1. Organisational `Safety Stressors` and their Relationship to Severe Accidents and Incidents Occurring within the UK Construction Industry. Organisational `Safety Stressors` and their Relationship to Severe Accidents and Incidents Occurring within the UK Construction Industry. Robin Chaplin ; Bovis Lend Lease UK EHS Director

2. The UK Construction Industry UK Industry overall saw 59 deaths (2005/6) UK Industry overall saw 59 deaths (2005/6) Highly dissociated and diverse operations Highly dissociated and diverse operations Traditional workforce Traditional workforce Recognised industry requires improvement (Egan) Recognised industry requires improvement (Egan) MCG £20 billion annum of work MCG £20 billion annum of work Major companies performance significantly better than smaller construction companies Major companies performance significantly better than smaller construction companies Nil fatalities 2005/6 in Major Contractors Group Nil fatalities 2005/6 in Major Contractors Group Majors seeking significant improvement and new approaches. Majors seeking significant improvement and new approaches.

3. Milton Keynes Scaffold Collapse

4. Worthing Crane Collapse

7. The Study Review to establish key factors `underpinning` serious accidents Review to establish key factors `underpinning` serious accidents Aim to address circumstances and understand `stressors` if present Aim to address circumstances and understand `stressors` if present Key `root factor` analysis process Key `root factor` analysis process Conducted by `expert panel` in a team review Conducted by `expert panel` in a team review Review of 100 `events` drawn from MCG companies and also other UK majors Review of 100 `events` drawn from MCG companies and also other UK majors

8. Expert Panel -Process of evaluation 100`events` to which full background provided. 100`events` to which full background provided. Against the background to each `event`, the reviewers were asked to Against the background to each `event`, the reviewers were asked to Consider in the light of the investigation which factors were considered presentConsider in the light of the investigation which factors were considered present Which of these factors are viewed as being of the major contributors to the incident or accident occurrence?Which of these factors are viewed as being of the major contributors to the incident or accident occurrence? Mark only after collegiate agreement with other members of the panel. Mark only after collegiate agreement with other members of the panel.

9. Range of serious `events` covered

10. Factors considered within panel review of ‘organisational factors and stressors‘ attributable to accident and incident events. PHASE 1. PLANNING CONSIDERATIONS: PHASE 1. PLANNING CONSIDERATIONS: PLANNING TIMEPLANNING TIME DESIGN CONSIDERATIONSDESIGN CONSIDERATIONS BUDGETBUDGET TIME CONSTRAINTSTIME CONSTRAINTS PHASE 2. DECISION MAKING PHASE 2. DECISION MAKING DESIGNDESIGN PROCESSES:PROCESSES: PHASE 3. EXECUTION PHASE 3. EXECUTION ORGANISATION AND RESOURCESORGANISATION AND RESOURCES CABABILITIES OF SITE MANAGEMENT TEAMCABABILITIES OF SITE MANAGEMENT TEAM TECHNICAL ISSUESTECHNICAL ISSUES

11. Expansion of Considered Points PHASE 1. PLANNING CONSIDERATIONS: PHASE 1. PLANNING CONSIDERATIONS: - PLANNING TIME - PLANNING TIME Lack of Forward Planning Time for overall operational deploymentLack of Forward Planning Time for overall operational deployment Lack of Forward Planning Time for selected operationsLack of Forward Planning Time for selected operations - DESIGN CONSIDERATIONS - DESIGN CONSIDERATIONS Aspects of design of the Construction phaseAspects of design of the Construction phase Late designLate design - BUDGET - BUDGET Budget pressures (client generated)Budget pressures (client generated) Budget pressures (self generated)Budget pressures (self generated) - TIME CONSTRAINTS - TIME CONSTRAINTS Time based pressure (self generated)Time based pressure (self generated) Time based pressure (client generated)Time based pressure (client generated)

12. Decision making and Planning

13. Organisation and Resource, Team Issues

14. Production matters

15. Data Evaluation : Conclusions Highest attribution is given to failure to pay `attention to procedure` Highest attribution is given to failure to pay `attention to procedure` Organisational `stressors` and internal production pressures are attributed high concern. Organisational `stressors` and internal production pressures are attributed high concern. Personal behaviour and competence are also rated significant contribution. Personal behaviour and competence are also rated significant contribution. Technical issues are attributed minimal attribution Technical issues are attributed minimal attribution Team communication, organisational ability and related facets of `on site` team work are a most relevant issue within construction site management, and this indirectly linked to organisational pressure. Team communication, organisational ability and related facets of `on site` team work are a most relevant issue within construction site management, and this indirectly linked to organisational pressure. Less relevance attributed to construction budget pressure, although time based pressures still are identified in the analysis. Less relevance attributed to construction budget pressure, although time based pressures still are identified in the analysis. From the data there is an overall conclusion that aspects of accidents and incidents evaluated are attributable in part to direct or indirect persistent stressors From the data there is an overall conclusion that aspects of accidents and incidents evaluated are attributable in part to direct or indirect persistent stressors

16. Construction :Some Traditional Workplace Concerns ORGANISATION ORGANISATION Poorly organised job or short lead timePoorly organised job or short lead time Client pressures to completeClient pressures to complete Difficult build or design arrangementsDifficult build or design arrangements PEOPLE PEOPLE InexperienceInexperience Intercommunication and relationshipsIntercommunication and relationships `bad apples``bad apples` ChangeChange SUPPLY CHAIN SUPPLY CHAIN Inappropriate deployment by sub-contactorInappropriate deployment by sub-contactor Poor attitudesPoor attitudes

17. Business State Transition Model after Sundstrum & Hollnagel (2005) Business State Transition Model after Sundstrum & Hollnagel (2005)

18. Resilience Engineering is Required !!! Implement processes which identify any degradation in practice Implement processes which identify any degradation in practice Symptoms will be creation of non-compliant practices which are replacing Safe practices Symptoms will be creation of non-compliant practices which are replacing Safe practices Evaluation should go beyond `standard` auditing and inspection and aim to ‘predict uncertainty arising‘ Evaluation should go beyond `standard` auditing and inspection and aim to ‘predict uncertainty arising‘ It is clear `stressors` plays a part in predicting deterioration of management control It is clear `stressors` plays a part in predicting deterioration of management control A second stage of a resilience process should be the competent mobilisation of resource to mitigate and manage a situation in developing crisis A second stage of a resilience process should be the competent mobilisation of resource to mitigate and manage a situation in developing crisis In effect ‘pessimistic impact analysis‘ is required to evaluate production operations In effect ‘pessimistic impact analysis‘ is required to evaluate production operations A Red Amber Green Traffic Light process with suitable formal high level intervention is an effective process A Red Amber Green Traffic Light process with suitable formal high level intervention is an effective process

19. Site Safety Review General site visit Re v iew output as usual RED Immediate Phone Call Immediate summary ( 24hrs) Meeting within 24hrs on site AMBER RAG Report (see e.g. enc) ( 24hrs) Review within 3 working days GREEN No further action Site assigned R, A or G Month end R.A.G. list Board Review DURINGMONTHWITHIN 7 days R.A.G. Procedure 5/11/02

20. Final Conclusions and Proposed Industry Action A significant number of `high potential` and tragically fatal accidents recorded over the last ten years within the data from the UK construction sector have involved indirect or direct workplace stressors A significant number of `high potential` and tragically fatal accidents recorded over the last ten years within the data from the UK construction sector have involved indirect or direct workplace stressors It should be recognised as a vital part of the strategy for accident and incident prevention It should be recognised as a vital part of the strategy for accident and incident prevention Action should be directed at the `live evaluation`, recognition and maintenance of organisational resilience factors in the management of safety within a construction business environment. Action should be directed at the `live evaluation`, recognition and maintenance of organisational resilience factors in the management of safety within a construction business environment.