A Culture of Unfortunate Circumstance
There is a tendency within institutions for a culture to develop which is self-serving and inconsistent with the original mission and corporate objectives of the organization. The change is insidious and can be difficult for managers to identify, let alone deal with. Once established, an adverse culture within an organization can be difficult to transform because it becomes entrenched in routine practices, and tends to justify itself on the grounds of custom and tradition, discouraging reference to fundamental purposes and responsibilities. Superior benefits are seen to derive from the new culture, allowing it to obtain greater loyalty from staff than the original corporate vision.
From a management point of view it is easier to avoid such a culture altogether than to correct it once established, but the apparently inspirational mission statements of organizations can be forgotten almost as soon as they are written, and can be relegated to a vacuous public relations tool, if not regularly revisited to maintain a positive culture focused on the primary goals and responsibilities of an organization. Adverse institutional cultures also tend to persist despite the intervention of enlightened administrative practice simply because it usually outlives the tenure of individual managers and executives.
This appears to have been what happened at our High School. While the Minister for Education attributed the unlawful dumping of asbestos in the school grounds to “unfortunate circumstances”, implying that it was a one-off occurrence due to the unauthorized conduct of an individual staff member, an historical view shows otherwise. The staff member who invited the dumping to take place may have been conforming to a culture which was already established more than twelve years earlier, as evidenced by a similar dumping incident, and which was never corrected, despite being characterized by unlawful conduct and involving the introduction of hazardous materials to the school. Both dumping incidents shared the same innocent purpose, which was to extend the school sports oval, a goal of certain staff members which appears to have grown to overshadow other considerations and responsibilities, such as the identification of hazards and the provision of a safe environment for students at the school.
Local residents and neighbours were puzzled by the school’s response to the dumping crisis. In correspondence with concerned residents the school principal vehemently denied knowledge of the dumping, despite the fact that more than 200 truck loads of material had entered the school. He also denied giving permission for the dumping to take place, yet the school administration did not subsequently declare the dumping a trespass to the school, nor did they demand that the earthmoving contractor in question remove the offending material. Instead they paid the same company to cover the hazardous material with additional clean sand.
In a later public meeting of the City Council to consider the transfer of the affected road reserve to control of the School, the Principal spoke in favour of the move and explained that a larger sports oval was needed in order to attract students to the school, but available space within the existing grounds was limited. Was this the “unfortunate circumstance” to which the Minister for Education and Training was referring, that the school grounds were too small for the school to have a sports oval of suitable size?
It appears that a culture had developed over time at our High School, one which encouraged the belief that parents judge a school primarily on the size of its sports oval, and this had become the primary motivation in some significant decisions affecting the school and the wider community. No adverse consequence had apparently been identified as arising from the first dumping. The City Council had not noticed the trespass onto the road reserve, and the Police had not brought a prosecution under Section 96(16) of the Police Act 1892 for improperly casting building waste onto a road, nor had there been any disciplinary action taken by the Education Department authorities. The staff conduct may have appeared tacitly sanctioned by the apparently harmless outcomes of that first event, and the culture of size over safety had entrenched itself for more than a decade before the second opportunity came along; an opportunity apparently too good to refuse. No one in authority paused to assess any hazard which might arise, and both events were precipitated by material being offered to the school by third parties with a vested interest in disposing of the waste in the most economic way, and regardless of the fact that it was not approved by building regulations as landfill, and certainly not as part of a School sports oval. It is quite likely that, were it not for the asbestos being identified by a local resident, the second dumping would also have gone unnoticed by authorities and would have fed the culture of unfortunate circumstance for another decade. The challenge in any safety conscious corporate culture is to replace individual complacency and indifference with a trained approach to hazard recognition and a systematic method of dealing with the risks identified. Unfortunately this transformation has yet to happen at our High School. There is an irony in all this, at a time when P plate drivers are attracting so much criticism for their reckless conduct on the road. The question has been raised whether, in the light of their accident rate, they should be allowed to carry passengers in their cars. An expert recently offered the explanation that young people lacked the ability to identify risk in their driving control decisions. A school like ours, with almost a thousand students, is very much like three jumbo jets full of passengers, all seeking a safe journey into adulthood. If we apply the same expert advice to the school situation we might conclude that the present quality of hazard identification and risk management qualifies the school administration for P Plate status. Given the long term health effects of exposure to asbestos, the full consequences of their actions may take decades to be revealed, but the failure to comply with existing statutes has already cost the Department more than $100,000 in earthmoving expenses, with no resulting benefit to the school.
Child Safety or School Reputation
In recent years within Australia there have been some glaring examples of conflict between the duty of institutions to individuals in their care, and the perceived risk of public scrutiny or litigation. Nevertheless, it might come as a surprise to parents to discover that the safety of their children must compete with risks to the public image of Schools and the Department of Education and Training in Western Australia. The Department’s policy is illustrated in its Risk Management Manual, which gives equal weight to risks involving child safety, and risks involving the reputation of a school and the Department, allowing the possibility for the two to be in direct conflict in the mind of any decision maker. Instead of arbitrarily prioritizing child safety, the manual invites school safety officers to judge the reputation of the school as having the greatest priority in a particular set of circumstances. An example at our local High School illustrates the point quite dramatically.A contractor had been employed to cut down and mulch several trees in one corner of the school grounds, adjacent to the main entrance. Work commenced at approximately 7.30am on a normal school day, and the contractor parked a truck and chipping machine at the curbside with the chute of the machine aimed in the direction of the school entrance. The tray of the truck was partly covered with a canopy, but this was insufficient to capture all the chips being expelled at high speed from the machine, and the chipper was spewing chips on both sides of the truck and directly over the truck a distance of up to 23 metres. The operation continued in this fashion for more than two hours until a missile from the machine struck the windscreen of a car passing on the opposite side of the road.
The motorist brought the apparent hazard to the attention of the operator, who denied the flying chips posed any risk, and chose instead to question the motorist’s right to complain. It was only when the motorist advised the operator his intention to report the matter to Worksafe and Police Traffic Branch that the operation was halted. The operator immediately instructed his staff to clean up the chips which had scattered over the road. The motorist also brought the problem to the attention of the school administration, and questioned why the contractor had been allowed to operate in an unsafe manner for several hours that morning.
The School Principal chose to pass the query to the Department of Education and Training District Office, which eventually responded by denying that any unsafe operation had taken place, and claiming that the inspection by Worksafe had found only minor operator error, which had been corrected. The reality was that Worksafe had found the operator in breach of the relevant legislation and had issued an improvement notice on the machine. The truck canopy had been found inadequate to catch the chips generated by the machine, resulting in them being projected past the truck tray and scattering all over the road.
The first response of the School and the Department was not, how could this have happened, and how can it be prevented from happening again? It was to deny that any problem had arisen, even to the motorist whose vehicle had been struck, who had witnessed the event first hand. They also claimed that it was the responsibility of the operator to conduct the contract in a safe manner, and was therefore not the responsibility of the School or the Department, despite the fact that the tender was let by another government department on behalf of the School, and the operation was being conducted in and immediately adjacent to the school during school hours. This behaviour appears irrational until viewed in the light of instructions in the Risk Management Manual. Then it appears that the risk to the reputation of the school and Department was judged greater than the risk to safety from 5cm wooden missiles being projected at high speed from a chipper onto a public road in a School Zone.
Nor was it simply a matter of the Department being unaware of the outcome of the Worksafe investigation. They chose to misrepresent the outcome of that investigation to give the false impression that no hazard had arisen from the manner in which the chipper was operated. In doing so they either negligently or willfully failed to acknowledge the work order which had been issued, and instead claimed to the motorist that it was merely a case of operator error. The only reasonable explanation for these falsehoods was the intention to deny any wrongdoing on the part of the contractor, and consequently any failing on the part of the Department to supervise the conduct of the work. They were foiled in this subterfuge by the prompt action of Worksafe in attending the worksite after receiving the motorist’ complaint, and the fact that they documented their findings in the form of a work order. Details of the workorder were transmitted to the School before the misrepresentations were made by the Departments regional office.
The willingness of the Department of Education and Training to misinform a member of the public in this fashion, by denying the proven and verifiable facts of the situation also implies that the Department may remain in denial that their systems for recruiting and supervising work at schools need review. Their willingness to claim in correspondence with the motorist that responsibility for the safety of the operation rested entirely with the tree servicing contractor also suggests that they are not fully aware of the legal implications of their duty of care, both to the students and to the public. Instead, they suggested that the tender process by which contractors are “accredited” is in itself a safety procedure guaranteeing the competence of operators employed through that process. But as long as the Department remains unwilling or unable to feed back into that selection process any subsequent unsatisfactory conduct or performance by accredited contractors, there is no reason to assume that someone operating in a dangerous manner at one school might not be hired to conduct similar work at another, particularly if their adverse conduct is denied by the first school.
A disturbing feature of this example is not that the machine required modification, but that the operator was incapable of recognizing the hazard he was creating by operating the machine in that fashion, and despite being accredited to operate large and dangerous machinery in and near school premises. The other disturbing feature was that the Department in this instance was content to rely on this process of “accreditation” to ensure that the contractor conducted the work in a safe manner.
The fact that the Department does not distinguish risk assessment for the purposes of safety and risk assessment for the purposes of public relations fallout is a serious concern to anyone interested in natural justice and the well-being of children in the care of the Department of Education. The potential for the purposes of both to be in conflict is clearly illustrated in the case of the chipping machine accident, and doubtless played a role in how the Department of Education dealt with the dumping of asbestos and live ammunition at the same school. Regrettably, in both these instances, the Department appears to have prioritized the risk to public relations over any safety concerns, and dealt with each hazard accordingly. The real risks to health and safety then became a secondary issue.
