Unintended Consequences

Sep 21, 2018 12:04:53 PM


When an issue is found, there is often a sense of urgency to action a solution to immediately fix the problem. This urgency can push a less- than-ideal option, due to management's lack of appetite to have unresolved issues. Unfortunately, the quick fix can result in unintended outcomes that become permanent resolutions for the site.

A good example of this was seen on a Bluefield client’s site recently for a safety problem at the workers camp. Over the last year, there has been the potential interaction of buses and the workforce due to the bus overhang to the curb at camp. There is risk of a person being hit by the overhanging mirror if they are standing within 1 metre of the curb and hence, the client had painted this area with a yellow stripe as a soft control exclusion zone.

After witnessing several “close calls”, the client raised this continuing safety risk at a pre-start meeting and they resolved immediately to place a physical barrier to create an exclusion zone. This was intended to keep the staff out of this area on arrival of the bus and reduce the potential for interaction. The client had unfortunately misidentified the root cause of the issue and attempted to place a hard control which ended up becoming a soft one.

After the first day of implementation, it was then witnessed that the solution had created an even greater hazard placing more people in the line of fire. The use of the barrier had not accounted for the interaction of people getting on and off the bus where the entrance to the exclusion zone was blocked by the inbound traffic of people. This forced the outbound people to funnel along the barricade within the exclusion zone itself and caused further interactions with the second arriving bus.

With this situation in mind, Bluefield set out to assist the client in identification of the actual root cause and potential solutions to mitigate the risks. These solutions are aimed at the flow of traffic on and off the bus to ensure the use of the exclusion zone required is minimised. Hard barriers placed in the correct locations will allow the bus service to function as required and reduce the potential for a serious incident to occur.

Bluefield continues to pursue this problem with the client as part of our value add proposition and is working towards a long term solution to improve the safety at the camp. This example also highlights the capability of our people and processes in addressing site problems from multiple perspectives to ensure that when a fix is applied, the risk of unintended consequences is predicted as low and trialled before full integration.


By Luke Bayly