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How many of you have starting a H&S project looking at a specific risk , thinking that it will be a simple project and that you can bring a suitable solution together in a couple of weeks…. Problem solved…. So you have all been as deluded as me at some point in time… :o) While dealing with quad H&S at GWRC was never expected to be simply. I was not expecting this project to be quite so challenging to get to a consolidated and consistent approach embedded. A colleague said use images to get the message across – so if you will think about ripples from a stone dropped into a pool of water and cogs, balancing scales, the shapes of snow flakes, Octopus tendrils. On a journey chasing a floating island Fellow H&S team member – liquid, fluid….. Chaos. A problem that is not linear, rather dynamic, complex and highly connected Safe vs. dangerous. Safe for the operator on the quad and safe for the executive sitting around the board table. In my years as a H&S professional quad H&S @ GWRC has been a most interesting and challenging issue to address So are we safe (free from hazards)? – NO. But are we safer? YES. Can we get safer still? MOST DEFINITELY. This is the story of one our (in the words of Robert Long) “Wicked Problems” – our journey managing risk, a real story worth sharing
I hope that you have all seen and recognise this diagram from the AS/NZS ISO 31000:2009 Taking an active and on-going look at the risk to ensure that it is understood and managed as effectively as possible. So much more than just the 5x5 matrix in the risk assessment Each element/component of this process has been revisited several times and will be visited many more. Even the starting point of context can shift and slip. This is not a linear problem rather dynamic, complex and highly connected. Every component has proven to be real and related toward effective solutions I will highlight a few specific examples from the overall project. – areas where we identified specific risks underneath the broad risk of quad H&S
Is a regional council formed in the late 80’s amalgamation of various boards (harbour, catchment, pest destruction, water) and RMA regulatory duties. GWRC – lower end of the North Island, Region includes 8 Local Authorities (4 City and 4 District Council) with a snippet of a 9th divided down the middle by the Tararua and Rimutaka ranges – the legacy of these separate organisations and the geographical divide still affecting the culture today. Activity areas: Biosecurity, Emergency management, Environment management (air, land and water), Flood protection, Harbours, Land management, Parks and Public transport 450 employees based predominately across three main offices – Wellington, Upper Hutt and Masterton Work carried out on GWRC land – owned or managed – as well as many private properties/locations and potentially different ones each days Also as an organisation we are beginning to realise that we influence a huge amount of paid and voluntary work across the region, and with this influence comes the importance of GWRC providing strong H&S leadership both internally and externally.
One long standing elected employee H&S rep tells how on his first day he was given the keys to his Falcon 500 ute with a horse float attached and then was pointed to his horse in the adjacent paddock. Motorbike have been used for many years and we have one team that still predominately uses motorbikes Also in the Land Management area (Catchment Board days) would travel in chained up convoys with metal spikes fitted to wheels - to the backs of remote farm and make camp for weeks at a time to complete work First 3-wheelers and the quads came into the workplace and many uses and adaptation for their use were found.
At the time of the main project GWRC had a fleet of 20 quads including 3 Light utility vehicles Honda, Suzukis, Can Ams (quads and LUV’s) 350 – 800cc 1998 – 2013 A diverse fleet with a range of performance capabilities and characteristics Nearly 60 staff across Parks, Biosecurity and Land management either regularly or could be expected to have to operate quads as part of their roles – many of these staff have regular non-work experience operating quads as well We discovered later on the a large number of staff also had numerous experiences of interacting with third party quads – jump on and I’ll take you up their. New staff had completed unit based staff but many longer tenure staff had been operating quads from well before there were any unit standards Parks – operated their quads on their park property and are the only group that can like farmers can really get to know their property – hazards, no-go areas, safe routes etc. Biosecurity and Land management could operate quads on any number of properties/environment Land management required staff to operate quad in the wettest, remotest and most rugged farm land Quad used for – transport, equipment carrier, load haulage, spraying, towing, taxi Each department had their own procedure document – similar but different Over the previous years had been working with these different parts of the organisation to get improvements, but never managed to get traction to get them to work together INCIDENTS: We had had several reported incidents over the previous years – including one roll over and hitting a bollard – but not actual injury incidents Accept that the main injuries of concern were head injuries (from been thrown from or landed on by quad) and crushing/pinning injuries or suffication (from been landed on by quad)
Land management had taken initiative after a period of their own research to fit Crush Protection Devices (CPD) – Quadbar from Australia. They had real difficulty finding a motorbike shop who was prepared to fit the quadbars to their quads. Members of team had had personal experience of loosing a colleague (previous employer) due to crushing and suffocation. Had historical used old high T-bar – snagging CPD’s are a risk reduction feature and not a ROP Should a quad roll: Help to prevent a full roll – digging in Provide a level to help right a quad on it side Should a full roll over occur – prevent the quad’s full weight landing on rider and also a window for the operator to drop into to escape the quad Applicable to first/single roll – not multiple rollover situations. Issues with quadbar bracket coming loose and resulting in the slide jamming and compressing suspension causing adverse handling. Replaced with angel wings – fixed to back of carrier.
Growing media coverage of quad fatalities and injuries. MIBIE/Worksafe – post Pike River – increase regulatory effort and enforcement activity Participated in two ACC funded pilot projects, conducted by OPUS Human Factors research team: Quad Bike Rollover Protection Pilot Study – natural experiment comparing operator recollection of quad bike tipping or rollover incidents Ask question about the incident and also whether a CPD did or could have prevented a more serious outcome (50% believed it would have lead to an improved outcome). Also highlighted a potential issue of potential under reporting of significant non-injury incidents – what is perceived dangerous and what for some can be quiet normal Instrument quad bike study – GPS/gyroscope data logging on an in use quad – distance, speed, angle, tilt, slew – incident trigger point Justified further investigation, need to know what rider was doing – active riding – angle of quad + angle of rider = centre of gravity Cluster of 4 report significant near miss incidents: Tip over after front wheel dropped into a hole Tip backwards Jump off and tip Loss of traction slide off and track and assisted recovery – carrying passengers – said reported it as he had the data logging equipment on the quad at the time but unfortunately it was faulty All involved staff with a higher level of experience and not in extreme terrain or conditions Being a larger public service employer with a fleet of quads/LUV’s used by a reasonable number of employees….. & contractors. Should something happen we would be a sitting target for regulatory investigation and action
9 Sept recommendation to ELT Review report completed 18 October Standard operating procedure signed on late October
Many department procedures specified limitation in excess of actual manufacturer’s recommendation
CPD clarification for the fleet – snagging over hanging branch. Operator snagging in CPD. Question if lifeguard may actually induce multiple rolls due to design Training and competency beyond basic unit standard Organisation of work LUV SOP/ Passengers and seat belts engine type Keeping track of operator developments and trials Keep learning/Keeping track of non injury/damage events – need to establish a better way to gather and discuss the experience of staff
Quad bikes - Our story: managed risk rather than risk elimination
QUAD BIKES – Our story
‘Managed risk rather than
total risk elimination.’
(A wicked problem)
Senior H&S Adviser
Greater Wellington Regional Council
AS/NZS ISO 31000:2009 Risk
Management – principles &
• Health & Safety Advisory Group
reviewed reports’ findings &
• Recommendation made to Executive
– Temporary ban on quad use
– Review and report on the use of quads,
fit for purpose and training/competence
• Endorsed and review group formed
Some key factors
• Multiple slightly different procedures
• Riding a quad is a constantly active and
• Swiss army knife of farming - Fit for
purpose – use beyond design
• Challenge the accepted – lack of available
evidence to support and/or challenge
• Confidence, experience & judgement
• Risk transfer – who is best to manage it
• Only as per manufacturers
– Weight balance
– Random nature of weight
– Explicit ‘no-go’ in Worksafe guidance and
– Traction, experienced passengers
– Aid recovery of quads
Just before the end….
• Many H&S risks/issues are complex
• Need to engage those closest to the
risk and motivated to accept risk
• Need to continue to revisit context,
conclusions and solutions
• Remain vigilant of transferred risk
• Don’t be afraid of productive
• Are you making it safer? – KEEP
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