A metric applied to Management of Safety Implementation System in the workplace

Various players are there in the theatre of a workplace in any project site who have to play their role effectively and timely to ensure the play goes on as scripted. Who are these players? The answer is easy as well as difficult depending on how the roles are identified and enacted in the workplace. A play is scripted by the author in keeping with the plot of the play that has been conceptualized by the author. Likewise, in the workplace an activity in continuity is designed which combines various engineering inputs to achieve the final goal - be they manufacturing, construction or process industry requirements - leading to achieving the final objective, say building a high- rise building or a complex nuclear power plant.

Lest it becomes a complex ‘input – process – output equation’ to comprehend or leads to simplification, let me quote an anecdote.

In a huge construction project, a large multistoried building was being built. One element of a chain of activity involved breaking some concrete slabs with the help of an electrically operated stone breaker. A trained worker who is assigned to the task did not wear gumboots or rubber gloves as they were thought to be cumbersome and unnecessary both by the site supervisor and the worker himself, especially in view of the prevailing summer heat. In the course of stone breaking, the breaker stopped all of a sudden. Baffled and at his wit’s end, the worker could not figure out why the breaker had stopped even as power supply was interrupted. Nevertheless, he seemed to guess if the makeshift arrangement made by his helper to feed power to the breaker through a 3-wire cord inserted into the power socket and held in place by inserting wooden sticks/matchsticks had come loose resulting in the wires inserted into the socket coming off the socket. The worker who was operating the breaker asked his helper to check if his guess was right. The helper who had gone to the location of the socket, shouted from there – “yes, the wires have come off the socket and asked if he could insert the wires into the socket and switch on the power”. To the helper the whole situation looked very simple, no rocket science – three wires of the cord and three holes in the socket – why the hell should he wait for the site electrician to come to fix the connection. To the helper, it was a simple process of inserting three wire heads one each into three holes of the socket. Well, the connection was completed in no time. Once this simple process was completed, the helper shouted from there asking his operator if he could switch on the connection. Once equipped with the operator’s consent, he switched on the connection. No sooner had he done it, the operator collapsed on the breaker writhing in shock and pain. It took a while for the nearby workers to notice the plight of the slab breaker. They rushed to him and asked the helper who was yet to move away from the location of the socket to switch off the connection. It was too late though. The operator was unconscious. He was rushed to the nearby hospital where he was declared ‘brought dead’.

As per usual practice, an investigation was promptly ordered by the project head solemnly declaring - “I want accountability for the fatal accident to be fixed. I will punish the person responsible for this unfortunate fatality. The fatality is not only condemnable but a black spot on the otherwise green record of the site as well as the reputation of the company. The client company as well as their PMC will treat us as a roadside contractor. What a shame and embarrassment.”

Investigation team was constituted comprising the site safety head, a senior site engineer and a representative of the labour department promptly. After painstaking investigation lasting a few days and numerous visits, the team arrived at the most obvious conclusion: “The operator who had authorized his helper to fix the connection was himself to blame. The site SOP clearly required that all electrical breakdowns be handled by the site electrician only. The deceased operator’s action was not only in violation of the basic safety ‘do’s and don’ts’ but also most unexpected of an experienced and trained operator”. The report was consented to and forwarded by the project head to me in the Company’s HQ.

Well, I was not sure if the findings were based on a Systematic Technical Investigation. The conclusion seemed to be in keeping with the general belief that a dead person could not defend himself nor would he be there to tell his side of the story. Blame the dead and go on with life. All three members of the investigation had their own ax to grind – site safety head did not want his site which he was supervising as safety head to carry the scar of a fatality; the senior site engineer did want his name to figure as it was under his overall superintendence that the operator met with the fatality and the labour department representative did not want to go through the legal hassles that would ensue once any act of omissions or commission would be delved into once the accident is reported to the law enforcement authorities.

Since I used to receive numerous such cover up findings very often, I decided to visit the site even though it was located far away from Chennai and investigate the occurrence afresh.

My reinvestigation revealed the following:

• The fateful 3-pin socket was still there on the switch board and was an ordinary domestic type.
• The cord did not have a plug top, it was obvious that the cord which had originally come with the breaker must have had proper industrial type metal clad plug top which was removed and replaced with ordinary common-use plug top to fit into the sockets of similar make.
• Inserting wires into the socket and holding them in position with the help of matchsticks was a normal practice in the project site which my visit to the site revealed; it was obvious that this was being done with the tacit approval of the site electricians and other senior engineers. Perhaps, the project head was no exception.
• This grossly unsafe practice and illegal arrangement in vogue must have been approved by the project head as its existence would not have escaped his notice – he was reputed for visiting nook and corner of the site every morning and question all concerned if there was any delay or lapse noticed in the scheduled progress of work.

I, after collecting all relevant details and visiting the site for a closer look including interacting with the eyewitnesses, convened a meeting of the concerned work in-charges along with the project head. The following highlights were duly deliberated and recorded:

• Why domestic type sockets were being used? – the answer offered was straight and simple – there was no budget provision nor was there any separate fund available for such consumables.
• Why plug tops were missing? – the explanation given was ‘they were being pilfered frequently by the home bound workers and hence it was decided to make do with bare wires inserted into the sockets which was claimed to be as good and effective to meet the operational requirements.
• Why Electrical department did not object to these grossly unsafe practices that were also in violation of Indian Electricity Rules? – the site electricians did object in the past, but they were overruled by the project head.
• When was any indent for plug tops raised by the Electrical Department? – the last indent was raised six months ago, and it was still lying on the table of the site in-charge.

A visit to the Materials Stores and scrutiny of inventory register revealed that plug tops were not in stock at all. The site in-charge’s refrain was prompt and straightforward – this is the usual practice in construction sites and hence this site should not be singled out. He insisted “he did nothing wrong by holding back the indent for plug tops”. There was a common refrain heard in the meeting that “workers did not listen to the pep talk/toolbox talk carefully enough”. They found such exercises timewaster. Neither the site execution team nor did the subcontractors wanted good 15 minutes wasted on such “frivolous activity”.

• A query raised with the helper of the deceased operator revealed that he did not know that the three holes in the socket represented phase, neutral and earth respectively. He thought that inserting three wires into three holes of the socket was logical, no rocket science, and hence he reckoned why to waste time waiting for the site Electrician. His boss, the operator, was sweating out in the sun and he should not be made to wait as only small part of the job was left to be completed. To the helper, taking care of the physical inconvenience of his boss was more important than wasting time waiting for the Electrician. However, he was never trained in Do’s & Don’ts of Electrical safety nor was he given any toolbox talk. He was sure he was doing no wrong because he did the same in his hut if and when the wires came off the socket and the connection worked.

I returned to my HQ office and made a detailed report on the fatal accident. The operating part of the report consisted of the following observation:

• The site in-charge who did neither budget nor allowed contingency purchase of plug tops as a site policy was solely accountable for the fatality. During his routine daily morning rounds, he only cared for the daily progress
• Also, since he ignored unsafe use of ordinary plug tops and sockets, he was found to be complicit.
• All domestic type ordinary sockets and plug tops should be replaced with industrial type metal clad sockets and plug tops to deter frequent pilferage of these items as the industrial type of metal clad socket/plug would have no use in the domestic background.
• The site in-charge was popular for his belief that “speed of execution and progress must get top priority; it not only sustains profitability of operations but also helps meet revenue expenditure effectively. Everything else can wait. Safety aspect of a job is incidental to and not integral to progress.” He repeated these sentiments during our meetings convened to discuss the fatal accident in question as well.

The prudent and image conscious management of the construction company I belonged to agreed to my findings. It was decided by the management to sack the site in-charge and roll out a programme for replacing all ordinary sockets and plug tops with metal clad industrial type ones in a phased manner. Tough this involved a huge investment but the company management did not shy away from incurring this cost. Also, toolbox talks and electrical safety training effort was reinforced.

As a result, no case of electric shock incident on account of sockets and plug tops has been reported from the sites operated by the company.

So far so good for the happy ending, though my sympathies are with the operator who died in harness and my concern for the family of the site in-charge for losing his job. The project in-charge was a fairly senior guy in the hierarchy of management. Well, this man no doubt would find employment elsewhere sooner than later because of his engineering qualification and industrial experience, but the disregard of the matrix of responsibility, authority, and accountability in respect of Safety System Implementation will haunt him wherever he goes and forever.

In conclusion, I would like to explain the matrix so others who treat requisites of site safety as the exclusive responsibility of the site safety engineer who lacks the authority to substantially change an unsafe condition unless he has the consent of the project in-charge who alone controls all revenue expenditure but who looks at safety as a burden on their budget and fund allocation, should know they can lose their job and be summarily shunted out of the system if the controlling company is prudent enough and has the right safety value in an environment of prevailing safety culture. Also, the recent OHS Code enacted by the Government of India provides for deterrent punishment including imprisonment of the violator of the Code.

Responsibility – Authority – Accountability Matrix & Its relevance to Safety Management System

For Successful Delegation

Let’s look at the triangle/matrix and examine each side of the triangle to determine relevance of the Responsibility, Authority & Accountability elements to effectively manage safety in the workplace involving man, material, plant, and machinery individually as well as collectively. Also, let’s determine their Interoperatibility and interdependence.

If I take up Responsibility first – it is widely believed in the Indian industry that Safety is every body’s responsibility individually and collectively. We find slogan boards proclaiming “safety is everybody’s responsibility” meaning your safety is your responsibility displayed all over the workplace. Do you agree with this element of an organization’s mandatory Safety Policy? At least, I don’t agree. Why? My safety is not my responsibility as long as am working in a place that has been designed and controlled by others. In the instant case, it is the responsibility of my managers to provide safe and secure place of work.

Suppose I am flying from place A to place B and suppose the Airhostess announces on the public address system that it is the policy of the Airlines - my safety during the entire length of travel including during takeoff and landing is my responsibility; please tighten your seat belt and enjoy the flight and our warm hospitality but be careful about your own safety. How will you react to this announcement while you are seated in the aircraft and the aircraft is about to take off? I for one would not hesitate to call the Airhostess and ask her to deboard me at once.

Likewise, in the workplace if a group of workers is taken to an elevated work platform and asked to do erections work and if they are informed by the site Engineer-in-charge that their safety in the ‘work at height situation’ is their own responsibility irrespective of prevailing unsafe conditions like unprotected edges, missing deck boards/toe boards, no anchor point for fixing lanyards and fall arrest system and such other requisite safety arrangement. The workers who are ill informed, inadequately trained, and not knowing what to expect would perhaps agree to work but will the workplace management be absolved of their culpability and should the management in general be condoned for their blatant violation of the law? I am sure your response would be a big NO.

Let’s deal with the next side of the triangle – Authority. Any responsibility without matching authority for budgeting expenditure and providing resource for making the required safety arrangement is a myth. Who do you think has this authority? – of course, the management representative with due power of attorney duly delegated by his management – in the case of a construction project the contractor or owner of the establishment or in case of a factory the occupier.

If we discuss the role of the safety engineer – the obvious question arises, does he have the authority to commit expenditure of the kind that erecting a safe elevated work platform with safe access and egress would require? The answer is obvious – No. Responsibility without corresponding and commensurate Authority to commit and provide for the material resources and manpower is meaningless. Responsibility without matching Authority is a myth.

Indian jurisprudence clearly stipulates that the person with requisite Authority is duty bound to exercise due diligence at least in the matter of personal safety and occupational health by planning and laying down a hierarchy of management control in the workplace so the activities are carried on safely. The required hierarchy of risk control can’t be built up unless the authority to commit material and human resource is vested at the zero ground.

When delegating authority, responsibility and accountability are all interrelated - a manager is responsible for all actions of employees under his control and leadership.

The Project in-charge was punished for the dereliction of his duty towards safety and welfare of his workers who were never found lacking in ensuring scheduled progress of work.

I don’t regret the Project in-charge’s fate. The punishment is exemplary.

Dear Readers, I rest my case here.

Postscript:

What I have attempted to bring out in the open through this article is to explain the spirit of corrective and preventive action (CAPA) which is normally missed out in the prevailing safety management system. What an investigation team and also the safety engineers end up doing most of the time is to identify certain salient elements of corrective action which would prima facie lead to eliminating the identified accident cause(s) in respect of a particular situation. In this case, use of socket and missing plug top would get away with all the attention of the decision makers. But the underlying and potent causes which led to the missing plug top would never come to the surface. In my view, taking care of the missing plug top would merely amount to taking corrective action and that would invariably consist of fixing the missing plug top and punishing the offender, very rarely though. All such actions may at best lead to scratching at the surface of the problem.

However, the more potent, overwhelming, and critical element i.e., ‘failure of management control – popularly known as the hierarchy of risk control’ - leading to the creation of a blatantly unsafe situation, that led to the unfortunate death of the operator in harness, most often, if not always, is given a goodbye

Dear Readers, my understanding of a wholesome safety management system dictates that no meaningful ‘root cause analysis (RCA)’ is possible unless, going beyond the corrective action, the concerned decision makers as well who missed to act appropriately and timely are brought into the ambit of investigation and the culpable brought to justice. And that would indeed be the beginning of building a true Safety Culture. Or else, building a true ‘Safety Culture’ will continue to be a myth.

R K PODDAR
Head SHE Dept. (Retd.) - L&T Construction