Planning and control
Confined space work is a great example of where the ‘devil is in the detail’. The reasons that workers are tragically continuing to lose their lives in confined spaces is often because inadequate attention is given to planning and control of the work.
Critical control measures, such as thorough risk assessment, control of entry, gas testing and emergency response are often incomplete or not done at all. What makes confined space work particularly challenging is the fact that many of the hazards cannot be seen, such as toxic or flammable gases. Another complication is the dynamic nature of the risk, such as the fact that many spaces can become confined when the atmosphere within them changes. This means that the risks associated with confined spaces are frequently underestimated.
Confined space accidents are complex and typically involve a range of factors. Each of the different contributory factors provides insight into the nature of the challenge.
Industry figures show that in 92% of fatalities recorded, the victims were not adequately trained. If workers are not competent to recognise a confined space or taught the safety precautions that they must follow, they will not understand the risks involved, know to spot dangerous situations quickly and how to respond.
One of the factors that makes confined space work so dangerous is the speed at which things can go wrong. When we assess risks of confined space work, we tend to focus on the severity and probability of harm, but the speed at which a hazard can change is often overlooked. Within a tight and enclosed space, fluids, materials and toxic gases can enter quickly and overcome those inside.
A NIOSH report states that from the fatalities recorded, 31% of organisations involved had a written confined space procedure and yet not one of them were followed during these instances. Moreover, none of the organisations had an adequate rescue plan in place. One reason for this is that there is often a significant variance between the documented safety procedures and the way work is conducted. There can be many reasons for this, but one of the most common is the lack of understanding by the teams that develop the safety management systems and those who conduct the work.
Around 85% of fatal incidents involved inadequate testing of the atmosphere. This may be a result of a lackadaisical attitude to issuing work permits, a lack of awareness of the safe testing processes or underestimating the complexity of the environment. Robust testing processes are vital, and how the results are acted upon is even more critical.
One of the most common findings following a confined space incident is the failure to follow procedures. When a safety procedure is not followed, it’s common to focus on the individual failures. However, if we want to learn from incidents and prevent repeats, we need to consider if the process itself may be the problem. The complexity and length of many safety procedures can be the problem and contribute to mistakes being made. We need to learn from high-risk sectors how to simplify procedures, write them for the worker and introduce ‘errorproofing’ in the layout. Another key component for any confined space safety procedure is the need for an emergency process. Emergency procedure needs to detail how a rescue will be performed, but sadly this is often overlooked.
NIOSH found that 84% of fatalities involved failed supervision. Some workers are fearful of the repercussions if they refuse to enter a hazardous environment, especially if they are told to do so by their manager. This could be due to commercial pressures. For example, a lot of work in confined spaces involves cleaning, decanting, repairing or other maintenance activities. These are non-productive work tasks, where significant commercial pressure can exist to complete the non-critical activity and return the asset to operation.
Nearly three quarters of all fatal incidents in confined spaces involved regular and routine work. This supports the theory that the more we undertake a task, the more we become over-familiar with the task and complacent. Over-time, workers become normalised to the risk and this results in a decrease in attention, risks being underestimated, and shortcuts being taken, tragically, with fatal consequences.
Sixty-eight percent of fatalities involve toxic, flammable and stratified gases. This could be due to a lack of testing equipment or an inability to use the equipment correctly. It is essential that organisations conducting confined space work have effective detection and response equipment such as personal gas detectors and atmospheric testing for toxic gases to identify the changing situation, along with effective emergency evacuation equipment.
Nearly two thirds of fatalities involve attempted rescues. It’s common in confined space tragedies for individuals outside the confined space to enter the space and be overcome by the hazards. Rescuers need to be properly trained, sufficiently fit to carry out their task, ready at hand, and capable of using any equipment provided for rescue, such as breathing apparatus and lifelines. Human behaviour plays a critical role – especially in emergencies – and we need more research to understand why we often respond in an emergency in an irrational way.
Tackling the problem
Leadership has an instrumental role in creating a positive safety culture. A change in safety culture needs to come from the ‘top’, with a recognition of the risks and the importance of the process instilled at every level of the organisation. Empowerment, through a robust Stop Work Authority (SWA) programme provides workers with the authority and obligation to stop work when a perceived unsafe condition or behaviour may result in an unwanted event. Written policies alone, however, are not enough. Managers need to recognise, praise and promote examples where workers raise safety concerns and back them, even when their decisions may have been incorrect. A true culture of empowerment takes time and requires the organisation to identify and address the reasons an individual needed to stop work.
Training plays a key role in managing confined space work, ensuring that everyone involved understands the hazards and the safety measures that they need to follow, including the emergency procedures. For safety training to be effective, it’s not enough to just ‘train’ people – the training must be engaging and focus on a ‘head, heart and hands’ approach to help them appreciate the consequences of not following the right procedures.
The best training is a two-way process, where the workers share their experiences and feedback on any problems or variations with the safety procedures in their organisations. Using examples of incidents and openly discussing experiences is great way to achieve this. New forms of learning such as Virtual Reality, mobile and adaptive learning also enable us to make training more engaging and effective.
“emerging world of ‘safety tech’ is so significant in eliminating human confined space entry”
There are also many ways in which we can make improvements using technology – which is why the emerging world of ‘safety tech’ is so significant. The opportunities to make confined space work safer are best viewed through the hierarchy of control.
Eliminating human entry into confined spaces
Drones and robots provide the opportunity to redesign conventional ways of undertaking confined space working by eliminating human entry.
Re-engineering the risks
The use of ‘Internet of Things’ systems could also enable the different safety controls and hazardous conditions to be integrated, so they function as one system, such as gas and temperature monitoring and alarms and isolation points. Technology such as drones can be used to provide more accurate testing of the atmosphere within complex spaces, where the characteristics of the gas mean stratification occurs. Augmented Reality could also help to improve the assessment and management of confined space work by helping to layer the plans of the space with the actual hazards within, so workers can visualise the hazards within the space that they are about to enter with 3D plans of the space along with the modelling of the gas testing results.
Administration of controls
A lot of confined space work is managed using administrative controls, such as procedures, permits and training. Not only are these controls inherently weak, but they also function in isolation. For example, the information in training registers does not connect to risk assessments, likewise the essential information contained within a confined space entry permit does not link to audits or inspections. This is not only inefficient and fallible to human error, but prevents a feedback loop that will enable continuous improvement. Technology can address this by digitalising these processes, ensuring these systems are integrated and the information transfers between them seamlessly. Virtual Reality training tools can also transform training for entry and emergency response, enabling workers to experience the confined space within safe conditions, and help rescuers prepare.
Improve worker protection
We are seeing the emergence of Smart PPE that will provide better ways to protect confined space workers. Smart wearables/PPE could be used to monitor workers’ vital signs. Alongside the measurement of heat, temperature and vital signs, sensors within PPE and workwear can enable real-time measurement of hazardous substances, heat and noise. Emergency controls can be integrated, such as personal gas monitors, weather detectors, mandown and attack alarms, enabling a faster response.
The importance of standards
Standards play a highly complementary role to legislation. An ISO 45001 review for example, takes a system-wide perspective, which helps identify the underlying causes to problems that could result in serious accidents. Unlike a regulatory inspection that focuses on local compliance, ISO 45001 also considers improvement opportunities where risks are managed more efficiently, or how performance could be more effective. Similarly, in contrast to regulatory audits, where the frequency of regulatory inspections in many countries has reduced over recent years, ISO 45001 standard audits occur annually. Training and emergency drills are all core requirements of ISO 45001. These play an essential role in building up the ‘muscle memory’ so that if an emergency occurs, we respond automatically.
When it comes to ensuring leadership engagement and support, it is hoped that ISO 45001 will encourage more organisations to see OH&S Management as a key issue that needs the same leadership and structured approach as other aspects of their business. Under this standard, top management are responsible for ensuring the OH&S management system achieves its intended outcomes, so ISO 45001 will help embed OHS and continual improvement into the core of an organisation.
“a deeper understanding of human behaviour, the use of technology and certification will help to make a difference”
Our assessors tell us that ‘companies that have created a positive approach to occupational health and safety generally seek to continually improve their safety culture through leadership and worker involvement by properly incentivising best practice, positively intervening in hazardous situations, addressing close calls, and ensuring lessons are learnt’. A positive approach to OHS, for example, means that management are curious to learn from workers about the issues, incidents and near misses to improve the processes, and do not jump to punitive actions when things go wrong. We also know from our teams out in the field auditing against ISO 45001 that ‘one of the most effective ways to deploy strategy is to ‘walk the walk’ – which means management coming out of their offices or away from their desks and taking the time to see and be seen, to hear and be heard. Making this a part of the routine will enable management to influence and embed the culture and vision in their organisations.
Aligning the OHS management system and strategic direction together will help increase the focus on improving OHS performance. There are new requirements relating to the management of risks and opportunities, which will help organisations to develop a more effective and systematic approach to risk identification and management, making the system more robust. The proactive identification of opportunities will help to improve safety and drive OHS performance.
We also hope that ISO 45001 certification will help reinforce that Occupational Health and Safety is about a lot more than legal compliance. When it’s well integrated into the management of an organisation, good OHS Management is an enabler and an asset for a business, rather than just a cost.
There remains much more to be done to tackle this issue. A globally consistent definition of a confined space, improved legislation, a deeper understanding of human behaviour, the use of technology and certification all play a major role and must, collectively, work together to truly make a difference.