Paper Safe: The Triumph of Bureaucracy in Safety Management

February 3, 2021



In this podcast, international award-winning author and lawyer Greg Smith discusses the practical need to better understand the rising bureaucracy in health and safety management and how to make safety management beneficial for businesses and meaningful for workers.

List of cases mentioned in this podcast:

Wollongong Glass
Fry v Keating
SD Tillett
Harris v Coles
Orr Hunter Quarries Pty Limited

Download this PowerPoint presentation for further information.


Further information

[00:00:00] Nippin Anand: On the night of 3rd January 2015, a laden car carrier ran aground at the entrance of the channel while leaving the port of Southampton. A thorough investigation was carried out to find out what went wrong and how an accident of this nature can be prevented in the future.

[00:00:20] Now I’m not getting into the details of the case but for the purpose of this podcast what caught my attention was a specific quote from the official report. It says something like this, “One area of safety management system that is in need of modification is the use of extensive checklists the five-checklist contained within the PCC/PCTC operations manual that were completed by the chief officer during the ship call at Southampton contained a total of 230 check items. All of which had been ticked and none of which had been signed as having been verified by the captain. The value of the checklist as an important safety tool was diminished.”

[00:01:05] Now this is a powerful reminder that the same artifacts designed to manage safety have started to quite the opposite which is push us more towards failure. Today accidents are not necessarily happening because we do not have adequate rules and controls rather ships run aground and buildings that caught on fire because we do not, we have far too many controls that can easily skew the real issues. There has been even a study carried out by the Norwegian University of Science and technology to back this claim.

[00:01:41] I will put a short video with this podcast so that you can watch the video. It’s a really good video! If you appreciate the problem of rising bureaucracy in health and safety, the discussion in this podcast will make absolute sense to you.

[00:02:00] So welcome to another episode of Embracing Differences and let’s welcome our guest tonight Greg Smith, an internationally renowned lawyer, a global expert in operational safety and the author of an incredibly powerful thesis which I have recommended to many people around the world. A book called, Paper Safe, where Greg talks precisely about the problem of the disconnect between bureaucracy and purpose so let’s talk to Greg.

[00:02:32] Nippin Anand: Welcome Greg! Very pleased to have you with us today.

[00:02:37] Greg Smith: It’s good to be here. Quite humbled to get the invite. I’ve seen some of the people who are showing up on the podcast and am quite humbled to be thought of the same capacity so thanks very much.

[00:02:50] Nippin Anand: It’s an honor and to be honest with you I’ve been following your work for many years now and Ive recommended your book to many people. So, Greg maybe we can have a light introduction from you and the topic for discussion for today.

[00:03:04] Greg Smith: Okay, so the easiest way – I’m a lawyer. I’ve been practicing law predominantly, in initially starting with employment and industrial relations but I’ve been best known these days for my work in health and safety. But I’ve dropped in and out of the law from time to time. Most relevantly to this conversation I’ve been a safety advisor in the oil and gas industry for a few years. I’ve taught an accident prevention course at one of the local universities and most recently, took on a general manager’s role in a fairly multi-faceted mining support company in transport and a few things. So, legal background and operational safety background and involved in lots of fatalities predominantly which is where I draw a lot of my lessons from and quite a lot of my cynicism as very particularly dealing with organizations who are chasing their tails on injury rate data and minor incidents – those sorts of things. I think we often lose sight of what is critical and important in our organizations to manage safety. That’s it of my professional background. I live in Australia, you probably picked that from my accent, married and three kids and keeping very busy at the moment with lots of legislative changes happening in our part of the world around health and safety.

[00:04:43] Nippin Anand: Yes, and I see you talking quite a lot about it on the LinkedIn forum. You can obviously get in touch with Greg. He’s on LinkedIn and will leave his e-mail with us. You can get back if you have any further questions. Greg, reflecting back on what you said just now, a very interesting combination of a law background but also in health and safety operations as you’ve said. Any particular experience that you shaped your journey?

[00:05:10] Greg Smith: I don’t know if there’s anything in particular. The reason I can’t explain is either wrong place at the wrong time or right place at the right time, depending on perspective. But I found that quite earlier on in my legal career. I was in the military as well so I resigned from the law and went first as a soldier and then as a legal officer and dealt with some fatalities enquiries in that context. That was really my introduction to safety management and safety enquiry. Then I can back to the law working for one of the multinational war zones here in Australia. I just found myself caught up in a lot of fatalities and work place fatalities. I did that half a year. I couldn’t tell how many fatalities I’ve been involved in. I just thought – yeah, I need to understand more about this. I went an worked in as I said, for an oil and gas company.

[00:06:04] My thought was – well, oil and gas are the experts in this, they’re the world leaders in safety. If I can understand this better from an operational perspective, that’s going to add value to me as a lawyer. I got into the oil and gas work and I just thought – My goodness! How much of this stuff that we say that we’re doing in the name of health and safety is just window dressing. It’s just this constant noise about health and safety. This constant presentation of activity done in the name of health and safety. But as soon as you scratch the surface and you get to the people who are genuinely trying to deliver the business outcomes, it really felt this is overly cynical, but this huge tick and flick exercise of here’s something we have to do in the name of health and safety now we can get it out of the way and do what we need to do.

[00:07:04] Or the other manipulation which was interesting that the idea that here’s a decision that we have made and this is how we want to progress, we better do a risk assessment to confirm what we’ve already said what we want to do and it really felt that the decisions weren’t being made in the name of safety.

[00:07:25] Safety is just imposed in the organization and people just jumping through the administrative hoops to do safety or safety was being used as a political tool to achieve outcomes of different business units. I really found it as a surprising exercise and that led me down the path of more research and more study. My first book, I couldn’t even tell you when I wrote it but on management obligations because what I found really interesting was this fundamental disconnect between senior executives and safety management systems. So, what is it that you really asking the managers to do? It was written largely from a legal perspective as opposed to safety management perspective initially. Although I do think that I crossed both boundaries fairly regularly. That’s probably a very long-winded answer to a short question. But that’s kind of how I go to where I am today, I think.

[00:08:22] Nippin Anand: Great, no that reflects in your work, in your book that I have read also. So, tell us Greg, what is it that you would like to talk about today?

[00:08:32] Greg Smith: Well, you’ve asked me today in the context of the book, Paper Safe which is really my attempt to try and reconcile this disconnect between the documented process and what’s really going on in work places. Now, I didn’t come up with any of these ideas – the illusion of safety and the work as done and work as imagine. They are quite common terms and quite in use in safety these days. I found it interesting in Hollnagel’s work around resilience engineering which spoke about the gap and at the same time in Australia people like David Proven doing work on what he eventually came to call as safety clutter talking, another Australian researcher, David Boris, Sidney Dekker etc. I was quite oblivious to all this thing that was going on for many years but I was seeing it from a legal perspective the extent to which a documented safety, management system was really creating legal risk liability for organizations because the documented process did not represent what was happening in practice.

[00:00:00] By the time I came to write Paper Safe I described this as a disconnect between processes and purpose and that manifested itself in a few different ways. First of all, for many organizations or certainly for individuals within organizations, whatever the purpose of a safety process might have been and there’s lots of examples so, JHAs is a common one so I think across many industries, the documents definitely has a purpose for identification of hazards associated with work and how they are going to be done safely. It has a reasonable theoretical basis but what we find in practice and I found, I run training programs for mangers and I explain to them that in 30 years I’ve seen a JHA where I’m able to say to the client that oh these are going to be useful to put in front of the court because they never are there’s reasons for that. But it does strike me that organizations have lost sight purpose of those documents.

[00:10:41] They’re not investing enough time and effort to make sure of the processes being done properly to achieve the outcomes. So, we go through the process and go through these bureaucratic steps and we to do manically in some cases and religiously in other, we just do it. But we don’t connect the process with the purpose and we don’t say having invested all this time and effort into this activity, is it achieving the outcome that we want it to achieve? To me this problem is really compounded because of the way we measure and talk about safety. We measure safety around injury rates. It tells us nothing about safety. And even if you don’t want to accept that from a safety perspective and I understand the arguments. I can tell you as a lawyer, those numbers are utterly meaningless.

[00:11:30] You will not find a case in Australia, prosecution under health and safety legislation where a defense lawyer has stood up “Your Honour, this is my client’s injury rate data over the last 3 years as evidence that they have safe systems at work. We don’t do that because we know it’s not evidence of anything. I’ve always found that problematic and then I think there’s an inherent recognition about that. Enquiries have been talking about it for years and I’ll share it in a moment. So, we move on to this idea of lead indicators are nothing more than measures of activity. They tell us nothing about whether we are effectively managing hazards in the workplace. The fact that a manager has done two walk arounds conversation as a part of their KPIs, it tells us nothing whether we are effectively managing risk in our business. So, Paper Safe was in part to exercise and try to demonstrate how problematic that can be.

[00:12:31] So, what I might do, if everyone’s okay I’ll just share my screen for a moment. This is just one exercise that I work through in some of the workshops we run. There’s a lot of debate in the safety community at the moment. LinkedIn is an obvious example about the discussion on the conversation between safety 1 and safety 2. Well, my experience is that the courts actually don’t care about that. They don’t care about how people do safety. They don’t care if people are the problem or the people are the solution. What you just see here is a series of cases. The Desai case was a single person fatality where a worker was run over via a truck in a grain receival plant yard. The Wollongong Glass was a fatality in a glass manufacturing plant where a worker was crushed by a sheet / plate of glass. Now in both of the cases, none of the companies have written systems. At least in the Australian context and I suspect this is true in many other jurisdictions the courts never said that your systems need to be documented.

[00:13:42] That’s something we have created for ourselves. Neither of these organizations had written systems, they relied on their job training or relied on the buddy system. In the Desai case, the evidence was that the hazards weren’t known, the controls weren’t understood or implemented. The Wollongon Glass case, fundamentally the same way of managing the risk but the evidence was that hazard and controls were known. So apart from this one occasion where the fatality occurred the controls were understood, implemented and complied with and so they were acquitted. They passed the reasonably practicable test. I’m just trying to emphasize the point that it doesn’t matter how shiny or new or theoretically based your systems are, if they are not delivering the result of ensuring that you understand the hazards in your business are known or effective controls of those hazards which are implemented and actually effective.

[00:14:43] You’re not achieving the outcome of meeting legal obligations in that reasonably practicable type context but it’s difficult to actually see how you’re actually creating a safe workplace. I think this is a bit broader than simply in Australian judicial context because when you look across jurisdictions a court you see the same theme coming through regularly and there’s lots of examples. But I’ll share some with you now. Just to put some meat on the bones that I’ve been talking about. This is a recent district court case; in Australia it talks about this idea all the safety documentation in the world it’s not of much use unless workers are trained and that those practices are also followed and enforced and I think we lose sight of that. And I think safety as an industry quite frankly is far more comfortable sitting behind computers and creating process than it is actively testing whether that process works.

[00:15:47] I think we create process; we test if it is followed at a very superficial level, we don’t really dig in underneath the checkbox exercise. But then we were not very good at understanding implementation and efficacy. So, the next one so this is taken from the Baker Panel review followed from the BP Texas city refinery explosion and it just gives really interesting observations which resonate across all jurisdictions overtime.

[00:16:17] So, we’ve got this observation here that BP’s corporate initiatives have overloaded personnel at its US refineries to the possible detriment of process safety. Partly the observation there was that BP as a common entity were putting so many safety initiatives into the organization that management didn’t know how to prioritize them, resource, them or deliver against them so you end up with this kind of inertia and nothing happens.

[00:16:39] This is the thing that I talk about in the book that I refer to as the safety paradox – this idea that we can be doing so much for safety that we actually aren’t we make we undermine saving we make it less easy for people to actually deliver the safety outcomes we want. We saw something very similar in Australia the Esso Longford gas plant explosion this was a catastrophic event where two people died and cut off gas supplies to the greater Melbourne city. But you get observation in here, from the Royal Commission that there’s a tendency for the administration for safety system to take on a life of its own divorced from operations in the field. That concentration on the development of maintenance of the system diverted attention from what was actually happening in the practical functioning plants of Longford. Again, it’s a theme that I think we say repeated in major accident inquiries all around the world and we certainly see it repeated in individual prosecutions on very regular basis. Not just in Australia I think but certainly I think in the UK and Canada, we see similar sorts of observations both at a micro and macro level.

[00:17:52] I find this a particularly interesting this is something we don’t talk about enough as an industry in safety and health. In Australia over the last few years, we’ve had several public inquiries into the high suicide rates amongst fly in fly out workers on our mine sites. It’s very common system of work in Australia and I wouldn’t be surprised if we end up doing something similar in the construction industry.  Now there’s something about the demographics – young men tend to be a demographic with the high suicide rate anyway and they tend to work in those industries but all of these inquiries said no there’s more going on just a demographic. But one of the interesting things this was the lifeline report, lifeline is a mental health line over here, in Australia. One of the interesting observations to come out but was the extent to which health and safety rules contribute to mental stress an undermined mental well-being in the workplace. These very strict, very oppressive, very prescriptive rules with very significant consequences if you don’t comply.

[00:19:11] Particularly if you’re a contractor working on the mine site and you reach one of these rules there’s a very good chance you’ll just be kicked off site. You can’t terminate employment but you can certainly bar people’s access to site. It’s really interesting that, in trying to prevent physical harm by these prescriptive rule-based approaches we’re actually creating mental harm. Again, without wanting to sound overly cynical but I probably do, because the mental harm statistics don’t show up in injury rate data, I don’t think we really care that much.

I think there’s some problematic issues and I know no mental health is a big issue I know everybody is concerned about it but certainly for person takes a day sick leave because of work related stress it doesn’t show up in our statistics as a lost time injury. I think there’s a bit of manipulation going on there.

[00:20:10] Nippin Anand: Several questions here Greg, but I’ll stick to one or two maybe. I completely agree with you. In fact, I wrote a paper on this to say that all the mental health initiative that you take it for employee well-being are actually the byproduct of the unrealistic key performance measurements that you have already put in place. We spend very little time thinking about that. I suppose I have another question, which is listening to you, we all know, fairly well, in the safety world that bureaucracy does not make much operational sense, much of business sense.

What we’ve been told so far that it makes legal sense, it makes liabilities sense. But what I’m hearing from you is that it does not make any sense at all from a legal perspective either. So, my question really is that what is the real issue here what do you see as the real problem? Why do people do that?

[00:20:53] Greg Smith: Well, let me take a step back, I think our processes can make sense theoretically, that it can make sense of safety perspective and legal perspective. Safety processes can make sense in a legal perspective if they actually represent what’s going on. So, if you have tight alignment between our process and what actually happens in practice, that makes sense.

[00:21:25] The difficulty we have is that nobody is doing the hard work necessary to really deal with that alignment in a meaningful way and I can share some examples around that. So, what’s really going on? I think at its core, it’s a combination of incompetence and laziness quite frankly. I can’t see it any other way. It is easy to sit behind a computer and Google ‘working at Heights procedures’ and you’ll find them over the internet, and to take codes of practice from the regulator and turn it into a procedure. It’s boring it’s bureaucratic but it’s not difficult it’s not hard to do, it’s time consuming and all of that but not hard to do.

[00:22:13] Similarly, injury rate data, it’s not hard to collate leading indicators are not hard to collate and they’re not hard to express to an executive management group. Youre not persuading anybody about anything you don’t have to be you don’t have to write anything well enough to be particularly articulate you don’t have to work hard to convince people. you say here are the numbers and that tends to be the end of the conversation.

[00:22:39] I think there is something fundamental about the amount of work organizations are prepared to do to genuinely understanding, if their systems are in place and effective. Look, it’s a bit chicken and egg. there is no doubt that a lot of what we have to deal within health and safety has been driven by the insurance industry, the consulting industry, the legal industry. There’s a back to be made in the development of health and safety documents. Anybody who works in the oil and gas industry and has been around long enough to recall what a safety case looked like when it first came in and it was first developed by the operator for their facilities. And you compare that now to what safety case looks like because there is an outsourced commercial industry that writes safety cases and they’re two very different things. we had this whole industry in health and safety of technical writing which is in the essentially a function to outsource the creation of safety management system. That’s what’s going on.

[00:22:52] I think there’s a lot of some cost I think it’s industry I think it’s easier. I still believe that people do, Nippin, get a lot of comfort from the paperwork. I do generally think they believe that we get a phone call this evening they have got three dead bodies on the ground, and the regulators come talk to us, we can build this paper wall in front of us and says look at everything we were doing.

[00:24:18] But it gets shown up. So again, this is a coroner’s inquest in Queensland, fatalities a involved worker and load fell off the back of the truck and you see this observation, to my mind very acutely played out here. This idea of identification, elimination or minimization of risk through risk management leads to production of a suite of documents to pass audit requirements.

[00:24:43] So straightaway we’ve got a couple of vested industries in that first sentence. people creating the documents and the people auditing them. But then you see this idea that the evidence of this inquest suggests that workers in the field find by the document hard to comprehend and of limited relevance to their daily activities. Now it’s really interesting because when we sit down with a group of managers and you talk about due diligence and safety and you say well here’s your monthly health and safety report – which bit of that report tells you whether or not or the extent to which our workforce understands our processes and those processes are relevant?

[00:25:21] Because if we, if an executive management level we don’t understand a very basic concept that people understand our processes and they are useful we don’t have any sense of them, we don’t get the first base when it comes to questions of ‘everything reasonably practicable or due diligence’.

[00:25:40] These are the observations we get when people start looking critically really critically at safety management systems. Now, I know that you do a lot of work around incident investigations and trying to improve them but we know whatever we think we do in the name of incident investigation we do not get anywhere near the level of scrutiny that will come out if a couple people die and you getting a major public inquiry looking at those processes. On one level it is a really simple question do people understand their processes and are they relevant? But there is nothing in the way that we structure health and safety systems and health and safety reporting in particular that addresses those questions.

[00:26:23] Nippin Anand: I want to give you an example here which I picked up in many years of frustration. I completely get what you’re saying and I love the term you using the book, it’s called intellectual laziness which is basically- Cut, copy paste, irrelevant information to make it meaningful to you which is absolutely meaningless to your workers. One of the things find Greg is that, in the name of safety audits how many times we go on the site and make sure that all those small little documented leaflets those, small little sticky notes and what else people put beside their technical equipment, the operational equipment too to make it work. It’s basically a procedure which really helps them to work to do the job and they keep those reminders close to those equipment and systems. As overzealous inspectors what we do is go and destroy those documents in the name of documentation control. In many ways that is the safety management system that is working for people. That is the informal world that people create for themselves because they find so disconnected from their use. Instead of trying to make sense of those documents relentlessly destroy them in the name of auditing and control.

[00:27:45] Greg Smith: Which is odd again if you got a couple of dead bodies on the ground, that workforce very quickly explained to the regulator exactly how the work was performed. Very seldom it will have a strong connection to your corporate process.  I’m not sure people appreciate just how transparent the systems are and just how obvious the disconnect is. So again, this is a coroner’s inquest another one from Queensland this was a worker who was killed by a malfunctioning a track maintenance machine and it’s his idea around checklist.  So, the crew members told transport regulator that completed here’s to the checklist was time consuming so their usual practices for random crew members do cursory checks and then the entire checklist would be marked to indicate compliance.

And you can see there the coroner said well this was a tick and flick process that actually eroded assurance. So, you had a check process that was designed to ensure that the equipment was safe. It was just a tick and flick exercise; people actually weren’t checking whether the equipment was safe and signing it off.

[00:29:00] Now I wonder one might say, well that was just negligence on the part of this work crew doing this work. And that’s fine, maybe it is. even if it is, that’s not the end of the question. The issue is, how organizational process, to understand if this piece of equipment is safe to operate? That’s the whole point of the exercise. But what did we ever do as a as an organization to make sure that this process worked? that was being properly followed?  You see exactly the same criticisms in the Piper Alpha inquiry of permit to work system exactly the same thing occurred this is again from the season chemical Safety Board review of the Texas city explosion. same sort of thing functionality checks of alarms and instruments required prior to start up.

[00:29:48] There’s no time for additional check supporting your supervisor so they signed it off the risk as I say is history. That’s just an example of a process that is put in place that probably makes theoretical sense at the time to the people who were creating it but a process which overtime has become eroded and corroded as all processes do. Yet, it doesn’t seem to be any effort on the part of the company to make the effort to understand if these processes are in place and effective and working and again, that’s probably not possible for every process. But if we can’t check and understand if the process is being used effectively in achieving the outcomes designed to achieve, I think you really have to start the question why do we need to process? If we’re not going to give it the time and attention it deserves perhaps, we don’t need it.

[00:30:48] Again, this is a fatality prosecution in South Australia where work was killed during a lifting operation. There are two really interesting things you’ve got the normal safety processes pre start meeting JSAs, star cards or take fives. Again, the court saying these are all being treated as a tick and flick exercise, it is just a paper system, its window dressing, it’s not actually being used for the purposes design and this one is particularly problematic because it’s a contractor. So you get that classic scenario the principle demands of contractor to many safeties in particular way and then on the surface of contract it does exactly what is being asked to do but it doesn’t live up to their substandard outcome.

[00:31:32] Nippin Anand: What is the key message you’d like to give to people through this discussion?

[00:31:39] Greg Smith: To me, this again this type of the Piper Oil Commission: 29 workers killed an underground explosion and he got this idea on here that the board appears to have received no information proving the effectiveness of crucial systems.

So, my key message to organizations is that we need to ensure that our processes are achieving the purpose for which they were designed. Not that we’re going through the motions and doing them but are they actually achieving the outcome that we want to achieve. and critically what do we do in our organization to prove the effectiveness of our crucial systems and that’s a different conversation from saying we completed the form, we did the checklist, we did the inspection. What sits underneath that whereby we say that these inspections and processes are achieved the outcome we wanted and how to improve the effectiveness of our crucial systems to me that that’s my key message.

[00:32:37] Nippin Anand: That’s so in line with what I call it meaningful compliance and Prof. Andrew Hopkins who is joining me next week calls it mindful compliance. He’s come up with his book in 2020.

He talks about the idea of mindful compliance that not tick and flick for its own sake but making sure that it’s actually achieving the purpose. What a fascinating conclusion.

{00:33:00] Greg Smith: One of the things you can actually layer on top of that is we often align compliance with some sort of paper process. We can have compliance with expectations. So, you don’t actually have that with documented process. You can have a common understanding in your organization about what’s expected and test assurance against that as opposed to a bullet point of doc-check items.

[00:33:35] Nippin Anand: If you look at safety audit the web template is designed, it does not promote that but I’m thinking what it just said correct everything so disconnected the way we present these reports. There is no interaction between different elements to bring things together to actually make an attempt to put a coherent summary or what is the key message of this audit. Such a good point you made.

[00:33:47] Greg Smith: There’s a chapter on auditing in my book as well as you probably know so there is a whole another conversation. I’m a qualified safety auditor as well.

[00:33:56] Nippin Anand: Great! How interesting Greg. Thanks so much and thanks everyone who joined us today.

[00:34:03] Greg Smith: Thank you everybody and thank you so much again for the invitation. It’s a pleasure Greg.

[00:34:10] Nippin Anand: What do you think? When I hear from Greg, we learn that it’s not just the operational efficiencies we have created or inefficiencies we have created by pushing more ring binders down the throat of the workers. What we have also done is induced several liability and reputational risks. When the code of law finds out that there is a clear disconnect between safety management system and the lived experience of the people who are doing the work every day. So, what is the solution that Greg offers? What he says is that test your imagination regularly in the field in the sense that test your rules your procedures and checklists regularly to validate the content make sure you have a common understanding about how things are done. Not just another documented procedure because the term procedure in itself actually alludes to that, it means a common understanding. Not a documented procedure, not a documented writing!

[00:35:22] So far it is always made sense that unrealistic paperwork undermines efficiency safety and well-being but what reminds us in this podcast is what is years of expertise and wisdom is it makes absolute sense from a legal perspective too. So, what do we do? Credo experto! Of course, we don’t have to believe in what Greg has to say but let’s just slow down just think about it until then have a nice weekend and I’ll talk to you again soon.