no blame” culture and
then “just” culture
• SMS introduced from mid 1980s NOSA – NSCA –
SafetyMap – AS4801 – Rail - Aviation
• 1990s Focus shifts to “Organisational Accidents” –
“blame” shifts to managers – criminalisation of
accidents

10. 40 years of “band-aid” approaches
• Most companies below the regulators’ horizon
• Not enough inspectors to oversight all companies
• Most companies only become a focus after an
accident or injury
• No regulation of safety profession – anyone can call
themselves a safety professional
• Embroiled in the industrial relations paradigm
• Flavour of the month campaigns – little validation
• Very little independent safety research
40 years of accident and injuries continuing unabated
and still playing a version of the blame game:

11. HARMONISED WHS LEGISLATION 2012
• NOT MUCH HAS CHANGED
– Still based on the common law duty of care
– Still a risk based approach
– Still focused on blame & prosecution
– Still insufficient regulatory oversight
– Still mostly reactionary
– Still widely mis-understood
• Holding back the flood gates at best….the accident and
injury epidemic continues
– $61.8 Billion annual direct economic costs
– Plus …. what social costs, impact on families, pain and
suffering

15. SAFETY SYSTEM RELIABILITY
IMPLEMENTATION
EFFORT AND COST
FAILURE
PROBABILITY
10-1
NO
CONTROLS
10-3
SINGLE
ENGINEERING CONTROL
OR
REDUNDANT
ADMINISTRATIVE CONTROLS
10-6
DOUBLE
REDUNDANT
ENGINEERING
CONTROLS
10-9
MULTIPLE
ENGINEERING DESIGN
REDUNDANCY
10-2
SINGLE
ADMINISTRATIVE
CONTROLS
PLUS
10-12
MULTIPLE
ENGINEERING
CONTROLS
REDUNDANT
ADMIN CONTROLS
OBJECTIVE OF HIGH
CONSEQUENCE
INDUSTRIES
(EG AVIATION,
NUCLEAR
CURRENT
ENGINEERING
DESIGN TARGET
AVIATION
CURRENT
STANDARD ACROSS
MOST OF INDUSTRY
STANDARD OF
MANY GOOD
PERFORMERS
ACROSS INDUSTRY
SHORT TERM GAIN
LONG TERM BENEFIT
SIMPLISTIC WORK
PROCEDURES IN
MANY POOR
PERFORMING
COMPANIES
B747 (A380)
Citation: Dell G. (1999) Safe Place vs Safe Person: A Dichotomy, or is it?, Safety Science Monitor Vol 3,
http://ssmon.chb.kth.se/vol3/index.php

16. Boeing B747 – 1965 design Theoretical Failure
Rate ~ 1x10-9
Design redundancy includes:
3 engines providing services (Electrical &
Hydraulics)
3 independent engine driven electrical
systems
3 independent engine driven hydraulic
systems
3 technical crew members
Global B747 operations 1969 to present:
77.8 Billion kilometres flown
5.6 Billion passengers carries
~ 30 million flights flown
1x10-9 Accident has not yet occurred

17. SAFETY SYSTEM RELIABILITY
IMPLEMENTATION
EFFORT AND COST
FAILURE
PROBABILITY
10-1
NO
CONTROLS
10-3
SINGLE
ENGINEERING CONTROL
OR
REDUNDANT
ADMINISTRATIVE CONTROLS
10-6
DOUBLE
REDUNDANT
ENGINEERING
CONTROLS
10-9
MULTIPLE
ENGINEERING DESIGN
REDUNDANCY
10-2
SINGLE
ADMINISTRATIVE
CONTROLS
PLUS
10-12
MULTIPLE
ENGINEERING
CONTROLS
REDUNDANT
ADMIN CONTROLS
OBJECTIVE OF HIGH
CONSEQUENCE
INDUSTRIES
(EG AVIATION,
NUCLEAR
CURRENT
ENGINEERING
DESIGN TARGET
AVIATION
CURRENT
STANDARD ACROSS
MOST OF INDUSTRY
STANDARD OF
MANY GOOD
PERFORMERS
ACROSS INDUSTRY
SHORT TERM GAIN
LONG TERM BENEFIT
SIMPLISTIC WORK
PROCEDURES IN
MANY POOR
PERFORMING
COMPANIES
B747 (A380)
Citation: Dell G. (1999) Safe Place vs Safe Person: A Dichotomy, or is it?, Safety Science Monitor Vol 3,
http://ssmon.chb.kth.se/vol3/index.php

18. Qantas A380 VH-OQA
“Nancy-Bird Walton”
Departing Toulouse 2008
Qantas A380 VH-OQA
“Nancy-Bird Walton”
QF 32 Catastrophic Engine
Failure Incident -4 November
2010

19. Top 53 Safety Management System Validated Stocks
(Monash University Accident Research Centre, Westpac Investment Management, Ord Minnett)
Citation:
Larsson, T., Mather E. and Dell G. (2007), "To Influence Corporate OHS Performance Through the Financial
Market", International Journal of Risk Assessment and Management, Vol. 7, No.2, 2007, pp263-271,
Inderscience Publishers, Geneve.
SOME COMPANIES & AGENCIES ARE BEGINNING TO UNDERSTAND……..
and this provides us…….. TANGIBLE ENGAGEMENT OPPORTUNITIES!!

20. • The interesting group were the companies in the 50 to 75%
compliance group.....the managers thought they were very
good safety managers. However, they could not see the
deficiencies in their safety management systems
40,000 HAZARDS ARGUABLY ONLY 2 HAZARDS
but 10,000 plus critical controls
• So what does this mean for accountable managers? This is a
significant potential system weakness
Accidents at Epidemic Proportions: The Need for a Paradigm Shift – RSSB Forum 2016

21. • Important to recognise that high consequence low
probability operations only have a low probability of failure
because there are multiple layers of redundant controls and
interventions to ensure the fidelity and reliability of the
critical defences are maintained.
• Almost everything we do must be about ensuring the
integrity and reliability of the critical defences.
• Not surprisingly it is very much about the integrity of the
people component of the socio-technical system
• Accordingly, the focus needs to be on ensuring the integrity
of the operational management systems.....the
organisational arrangements for delivery of operating
standards
Accidents at Epidemic Proportions: The Need for a Paradigm Shift – RSSB Forum 2016

22. SMS
MHF Safety Case
Accidents at Epidemic Proportions: The Need for a Paradigm Shift

23. Accidents at Epidemic Proportions: The Need for a Paradigm Shift – Visions 2017
AVIATION SMS MANDATED:
DECISIONS & OUTCOMES CHALLENGED
Responsible managers identified & held
accountable :
• Chief Executive
• Line managers (Flt Ops & Engineering)
• Safety Manager

24. • In the mid 1980’s, the late Ben Cosgrove former VP Engineering of Boeing
Commercial Airplanes and Paul Russell former Flight Safety Manager of
Boeing Commercial Airplanes carried out a study to investigate why
Australia’s major airline operators had not suffered a hull loss accident
while other seemingly “good” airlines elsewhere had
• Tested airlines against the combined principles and processes prescribed
by the Boeing FOMs and EMMs
• Found Australian carriers were on average more than 95% compliant,
others who had experienced accidents averaged less than 75%
compliance.
The lessons for broader SMS applications
in other industries are clear!!
Accidents at Epidemic Proportions: The Need for a Paradigm Shift – RSSB Forum 2016

25. The need for a paradigm shift:
1. Whole of operation hazard management approach
2. Systems (engineering and administrative) redundancy
3. Mandatory SMS (focused on workplace hazards and conditions)
4. Step change in applied accident investigation standards across all
industries
5. Broader application of MHF principles to other industries of all sizes:
a) Independent safety assurance assessment
b) SMS audited by Regulator
c) Management decisions relating to hazard management validated
d) Accountable managers identified – line managers – safety
managers
6. Evidence based OHS practice and interventions
7. Regulate the safety profession – eliminate fly by nighters

26. At CQU we create…..Safety
Scientists!!
26
QUESTIONS ?