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This page provides information on the common areas for improvement identified across the entire range of ARPANSA inspections performed during 2020. The information is intended to assist licence holders in reviewing common issues and identifying potential strategies to address their causes.
Information on the outcomes of four specific types of source inspections carried out between 2015–17 can be found in the following advisories:
Processes or procedures not reviewed
Forty-one percent of the areas for improvement related to documentation, poor record keeping or review practices.
Regular review of processes, procedures and instructions is an important part of any safety system. The review and upkeep of documents demonstrates that risks of activities continue to be adequately controlled and that work is undertaken as designed.
Work-places are dynamic environments where personnel, equipment and work requirements change. Work practices tend to drift from how they were originally designed as people perceive easier, more efficient and better ways to complete tasks or adapt to new equipment and work demands. Where processes or conditions have changed without proper evaluation and documentation, risks may not be identified or properly controlled. There are many examples where this has unknowingly led to unsafe practices or accidents.
Strategies for improving and maintaining effective document control include:
- implement a robust document management system/software which identifies the date when each document is due for review and who is responsible for the document. This may also help to reinforce personal ownership of documentation
- implement workplace audit programs to verify that work is undertaken as specified in procedures and instructions
- perform a ‘needs analysis’ to ensure all relevant stakeholders review procedures which affect them
- raise the importance of regularly reviewing documentation, such as though the use of key performance indicators or attention at senior meetings
- promote a workplace culture in which processes, procedures and instructions are followed accurately but, where ideas for improvement are welcomed and implemented with awareness and management of any related risks and opportunities.
Eight percent of the issues identified related to change management or poor risk assessment or hazard identification.
Organisations need to have a wide range of measures to identify and control risks and hazards. However, even with high-level controls, some risks can easily be missed as they can depend on specific situations and changing processes. People should be actively identifying and assessing risks as part of their normal work and feel empowered to stop activities they consider unsafe.
Strategies to promote and improve risk assessment and control across the organisation include:
- use formal tools such as: Task/Job Hazard Analysis (THA/JSA), change management processes, regular risk reviews
- use informal tools such as: Take 5, HAZOB, Pre-start checks, Toolbox meetings
- regularly review operating experience and promote curiosity when things do not happen as expected, even when there is a good outcome
- create, use and disseminate information such as risk registers and organisational learnings.
Australian New Zealand Standard AS NZS ISO 31000:2009 Risk management – Principles and guidelines provides useful information on managing risk in the workplace.
More than 5% of issues identified where a procedure was not followed. There can be many reasons why a procedure was not followed. Even the best people make mistakes. Error is a human trait and it is often stated that a skilled manual worker will make five to seven errors per hour whilst the error rate for people involved in knowledge based work with ideas and concepts is three times higher.
Deviation from procedures may also be deliberate, although it is seldom of malicious intent. People may find that a procedure is poorly designed and cannot be followed completely. People are flexible and intelligent beings with a natural tendency to find and implement easier, more efficient ways of working. A danger of this type of deviation is that it may be undertaken without adequate awareness of the safety implications. Research also shows that human experts make consistent errors in judgement about uncertainty and risk.
Careful consideration of the circumstances which led to people not following procedures could uncover some important underlying issues. Strategies for addressing deviations from procedures include:
- Review procedures taking into account human factors. Where the workplace, equipment and procedures are designed with the user in mind, taking account of human capabilities and limitations, people can work effectively with technology. This can reduce the likelihood that workers deviate from the defined procedure when they think there is a better or more efficient way to perform the job.
- Audit work practices to determine if they are being carried out to procedure. If not, understand the reason and implement change control measures or training as appropriate.
- Review change management and document control measures to ensure that where processes are changed, procedures are also updated.
- Review workplace training and supervision arrangements, with a focus on ensuring that all staff are sufficiently familiar with a task or procedure. See staff training section below.
- Promote safety culture across all layers of the organisation to ensure that unhealthy workplace cultures do not affect individual’s performance. For example, production pressure can cause the perception that production is more important than following procedures or safety requirements.
Ten percent of the issues identified related to training. Training is important to provide people with the skills, knowledge and attitudes required to safely perform their job. This can be particularly important for new staff and for rarely performed tasks including emergency response. Strategies to implement a systematic approach to training include:
- perform a training needs analysis to identify the competencies and experience required to perform particular tasks or roles
- implement software to track training and staff competencies, and capture training needs at an individual level
- implement formal teaching and mentoring systems in the workplace to help promote teamwork and share lessons
- implement or review succession planning and business continuity arrangements to ensure that critical skills are not held by only one or two people in an organisation
- evaluate the effectiveness of existing training to ensure that training is relevant to the tasks being performed.
Labelling issues/warning signage
Six percent of the areas for improvement related to labelling and signage.
Accurate warning signage such as the radiation trefoil, or labels such as ‘Class IIIb laser’, is important to ensure that users are aware of the hazards in the workplace. Strategies for improving signage control could include:
- Document the signage needs in workplace procedures or management plans. These requirements should relate to specific relevant standards – for example, in a laboratory requirements may include AS2243.4, AS2243.5 and AS1319.
- Perform regular audits of signage in the workplace; this could be part of monthly/quarterly safety checks.
Training assessment and verification
A licence holder introduced a three stage learning and assessment program with a delayed final sign-off of one month. This helps to ensure newly learned skills are embedded and that skills are transferred, prior to accreditation of staff undertaking hazardous tasks.
Post-inspection survey results
Following each inspection, the licence holder was independently requested to complete an online survey to provide feedback on the inspection process. In 2020 positive feedback outweighed negative feedback and the overall satisfaction score was 93 percent.
Feedback and suggestions are circulated to all inspector staff, used as part of training activities and help to reviewed the inspection processes.