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Things to learn

kerry davies

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I have been extremely saddened today as an LFC supporter from way back reading the Hillsborough Report and also news of the fires in Pakistan.


The deaths in Karachi and Lahore seem criminal and insane, only one exit/entrance to multi-level premises with barred windows and electrical inspections of factories banned by law. We need to bear these tragedies in mind when anyone asks to block a fire exit and just say no.


As for Hillsborough, we can learn many, many lessons. Follow good practice. Do not ignore safety inspections. Record and act on "near misses". Include everyone in safety meetings. Record what actually happens during incidents. Do not put safety at risk on cost reduction grounds. Keep communications open. Have a plan for emergencies. Do not be prejudicially influenced by personal opinion or reputation. So much about that incident was reprehensible behaviour by various parties I could go on.


Read the report summary if nothing else and ask yourselves "How much better than this am I?" I trust everyone can say; "Lots and lots!"

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Thankyou very much for this.. I am reading it and going oh my god, Jeez, WTF etc. Such a huge emphasis should be placed on H&S at events, and cost cutting is never a justifiable excuse when I comes to the safety of your colleagues, employees, or members of the public
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Such a huge emphasis should be placed on H&S at events, and cost cutting is never a justifiable excuse when I comes to the safety of your colleagues, employees, or members of the public

Sorry, but I'm going to jump in here with a huge pair of devil's advocate boots (and this is not specifically talking about Hillsboro).


Of COURSE cost is a justifiable reason (note I changed that from excuse).

All H & S assessments must bear in mind the potential financial cost involved in mitigating any resolutions to issues identified. That MAY mean that if a solution is going to be financially disastrous to the event provider then some part of that event (affected by the risk) may need to be abandoned.


Other aspects may have low risk, but high consequences, but here the bean counters may decide that the cost of providing some preventitive measures outweighs the likelihood of the thing actually happening, and thus they don't implement them - that is the RISK that they take, hence why it's called RISK.


The key here is that all risk assessments are compiled with regard to there being reasonable and practicable mitigation of those risks - and finance will ALWAYS be part of the practicable portion of that formula. After all, regardless of who it is, there will always be a limit on how much gets spent on any event or activity.

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As I've found out quite a few times, the world is sadly not a perfect place where people in reality can make these decisions. Whistleblowing is patently dangerous, for the individual. How many of the people involved at the time spoke out? Those that knew what was happening? I find it difficult to believe a senior Police Officer would be able to get access to official paperwork and alter and amend it without people being aware. The consequence were clearly what is now being released - people were faced with loss of career prospects, and potentially the sack if they told what they knew. Nothing new there. In my last job I stood on principal and told it as it was. Doors suddenly shut, and easily manipulated senior members of staff make choices designed to encourage you to leave, when your working life changes for the worst. Jobs get distributed unfairly, things they know you enjoy get withdrawn and given to others and 'promotion' to unpleasant roles happens. In the end, the only choice is to leave.


I have learned my lesson and now, when I see things that are wrong, do I really see them, or do I dismiss them? I really don't see that it is reasonable to expect people nowadays, especially with the Government reducing employee protection, to do these things any longer. You see a young person with a wife and kids who needs their job. In anything other than a company with a genuine concern for employees health, then costing the company money will not be received as a positive trait. I know of one company who did not do essential repairs and an employee hurt himself. The repair was bodged and the same employee hurt himself again in exactly the same way. The particular danger not being visible to the naked eye. Only after the second accident is anything happening, and he's suing his own employer. The accident book is missing, so they've started an new one.


An employee needs to be very sure of themselves to report near misses, let alone accidents.


Kerry's list of important areas is laughable when applied to some businesses. I've added some comments based on my own experience of jobs over the years - not made up - real!



Follow good practice. This assumes the management would actually know what good practice is - my experience is that many have no idea at all!

Do not ignore safety inspections. What safety inspections - the ones at college were done by somebody from the office, who spotted a fire extinguisher missing, but missed everything else!

Record and act on "near misses". No reporting of near misses has ever been carried out at any of the places of work I have worked - ever!

Include everyone in safety meetings. What safety meetings? It's a myth that these happen, because management don't know they need to!

Record what actually happens during incidents. "Got splinter- removed". I've discovered only recently that splinters from certain species of hardwood are VERY dangerous and should be treated as a real hazard.

Do not put safety at risk on cost reduction grounds. Ha! Cost reduction is the major driving force. Safety rarely impacts on decisions unless VERY obvious.

Keep communications open. As long as it's downwards communications. So many organisations have no return path, because bad news is NOT passed on by insecure management.

Have a plan for emergencies. Absolutely. When the alarm goes off leave. Many firms have this as their only plan. I have had contact with one business location for 15 years - not a single fire drill, ever! It was put to me that they had costed a fire drill at a loss of £15,000 - so best to treat malicious alarms as the drill, as they happen frequently - however, the process is to identify it as a false alarm as soon as possible, then carry on - and put a tick in the fire drill box!

Do not be prejudicially influenced by personal opinion or reputation. I'm self-employed. I need a reputation, and sometimes as a result I suffer from random myopia. Don't upset the boss, or your family don't eat!


Look back to the anti-union, Thatcher days when being the trade union rep was a career dead end. Do jobs go to the yes men, or the patriots of safety and fairness?



With what has happened in the last day or two, I'm sure an awful lot of people are reconsidering decisions made a long time ago. If they have retired and are on a fixed pension, then I expect memories may become sharp. However, look at those who now hold good jobs but who were active in the disaster at the time. They're not the ones willingly falling on their sword are they?


I suspect many of us maintain a face that suggests we are on top of all things safety, and would of course carry out Kerry's excellent advice. However, many are in employment scenarios where their job is on a knife edge. Those people are not going to be the ones to push the envelope. The danger of simple fire exits not being available is not something that would have been hidden. Everyone who worked there would have known. These things are not 'secret' - they're a risk of having a job in a community where not having one is a unthinkable. Anyone complaining would have been in no illusions that the management would have cared. Blame the law, blame the Government and blame themselves, but I'm certain there are truly dangerous workplaces in our country too.


Remember the school I mentioned last year where they didn't even have a fire drill system? Some staff could be in the dark, but many older staff would have noticed the old system fall into disuse - so there were people there who knew the school could have been unsafe - and there has even been a bad school fire recently. These members of staff, unlike me - who had no interest in a job there - had obviously decided to make no fuss, because they didn't want to compromise their position - and THAT is what needs to change for all of us, but I see no way to make it happen.


Maybe things may change, but I suspect we should not hold our breaths.


As an aside - I've even edited this to remove some content that could have repercussions, so I'm still unable to tell the truth, even now!

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I am gobsmacked, don't know where to start responding.


I stand by a very simple principle: If you can't afford to do it safely, you can't afford to do it at all.

And whilst costs to fix a problem must be realistic, the thought that serious issues are ignored simply because someone decides that it is too costly, or not worth their job, beggars believe. If you can't afford to fix it, don't use it.


And for those who choose to 'ignore' safety issues because of fear for repercussions I have one question:

If someone died or became permanently disabled because of something you choose not to see or report, could you sleep at night?

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I thought that would be the response = mainly because up to now, I've also been one of the indignant brigade. Please don't think I support the idea of having blinkers, but going back through the events I personally have been involved in, keeping the recent report in mind, it's pretty clear that this is exactly what does happen. When I look at the things I have been the one making the safety point, I didn't really think about all my colleagues who MUST have seen the very same things and did nothing. Think about the daft things too. At five minutes to doors open, I find the cable across the aisle that everyone else missed, and why is it always me who says "anyone smell burning?" and everyone says yes?


With so many people out of work, and bosses who see no issue with the replacement of staff with new people without the same skill set, yet don't provide training - those people with jobs are under considerable pressure to keep them! The recent report has made me realise that keeping quiet has possibly become the way it is.


As for sleeping at night - might the real answer be that it is perhaps better to sleep poorly with job intact, then try to sleep well with a family you cannot support.


I'm not expecting any support on this at all - because that isn't the point of the post. The point is just to make people consider if expecting people to go out on a limb is actually how the real world is? Clearly, a very large number of people knew about what happened at Hillsborough - the evidence is overwhelming - and clearly a large number of people at the time did NOT speak out.


Safety is not, in my view, as embedded as the large organisations really think. Look at ISO9001 companies. They tend to understand their safety responsibilities, because maybe they read the Investors in People material, but the firms who are not aware, I suspect, outnumber them considerably.


I hate polls, but they are anonymous. Why doesn't somebody make a list of "does your employer ........?" questions, and have boxes to identify - company size, numbers of fulltime permanent and part time/casual people and we could get a better view of how safe the industry really is?


All our sections tend to tell it as it ought to be, as if this is normal - I just wonder if we assume everyone does it correctly.


Perhaps somebody like Kerry, with experience of the ideal system could ask some two part questions - like "Do you have a ladder register?" then "is it used?".

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I am reading that report and wincing, but could see how it could happen and how the pressure would be there for a cover up, the fact that the whole thing was being covered up within a single chain of command helped it to work for as long as it did of course.


There is a hug amount of lip service paid out there, even among those of us old enough to no longer buy into the whole 'show must go on' thing.


Accidents don't go in the book unless they are serious enough (this time) to send someone home, or to call for an ambulance, near miss reporting? Don't make me laugh, pretty sure it never happens, anywhere.


While it would be nice to think that incidents were reported and lessons learned, I don't for a moment think that this is actually the case (outside the group immediately involved), and I think the health and safety culture encouraged by the armies of half competent 'elf and safety officers' that spring up in organisations is at least in part to blame.

If you look at the marine industries (which really are bloody dangerous), the system is quite different and actually seems to work for the most part... The MAIB will investigate and report but will never prosecute (And their reports are written so as to not be usable in court), the effect is that people DO report near misses and even incidents they have been involved in, and will usually tell the truth.... The MAIB reports are also pretty much required reading among sailors and provide useful education in what can really go wrong and the right ways to avoid it.


Unfortunately the HSE (By being both the investigating and prosecuting authority) has enough fear attached that it will not be informed of the near misses, will be lied to instinctively, and for health and safety to have become a byword for bureaucracy.


Now maybe things are different in industries where the job is more repetitive (But I would not bet on it), but everywhere I have worked there has been a culture of laugh off the little stuff, and get on with the job.


What does annoy is that so many allegedly competent people will not stop and investigate something that is clearly wrong and within their area of competence, that smell of hot wiring, for example, or that spilt diffusion fluid that nobody is cleaning up... The assumption seems to be that someone else will have noticed and will deal with it, far better to stop and go sort it yourself, tell the chief, or (if appropriate) delegate someone to do it (But then check yourself that it was done).


Regards, Dan.

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Tony, in some ways you are right to highlight Cost Benefit Analysis and "grossly disproportional" costs. We have had plenty of topics over the years claiming that theatre "can't afford it" and most times I have responded with "bog off". All I can do now is quote the law;

HSE cannot take into account the size and financial position of the duty-holder when making judgements on whether risks have been reduced ALARP.


Paul I truly empathise and have walked away from things I realise others find difficult if not impossible. The culture in both theatre and education is that they are "special and different" and the rules do not apply in the same way. That has to change and change starts with individuals. Human beings don't like change, it hurts, so they will do everything to avoid it and the changing individual usually suffers. Baby steps is all it takes, however.


When it comes to H&S I don't need a GCSE regrade because the only marks I give myself or anyone else is "could do better". There is no ideal system. H&S like a good RA is an organic thing, changing and growing constantly. Just take the baby steps...and keep taking them.


HSE don't want near miss reporting, Dan, and reputable industrial firms do it as a matter of course. It saves money, big time. The MAIB system might be of use on land but the dire consequences at sea encourage the pro-active approach to "warnings". The tools exist on land and the bigger organisations use them, other people let them rust.


What makes me weep is that Hillsborough near misses WERE reported to: Sheffield CC, SWFC, The FA, SYP and even in national newspapers at the time. Someone should pay for "laughing it off."

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I thought RIDDOR required that near misses be reported?


Risk from crowd behaviour is now (Following Hillsborough and a few music festival incidents) much better understood by all concerned, and I am not that surprised that it took a major incident with attendant loss of life to get the understanding of the issue out there.

Theatre fires did not start with Exeter but it took the major tragedy to get change pushed through, so has it ever been.


The coverup is the disgusting thing for me, precisely because it probably delayed the learning of the lessons from the disaster, and yea some people need to end up in court over that matter, irrespective of criminal liability for the disaster itself.


Big organisations can (Best case) use all the tools available, but I bet that does not scale down real well to the smaller organisations or the individual contractor.


Regards, Dan.

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The most telling remark I heard about Hillsborough was regarding the verdict of "accidental Death" on the victims. I can't remember off hand who said it, but it was along the lines of, 96 people dying at the same time, in the same place, of the same thing, is not an accident! As a big footy fan who was a late 20-something at the time of Hillsborough, my main thought was "there but for the grace of god go I"! I lost count of the number of times I was assaulted and viciously abused by Policemen back then. Still, to put it into a H&S perspective, the 80's were the decade of, the Bradford fire, Kings Cross fire, Piper Alpha, Clapham, The Marchioness, the Herald of Free Enterprise, etc. Nice to know that the current Government are "freeing business from red tape"! Well what could go wrong?
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