1. Michael Quinlan
Avoiding Back to the Future
Learning from Past Failures to Build
Healthier and More Sustainable Work
Organisations
Emeritus Professor, School of Management, University of NSW
Business School , Middlesex University London
Perth Safety Symposium
#AIHSinWA #WAsafetysymp2019
2. Content
Fermi’s Paradox and global risk
Why study failure
Ten pattern causes of fatal incidents at work
Human dimensions of harm
Pattern failures in organisation: financial disasters
Changes to work organisation and health, safety and
wellbeing
Observations and lessons/remedies
3. Apparent contradiction between lack of evidence
and high probability of extra-terrestrial
civilisations
Physical/technological threats/barriers
◦ Doomsday physics/accidently creating a black-hole
◦ Technological risk – runaway AI (general intelligence) nano-botts
Or are the barriers/extinction points social?
◦ Over-population, social fracturing
◦ Resource depletion (including species diversity)
◦ Environmental degradation (eg pollution)
◦ Induced climate change
◦ Unsustainable forms of social organisation like rising
inequality/rise of authoritarian regimes/nuclear war
4. Over-population
◦ 1AD (275m), 1,000AD (300m), 1900 (1.6b), 1950 (2.55b),
2020 (7.66b), 2050 (9.3b)
◦ Urban concentrations (social dislocations/pandemics)
Resource Depletion
◦ Demands on water, food and energy
◦ Loss of forests, bio-diversity/species extinction (eg 80,000
acres of rainforest & 135 plant/animal species lost per day)
Environmental Degradation
◦ Fresh water (rivers, lakes and aquifers), clean air
◦ Pollution (eg air in China & India)
◦ desertification, erosion, excess irrigation/salination
◦ Oceans of plastic waste – Glitterati or Litterati?
5. Rapid Climate Change
◦ More extreme weather events (floods/long-droughts & glacial melts)
◦ Sea level rises/ shifts in disease vectors
Rising global inequality
◦ USA 1950 CEO/worker salary differential 1/20 2019 1/361 (Oz 1/68)
◦ Precarious work growth (multi-jobholding, under-empt, NEET exclusion)
◦ Wage stagnation (decline in labour share of national income)/wage-theft
◦ Growing inequality not confined to rich countries (ADB report)
◦ Cause of Great depression and GFC
◦ Rise of authoritarian politics (role of social media liberating/stultifying?)
Does this amount to perfect storm? Risks interact
urban growth/subsidence with rising sea levels/flood plain vulnerability
Antibiotics misuse/engineered pathogens/pandemics (biodiversity loss)
Inequality with drug-use (eg opioids), disease (obesity), suicide
Unprecedented combination (compare to 1930s crisis)
6. Sustainability needs to become core to human organisation
and action
Integration & ‘big picture’ thinking not thought ‘silos’
Avoiding Einstein’s definition of insanity/ stupidity
Learning from mistakes/failures
OHS provides both evidence of failure/causes for alarm but
also learning from them
7. In rich countries at least injury risks, and particularly fatalities,
significantly lowered since 1900 (social democracies do best)
though less so regarding disease
Managing risk and sustainable systems concepts that include the
environment are now common
We now know reducing routine (high frequency/low impact) harm
doesn’t reduce the risk of non-routine (low frequency/high
impact) harm?
This requires separate management and regulatory devices,
found in mining and energy but needs to extend (ie Dreamworld)
Worker rights/involvement integral to OHS laws since 1970s (ILO
Convention 155) though ‘reach’ corroding
Increasingly OHS research/professional practice looks at patterns
of risk harm but need to get message out (there are education
needs which the SIA is addressing)
8. Failure can be as instructive as success, especially in
case of low frequency/high impact events where
◦ Statistical records like workers’ compensation, lost day and
medical treatment injuries of little value
◦ Need to use different indices, KPIs and remedies
Examining series of incidents identifies recurring
causes, why systems fail & how to remedy
◦ Managing risk is about identifying patterns (causes and
effects) and examining series of failures is arguably best way
to identify patterns
Strategic decision making needs to draw on past
while recognising risk of misinterpretation & change
9. M. Quinlan (2014), Ten Pathways to Death and Disaster: Learning
from fatal incidents in mines and other high hazard workplaces,
Federation Press, Sydney.
Detailed examination of 24 fatal incidents in coal & Metalliferous
mines in 5 countries (Australia, New Zealand, USA, UK and
Canada) 1990 and 2011. 15 involved 3 or more deaths while 9
single fatalities. Identified 10 repeat/pattern causes.
Examined over 30 multiple fatality incidents in 10 countries in
other high hazard workplaces (chemical plants, refineries, oil rigs,
aviation, shipping and road transport). Same pattern causes.
Identified 10 causal pathways to fatal incidents (at least 3 present
in virtually all while majority had 5 or more – some had all 10)
More thorough the investigation the more pattern causes identified
10. Design, engineering and maintenance flaws
Failure to heed clear warning signals
Flaws in risk assessment
Flaws in management systems and changes to work
organisation
Flaws in system auditing
Economic/production and rewards pressures compromising
safety
Failures in regulatory oversight
Supervisor and worker expressed concerns prior to the
incident
Poor management/worker communication/trust
Flaws in emergency procedures and resources
13. Pike River
◦ Hydro mining
◦ Locating main ventilator UG
Dreamworld
◦ Evidence to coronial inquest
Allegations of poor maintenance of rides
design flaws in spacing between two full-length slats spanning
water channel
Wiring ‘rats nest’ on Thunder River Ride, electrician agrees could
lead to major malfunction
water pump failure on ride on day of incident (several instances
prior to event)
14. Pike River
◦ Board informed of safety concerns prior to incident
◦ Notifiable methane levels exceeded
Dreamworld
◦ Potentially fatal prior incidents on rides prior to disaster, including
several on same ride
2001 4 rafts collide on Thunder River Ride
2014 2 rafts collide on Thunder River Ride
2014 Cyclone rollercoaster released unharnessed
15. Pike River
Failure to risk assess hydro mining or UG main
ventilator (Pike River)
Dreamworld
Failure to do comprehensive risk assessment of HPIs or
safety implications of cuts to operator numbers below
manufacturers specification in at least one case.
Risk assessment process of staffing changes and ride
maintenance will hopefully receive detailed treatment
in coronial inquest findings
16. Pike River
Failure to maintain safety critical systems –rock dusting,
ventilation, equipment
Poor management of contractors
Dreamworld
Reduced/inadequate staffing on rides seems to have
been serious deficiency (critical in other incidents like
Herald of Free Enterprise)
17. Pike River
No proper OHS audit (Pike River) although concerns
raised with Board
Dreamworld
HPIs didn’t lead to reassessment of system, including
staffing levels on rides
Need to know more about auditing regime
18. Pike River
Production pressures/financial difficulties
Time sensitive bonus encouraged unsafe practices
Dreamworld
Were cuts to staffing or maintenance shortfalls due to
cost-cutting? Need to know more about this.
19. Pike River
Legislation inadequate re HPIs, systems-requirements (including
principal risk management and TARPS), specification standards on
known hazards, worker involvement, enforcement and penalties
Inspectors lacked expertise/resources and poor strategic use (also
no Chief Mines Inspector)
Post-Pike changes addressed these & most other pattern failures
Dreamworld
Legislation inadequacies, not designated high-hazard workplace
which it was
Inadequately trained inspectors and poor strategic use/oversight (eg
HPIs)
Post-Dreamworld changes to inspection/regulation but more needed
& will Coronial Inquest findings address all relevant pattern causes?
20. Pike River
Leading Hydro Management consultant resigned over
safety concerns
Management threatened union after it endorse safety-
related withdrawal led by supervisor (later amongst those
killed). Breach of century old principle in mining.
Worker concerns, at least one planning to leave
21. Dreamworld
Notice to inspectorate from AWU 6 Feb 2015 ‘Dreamworld has cut back its ride attendants on all its major
amusement rides to a single operator. This practice began around 15 months ago with just a few rides
but now has begun on all rides. In November 2014 the Cyclone Rollercoaster was released from the
station with its safety harnesses up. This was from a direct impact of having one operator working this
ride. Dreamworld fired the operator, they put the sole blame on him. Dreamworld called this a MAJOR
SAFETY BREACH but did nothing to rectify the problem. In February this year the same thing happened
again and this operator was also suspended. This has caused great concern to the Australian Workers
Union. The operators made contact with the union, one operator who had been an instructor for 17 years
has said that it is a disaster waiting to happen. The pressure on a single operator is too much. I have also
been informed that the Madagascar Rollercoaster was released with its safety harness unlocked WITH
PASSENGERS however it was stopped on the conveyor. The major concern to the union is that these rides
should not be able to depart without the harnesses being locked, there should be a device that shuts or
locks the ride down till they are locked, so it is impossible for the ride to start. Also the stress and
pressure that is put on our members and employees due to single operator. The AWU tracked down from
overseas the manufacturers manual for the Cyclone rollercoaster. It clearly states that ride should and I
quote “have one person operating but 2 but preferably more persons on the loading and unloading
operation of the ride”…The AWU would ask that a full investigation into Dreamworld’s dangerous
practices be done asap. Dreamworld’s response to the AWU is that they have conducted a risk
assessment. However, they also admit that what happened at the Cyclone Rollercoaster was a major
safety breach, yet they still continue to operate rides with a single operator. It should also be noted that
the ride-operators do not get rotated around. Dreamworld management say they do, but our members
have told us different.
22. Pike River
No effective worker input mechanisms (eg HSRs) and
poor management response to worker, supervisor and
union concerns (Pike River)
Dreamworld
Rejected union/operator concerns – need to know more
about this
23. Pike River How and some incidents where
contributed
No effective second egress
Poor safety management (location of ventilator
machinery) made rescue or even recovery more
dangerous
Dreamworld
Operator at time new and claimed not properly trained in
emergency procedures (doesn’t appear it made difference
but has in some eg Esso Longford)
24. Pattern causes go long way to explaining recurrent fatal incidents in
high hazard workplaces & focusing on them would minimise fatalities
Systems as hierarchies of control that corrode over time & better
suited to routine risk? Need to guard against this.
Pattern causes apply to both single fatalities and multiple fatalities
(both low frequency/high impact events)
Pattern causes generally latent failures (Reasons), any one could
cause fatal incidents but more you have more likely (only requires
trigger which is often minor of itself and difficult to predict/target)
Changes to work organisation like subcontracting can weaken
Safety ‘culture’ was not a pattern cause rather symptom of failure in
OHS management regime and priorities
25. ◦ Identifying & assessing/remedying OHSMS
gaps like
Does it address all fatality risks?
Does it sufficiently target both routine & fatality
risks?
Does it use risk-based systems & rules/remedies
where hazard controls well known?
Does it ensure risk assessment documented &
changes to work organisation etc considered?
Does it include appropriate HPIs, KPIs & TARPs?
26. ◦ Informing monitoring, incident reporting &
investigation (effective HPI reporting differentiating
routine/high-impact, upstream focus in incident
investigation)
◦ Strengthening auditing requirements
◦ Mutually reinforcing multiple feedback loops to
identify failures and ensure constructive dialogue (ie
potential for different/critical views)
◦ Deep listening/communication, problem solving and
upstream solutions (design/exposure). Companies
now targeting single fatalities, focus on fatality
mechanisms, pattern causes, involvement and
upstream (eg engineering) remedies
27. Sandra Welsh and her daughter Jenna leave the Burnie
Magistrate’s Court after charges withdrawn against CMT with
regard to the death of Michael Welsh asphyxiated in a mud-rush
28. ◦ 2007-18 study - impact of workplace death
◦ interviews institutional representatives/families & global
survey (respondents 62% Australian, Canada 17%, USA
16%, UK 5%/ respondents 90% female/fatalities 90% male
◦ Survey findings 61% experiencing (PTSD), 44% (MDD) and
42% (PGD)
◦ Also significant effects on children, financial effects
(especially self-employed), key role of self-help groups
◦ What families want regarding prevention
Clear and timely information of how/why death occurred
Deceased not dehumanised by legal processes
Identification of responsibility and timely prosecution if breach with
significant penalties that will act as deterrent
Remedial measures so other families spared similar tragedy
29. In examining recent calamity exposed by Banking Royal
Commission Stewart Howe identified 8 pattern failures
◦ Economic pressures compromise customer outcome
Financial performance was pre-eminent in company goals and executive incentives (and
not penalised for failures on operational and regulatory risks). Sales staff were
incentivised by rewards and product commissions.
◦ Prior warning or causes for alarm ignored
Over 3 years 3 “red flag” audit reports by Audit Committee on CBA’s AUSTRAC failures.
“Fees for no service” and charging unlawful commissions subject of regulatory
investigation. Inherently conflicted appointment of executives as superannuation
trustees widely acknowledged.
◦ Failures in regulatory oversight and inspection
APRA and ASIC lacked adequate funding, specialist skills and exhibited little bias to use
litigation to penalise serious breaches, preferring negotiated enforceable undertakings.
◦ Employees and others expressing concern
Cacophony of complaints by customers, ombudsmen and others. Whistle-blowers
harmed and staff compromised by financial incentives
30. ◦ Management process and risk management plan failures
Most organisations had reasonably resourced and skilled internal audit functions but
subordinated to revenue earning units. Audit actions for breach/risk mitigation not
priorities for revenue units or their executives.
◦ Failures in risk assessment
Systemic law-breaking not perceived risk/threat to operating license, with inadequate
metrics and escalation processes. Harm to customers, company brand and reputation
apparently a blind spot in risk assessment.
◦ Failures in auditing
Failure response to defects detected by audits, lack of priority/resources to deliver
remediation in the revenue units. Executive Committee and Board governance failed
to monitor/correct engine room failures.
◦ Product design, and system maintenance failures
Many failures in product design. Revenue generating features often trumped
legal/regulatory product attributes. Remuneration system design were a latent
hazard driving many other pattern failures. Delays/inability to detect systems failures
indicate poorly maintained infrastructure.
Note: Institute of Company Directors and AFR/SMH weren’t ‘interested’
and Royal Commission only addressed some failures – expect more
financial/banking disasters
31. ◦ Repeated rounds of downsizing/restructuring
◦ Outsourcing/use of subcontractors/supply chains
◦ Growth of labour leasing, franchising and self-employment
◦ Privatisation (note how this ‘improved’ energy supply in Australia)
◦ Decline in full-time ‘permanent’ jobs (once the norm)
◦ Growth of temporary/fixed contract work
◦ Growth of part-time jobs/multiple jobholding
◦ Increased immigration/temporary guest-workers
◦ Growth of home-based work & telework
◦ Automation/digitalisation
Note: Shouldn’t overstate the new digital economy which often entails recycling
very old forms of work (eg Uber etc simply app-enabled subcontracting)
32. Work scheduling (e.g. extended hours, irregularity &
worker control)
Psychosocial factors, including effort/reward, control,
harassment/bullying
Worker involvement/participation
Critical assessment of OHS regulation
including political economy of disasters
Exposure & response to hazardous substances
Precarious employment & vulnerable workers
Now have persuasive models of work organisation &
health connections – ERI, JDCS & PDR
33. Effort/Reward
Pressures
Disorganization Regulatory Failure Spill-over
Effects
Insecure jobs
(fear of losing
job)
Short tenure,
inexperience
Poor knowledge of
legal rights,
obligations
Extra tasks,
workload
shifting
Contingent,
irregular
payment
Poor induction,
training &
supervision
Limited access to
OHS, workers comp
rights
Eroded pay,
security,
entitlements
Long or
irregular work
hours
Ineffective
procedures &
communication
Fractured or
disputed legal
obligations
Eroded work
quality, public
health
Multiple jobs/
under-
employment
Ineffective OHSMS
/ inability to
organise
Non-compliance &
regulator oversight
(stretched
resources)
Work-life
conflict
34. Temp agency worker study (Underhill & Quinlan 2011)
◦ Economic pressure (low/irregular pay, easily replaced)
◦ Disorganisation (placement mismatch, less training/induction)
◦ Regulatory failure (afraid to report problems, less RTW if
injured)
Hotel cleaners study (Knox et al 2017) of bullying and
intention to leave
◦ The path model indicated that disorganisation and regulatory
failure had direct positive associations with bullying.
◦ Financial pressure and bullying had direct positive associations
with ITL.
◦ Bullying and turnover are significant problems but the
◦ contribution of work organisation is poorly understood. Study
preliminary evidence on role of PDR as an antecedent of both
bullying and ITL.
35. More knowledge always valuable but we actually know a lot about why
organisations fail/features of work that harm health.
Organisations, professions and government need to target key failure
points and reshape work arrangements to remove health-harming
aspects – this is practical/achievable
Organisations focusing on sustainability in their operations,
products/services and work that is secure/stable, adequate rewards,
effort/control balance, trained, clear OHSMS targeting both routine
and non-routine hazards, genuine worker rights to report/participate
and effective regulatory oversight
Informed professions committed to the ethic of safeguarding human
health, safety and wellbeing (licensing?)
Engaged unions, devoting more resources to OHS
Boards/CEOs and governments taking genuine responsibility for the
human consequences of their activities
36. M. Quinlan (2014), Ten Pathways to Death and Disaster: Learning from fatal incidents in mines and other
high hazard workplaces, Federation Press, Sydney.
Hopkins, A. & Maslen, S. (2015) Risky rewards: how company bonuses affect safety, Ashgate, Farnham,
Surrey.
Howe, S. (2019) 10 Pathways to Death and Disaster, unpublished paper.
Underhill, E. and Quinlan, M. (2011) How precarious employment affects health and safety at work: the case
of temporary agency workers.Relations Industrielles 66(3):397-421
Bohle, P. Quinlan, M. McNamara, M. Pitts, C. & Willaby, H. (2015) Health and wellbeing of older workers:
Comparing their associations with Effort–Reward Imbalance and Pressure, Disorganisation and Regulatory
Failure, Work & Stress, 29(2):114-127
Quinlan, M. Hampson, I. Gregson, S. (2013) Outsourcing and offshoring aircraft maintenance in the US:
Implications for safety, Safety Science, 57:283-292.
Quinlan, M., Fitzpatrick, S. J., Matthews, L. R., Ngo, M., & Bohle, P. (2015) Administering the cost of death:
Organisational perspectives on workers’ compensation and common law claims following traumatic death at
work in Australia. International Journal of Law and Psychiatry. 38:8-17
Bohle, P. Knox, A. Noone, J. Mc Namara, M. Rafalski, J. Quinlan, M. (2017) "Work organisation, bullying and
intention to leave in the hospitality industry", Employee Relations, Vol. 39 Issue: 4, pp.446-458, doi:
10.1108/ER-07-2016-0149
Matthews, L. Quinlan, M. Rawlings-Way, O. and Bohle, P. (2019 online) Work Fatalities, Bereaved Families and
the Enforcement of OHS Legislation, Journal of Industrial Relations,
https://journals.sagepub.com/doi/full/10.1177/0022185619829181
Walters, D. Quinlan, M. Johnstone R. & Wadsworth, E. (2017) Representing miners in arrangements for health
and safety in coalmines: A study of current practice, Economic and Industrial Democracy, DOI:
10.1177/0143831X16679891
Matthews, L. Quinlan, M. Bohle, P. (2019) Prevalence and correlates of post-traumatic stress disorder,
depression, and prolonged grief disorder in families bereaved by a traumatic workplace death Frontiers of
Psychiatry https://www.frontiersin.org/articles/10.3389/fpsyt.2019.00609/full