Part 1 On a construction site, a migrant worker died on duty. Prior to start working, he requested the Site Manager to grant him a sick leave as he was not feeling well at all. As half of the manpower was absent due to a flu outbreak and he was the sole English-translator employee, the Site Manager refused. Moments later, the Site Manager had to leave for another site and quickly handed over the site to an inexperienced Junior QS, emphasising with him to focus on work outputs. The worker reiterated his request for sick leave to the Junior QS, who also refused. Afterwards the QS found the dead body of the worker down the stairwell, with his body perforated with steel rods. In this assignment, we shall go through a reflective process by the Site Manager, the Junior QS and the Contracts’ Director to identify shortcomings and improvements for the future. A reflective process is an activity through which one methodically reflects on his own actions and actions of others to identify where improvements can be made for the future. “You can never make the same mistake twice, because the second time you make it, it's not a mistake, it's a choice.” This quote which is said to originate from different personalities, actually tells one to learn from experiences. Thought it is a pretty simple principle, if the right methodology is not applied, one may fail to learn from his own mistake. There are existing methodologies termed as reflective learning models, which set frameworks for reflective practice. According to L. Finlay (2008), reflective practice is to learn from one’s experience to get new insights of self and practice. A crucial aspect of project management is ‘lessons learned’ on a past project, on which professionals shall reflect to be able to improve upon. The Reflective Models To be able to properly reflect on an event and learn from it, without leaving behind details which may be important, a framework for the reflection must be set up. There are already several reflective models which outline different frameworks, namely; Kolb’s Reflective Cycle, Gibbs’ Reflective Cycle, Boud’s Framework for Reflection and Johns’ Framework for Reflection amongst others. Kolb’s Reflective Cycle Professor David Kolb is an educational theorist who focused mainly on Experimental Learning. In the 1970s, alongside Ro Fry, they both developed an experimental learning model which would later be known as Kolb’s Model (Kolb and Fry, 1975). Kolb’s Model consists of four stages, namely; • Concrete Experience – a past experience which will become the basis of the reflection process. • Reflective Observation –assessment may have been rightfully done or what may have been mistaken pertaining to the event. • Abstract Conceptualisation – actually determining what went wrong and conceptualise the improvement/changes that can be made. • Active Experimenting – test, if concepts suggested, will work in similar experiences. Prof. Kolb (1974) perceived all these four stages to be mutually supportive, but one should still be able to integrate the cycle and any stage. However, for the learning process to be effective, it is important to go through all four stages. Active experimentation may however not be feasible in all reflective scenarios. Gibbs’ Reflective Cycle In 1988, Prof. Graham Gibbs published another reflective cycle in a book titled ‘Learning by Doing’. The illustration below from Sarah Stewarts summarizes very well what the reflective cycle proposed by Prof. Gibbs. The model consists of the following six stages; • Description – What happened? • Feelings – What were you thinking? • Evaluation – What was good and bad about the experience? • Analysis – What sense can you make of the situation? • Conclusion – What else could you have done? • Action Plan – If it arose again, what would you do? This model is appropriate for people who go through similar experiences regularly. All these six stages provide a very systematic approach to the reflective process where one can structure his reflection to make the process more effective. Gibbs’ cycle is, therefore, a quite complete one. Boud’s Framework for Reflection Prof. David Boud is an experienced researcher in higher and professional education. In 1985, alongside Keogh and Walker, Boud published a book entitled ‘Reflection: Turning Experience into Learning’ in which a reflection framework is elaborated (Boud et al, 1985). Boud’s Framework is one of the simplest reflective frameworks to be discussed. It is a model where Experience, Learning and Reflection are directly linked to each other. The framework starts at the moment of the experience taking place. During the experience, one will have Ideas, Feelings and Behaviours. After the experience, one can go back and reflect on the successful and unsuccessful behaviours, the positive and negative feeling which either helped or hindered progression and the ideas that were implemented or could have been implemented. From this reflection, new perspectives can be found, there can be changes in behaviour, readiness to implement improvements is enhanced, and commitments to changes can be taken. This model is more focused on emotions and may indeed lead to some very conclusive results. However, according to Read (2016), the model lacks structure for a thorough reflective process and may also be too introspective for some situations. Johns’ Framework for Reflection Johns’ framework was initially developed for nursing practitioners. It is however applicable in other fields. It is based on two main reflection categories; “Looking in” which is Reflection in Action and “Looking out” which is Reflection on Action. According to Johns (2000), Looking in consists of: • Find a space to focus on self; • Pay attention to your thoughts and emotions; • Write down these thoughts and emotions and Looking out consists of: • Write a description of the situation; • What issues seem significant? • Aesthetics o What was I trying to achieve? o Why did I respond as I did? o What were the consequences for myself and others? o How were others feeling? o How did I know this? • Personal o Why did I feel the way I did within this situation? • Ethics o Did I act for the best? • What factors were influencing me? • What knowledge did or could have informed me? • Reflexivity o How does this situation relate to previous experiences? o How could I have handled this better? o What would have been the consequences of alternative actions? o How do I feel now about the experience? o How can I support myself and others better in the future? Johns’ framework is very broad and covers most aspects of any possible scenarios. However, in this framework, there is a lack of structure which would help a practitioner reflect in a systematic way which will result in effective outcomes. Choice of Reflective Model For our purpose, a reflective model should be chosen to provide a reflective framework to managing staffs relating to a fatal site accident. The model chosen shall, therefore, be feasible in the above context and should cover enough aspects to give a reasonable insight into the accident. Kolb’s Reflective Cycle has a proper structure which will help in this reflective process. However, it does not go into details as some other models and includes active experimentation which may not be feasible in all reflective scenarios. Gibbs’ Reflective cycle is very well structured and does go in more depth that Kolbs’ Cycle or Boud’s Framework. The sequential and methodological approach provided by Gibbs’ Cycle will be an advantage to the reflective process. It may also have to compare the outcome of the reflection from the three persons. Boud’s Framework is not structured enough to be able to target all aspects which may be desired from this reflection. Moreover, as three persons are to take part in this process, the absence of a defined structure may hinder any possible comparison between the three outcomes. Lastly, regarding Boud’s Framework, it has a strong focus on emotions whereas in this case facts and evidence areas, if not more important than emotions. Therefore, Boud’s Framework will therefore not be chosen as well. Johns’ Framework is very broad and may help to capture all the desired details. However, a structure to proceed is not defined so that one can easily come to conclusive outcomes. The amounts of details to be captured in Johns’ Framework also make the reflective process too long and without a structure, even less conclusive. Gibbs’ Reflective Cycle is, therefore, the most appropriate model for the context of this reflection. Gibbs’ Cycle will provide the following advantage: • The structure and sequence provided will help the practitioner go through the process in a systematic and conclusive way. • It goes into enough details for this context. • It captures all the aspects relating to a construction site accident. • It does not require active experimentation. Reflection The Site Manager As the title states, the Site Manager is the one in charge and responsible for the site, the work progress and schedule as well as safety and health. The Site Manager has more than 25 years of experience in the construction industry and has never been implicated in any site accident before. At the moment of the accident, he was however not on site. Below is his reflection. Description of the event • As usual, every morning head of migrant worker comes to my site office to take instruction for the day from me as he is the only foreign worker speaking fluent English. • The migrant worker informed me that he reported working only to pass on instructions to the rest of the workforce and then he shall take leave as he is feeling sick. • Convinced the latter to stay as it will be extremely difficult to pass any instruction without him during the day. • I was urgently called on another site which I manage. I, therefore, called in our Junior QS, to whom I handed over the site after a quick briefing where I emphasised to him that works must keep going. • Half an hour later I received a phone call from the QS. He informed me that a tragic accident happened, migrant work fell down the stairs and his body was perforated with protruding steel rods and found him dead and was in total panic. • Instructed the QS not to move anything, call the police and wait for me to come back. • When arrived back on site, the scene of the accident was restricted and the police took my personal details and informed me that I would be contacted for a statement. Feelings to the event • I have always been under stress to cater for the proper management of several sites and I was pretty carefree and never imagined that anything could go so terribly wrong. I knew the junior QS, despite being very brilliant, is not experienced at all. As I did not feel there could be anything going wrong, it did not bother me to leave the site under his control. • Devastated. Guilty. Irresponsible. It is hard to describe what I felt, but one thing for sure, I knew I may be largely responsible for this the moment the QS informed me of the accident. Next, I thought about the family of the migrant worker, his co-workers, junior QS and all those who will now all be affected by this tragic event probably because of me. I asked the Lord why I did not authorise him to take the leave he requested so rightfully. • The whole company and workforce got the news that I refused the migrant a leave that morning. I think I was hated by everyone working with me. Evaluation of the event The Junior QS kept his calm and reacted properly to the accident. The remaining Migrant workers did not turn to violence to protest. It is quite hard to find anything else which may have gone right. Mostly everything went wrong on this project: • We have cash flow problems. Further delays in site works may be fatal to the company. • There was a flu epidemic causing half of the workforce to take sick leaves. • We had only one Migrant worker fluent in English to convey our instructions. • I refused sick leave. • I was forced to leave the site. • There was no other staff experienced enough to handle a site. • There was no focus on Safety and Health on the site. Analysis of the event The company is focused on financial survival only. No attention is given to staff welfare or safety and health on site. The flu epidemic combined with heavy Liquidated and Ascertained Damages meant that more work had to be completed with only half of the workforce present. I left someone with no experience to handle the site. Due to pressure from higher management, I was also focused only on keeping works going and therefore refused to give sick leave to the migrant. There is no fear of authorities taking action on unsafe sites as they never inspect any site. Conclusion about the event • I should have prioritised the welfare of staff over the progress of works and approved the leave. • I should have implemented safety and health policies on site even if higher management shows no concern about this or authorities make no inspections. • I should have not left the site without a proper and thorough handing over. • I should have not left an inexperienced staff in charge of the site. • I should accept to manage only one site at a time. • I should include contingencies in work schedules in case of disease outbreaks or other unforeseen circumstances. Action Plan about the event • The company should set up a strict safety and health policy to be followed on all our sites. • Projects should not be under-priced during the bidding process at the expense of the welfare of staffs. • A list of prerequisites shall be drawn for anyone applying for a job at the company. • Criteria of approval of leaves must be established. Anyone satisfying the criteria will have their leave approved. • The work schedule should include reasonable contingencies to cater for unexpected events. • In case of absence of the Site Manager from the site, procedures must be set up to divert important decisions from junior staffs to senior management. • Being more aware than ever before of potential consequences of mismanagement, it would surely act differently. The Contracts’ Director The Contracts’ Director who is also the Finance Director of the company is in charge of all contractual and financial matters on all the sites of the company. The Contracts’ Director is the one responsible to prepare claims, prepare contracts, prepare bids, effect procurement, amongst other duties. The site managers usually take instructions and advice from the Contracts’ Director. The site managers of the company are therefore accountable and report to the Contracts’ Director. The latter rarely visit sites and may not be aware of site conditions. Description of the event I was preparing some claims for a client when I received a call from one of my newly recruited staff, the QS on one of our sites. He informed me that a fatal accident had occurred on the site where he was posted and he was awaiting the arrival of the police. I asked him to remain calm and if any tensions arise with the other foreign workers to leave the site immediately. He, however, reassured me that everything was calm. After the call, I informed the board members of the company of the tragic accident and drove to the site. When I arrived there, the corpse had already been taken away, but the police had barricaded the site to record evidence. The site was indeed a mess. It was not necessary to look closely to realise that almost no safety norms were being respected. An officer from the Ministry of Labour informed me that a stop order is being issued with immediate effect this site. I tried to communicate what I could to the workers, asking them to go back home and that I will contact them once the site reopens. I am not sure if they understood all of what I said. Apparently, the worker who died was the only one who could understand English properly among all our Migrant workers. Feelings to the events My main concern was about the Liquidated and Ascertained Damages on that site. We were on the brink of starting to make losses. It was imperative to catch up with the schedule or we would run at a loss. No day had elapsed without me pestering the Site Manager about the catch-up works. I felt that my job was to ensure that the company was profitable and this is what I thought I had to do. This is the moment where the reality on our sites had hit me. I felt so guilty about hitting so hard on the Site Managers without having a look at their sites or considering how critically understaffed they were. I was guilty to have forced them to work in such conditions. I was so saddened and felt so guilty because I knew this was probably the indirect results of my actions. Evaluation of the event • The Site Manager, as well as the QS, refused to approve the leave of the Migrant worker. • The Site Manager had to attend another site at the moment of the accident. • Young and inexperienced QS who was employed just for metering work progress was left in charge of the whole site. • The site was in an unacceptable mess. • Liquidated and Ascertained Damages were reaching astronomical amounts on this project. • When I allocated budget and workforce to each site, Safety and Health were never included in our spending. Analysis of the event • We overlooked safety to make profits. • We under evaluated costs of projects while bidding. • The schedule we propose to clients is probably too tight. • We do not have enough workers speaking English. • We should have more qualified Site Managers in our team. Conclusion about the event • I should have been present on our sites more often. • Before talking about getting jobs done, I should ensure that proper working conditions for our workers. • I should have seen the need for an internal Safety and Health Officer to systematically review the status of our sites. • Before pestering any Site Manager to get jobs done, I should listen to what they have to say and their concerns. Action Plan about the event If the company survives, I shall ensure that • There is a Safety and Health Officer in-house to meticulously verify the sites. • Projects are not under evaluated while bidding so that enough staffs can be engaged on the projects. • At least 3-4 foreign workers on each site can speak English. • All work schedules are feasible and we will not run short of time. . The Junior Quantity Surveyor (QS) The Junior QS is a young and inexperienced man who has just been employed by the company. He is responsible for metering work progress on this site and helps prepare claims. However, at the moment of the accident, in the absence of the Site Manager, he was in charge of the site. The Site Manager handed the site over to him after a quick briefing where he asked the QS to focus on work progress. Description of the event I do a quick site check to see where we stand with the work progress and report to the Site Manager. However, that morning I did not have time to complete the check when I was called upon by the manager to his office. He informed me that he will have to leave immediately to attend an urgent issue on one of his other sites. He quickly briefed me of the targets he had set for the day and I should meet that target with only half of the workforce as there was a flu outbreak. He moreover informed me that our Contracts’ Director called him in the morning and was very unhappy about the delays on our site. He also informed me that he refused a worker, our only foreign worker who speaks English, a sick leave. The Site Manager is used to leaving the site now and then as he has several other sites to manage. Nothing ever went seriously wrong in his absence up to that date, as the workers were experienced and already knew what they had to do. Although it was only my second week with the company, I was already used to this situation. However, after the site manager left, the migrant came back to me asking for a sick leave as he was not feeling well at all. I never had to approve leaves for anyone before and did not even know if I was empowered to do so. I was moreover informed by the manager that he refused leave to the worker and the work progress was at a very critical stage. It was obvious that the migrant was not well at all when you looked at him. Although I wanted to give him that sick leave, I could not. He was the only guy who spoke English among our Migrant workforce and none of the local staffs speaks Migrant. In his absence, it would be extremely difficult to get instructions through. Against my will, I, therefore, asked him to stay on site and do whatever he felt he could do. No more than ten minutes later, I found the body of the migrant down the stairwell; steel rods through his chest. I ran down and checked his pulse, hoping he could still be alive, but this was of course not the case. It was a horrific bloody scene which is stuck in my head. I called the site manager, the Police and our Contracts’ Director and waited for their arrival. Feelings to the event I was not worried about anything going wrong but already felt sorry for not being able to give a sick leave. The pressure to get the work completed was on everyone, including me as well. This was our only focus. I was able to prevent myself from crying, but this was the most horrific moment of my life. It was all because of me, I knew he deserved a sick leave and I refused it to him. I tried my best not to panic, but I know I was responsible for the situation, I was the one in charge of the site and I surely failed in my duty. I was not made for that job probably. All the other workers on site were extremely saddened, particularly the Migrant workers who unofficially considered the migrant as their superior. They usually report to him for all their problems. The director thought that they could turn violent against me when he talked to me on the phone and asked me to leave the site if this was necessary for my safety. This was not the case at all. I was new to the company, and the workers thought, that like them I only execute orders. But I was in fact truly in charge of the site. I never felt so terribly guilty. Someone died because of me. My whole career was probably over just when it started. I was probably going to jail as well. Too many things were going through my head. There was a sense of revolt towards the company management due to the work conditions. However, the top management of the company may have not necessarily been aware of the actual work conditions as the contract director was shocked himself seeing the state of the site. All my family and friends felt that I did my job well and I was not to be blamed. They were very supportive. Evaluation of the event • Both site manager and I refused to grant sick leave to the migrant. • The site was a complete mess with random objects lying around everywhere. • The Site Manager had several sites to manage and was absent at the moment of the accident. • The top management insisted too much on getting works done at the expense of staff welfare, safety and health. • The deadlines with which we had to work with were impossible to meet, and we had heavy Liquidated and Ascertained Damages on this site. • Many workers were ill due to a flu outbreak and were not helping with catching up with the schedule. Analysis of the event • Sick leave was refused twice • We gave priority to the work progress at the expense of safety • Not enough Site Managers are employed by the company • Only one Migrant worker who speaks English was employed • We were given impossible deadlines to meet by the management compared to the small workforce we had. Conclusion about the event • I should have approved the leave • I should have raised the Safety and Health issues. • I should have probably refused a responsibility which I am not experienced enough to undertake. • The Company should provide reasonable deadlines which take into account events like a disease outbreak. • The company should not have posted only one foreign worker who speaks English on a site full of Migrant workers. • The company should employ more qualified Site Managers to manage all their sites. • Safety and Health should be prioritised over making profits. Action Plan about the event If the company survives; • We should implement Safety and Health policies. • The company should employ more English speaking workers from Poland • The company should employ more Site Managers, • Policies for staff welfare must be set up. • Project Managers and Directors should plan the project more thoroughly to provide workable deadlines. Conclusion Going through the reflective process following Gibbs’ model impressively made things clearer. Three different individuals who experienced the same event in three different ways finally arrived at converging outcomes after the process. They all found their individual shortcomings, although the Junior QS may be judging himself too severely and already planned how they should act properly if a similar situation arises again. They also all found that the root cause of the problem was the company trying to get too much work done within too tight deadlines, to get a viable cash flow while ignoring all aspects of safety, health and staff welfare. The reflective process has therefore been a very productive one which will surely help that mistakes are not repeated in the future and to preserve lives as well. Part 2 Executive Summary On a construction site, a foreign worker suffered fatal injuries following a fall from the second floor of the site. This report was commissioned to find the extent of the liability of the company in this tragic accident, to devise a risk management framework and the extent to which the culture of the company contributed to the fatality. Below is a summary of the outcomes of this report. Liability of the company It was found that the company obviously committed numerous offences; namely under The Occupational Safety and Health Act (OSHA), The Employment Rights Act (ERA) and the Mauritian Criminal Code (MCC). Infringements to the OSHA relates mainly to the employer not providing safe working conditions, the absence of barriers and the untidiness of the site. An infringement was committed under the ERA as a sick worker was refused a sick leave instead of being granted the leave and provided with a means to return home. Moreover, involuntary homicide due to negligence or non-observance of regulations is punishable under the MCC. The family of the victim can also sue the responsible parties under the Mauritian ‘Code Civil’. In a nutshell, all these means that the company shall be liable to pay heavy fines and compensations to the family of the victim, and some employees may even face prison sentences. Risk Management Framework A 5-stage risk management framework was devised based on the Risk Assessment Guidelines provided by the Ministry of Labour, Industrial Relations and Employment. For the company, this framework will be effective only if a registered Safety & Health Officer is employed, a Safety and Health Committee is set up and Safety and Health Policies of the company are working out, as required by the OSHA. Culture of the Organisation Following reflective learning outcomes from several key employees and evidence from the site of the accident, it was clear that the focus of the whole company was towards getting works done in impossible delays to resolve financial issues. Due to this, employee wellbeing and good safety and health practices have been overlooked systematically at all levels of the organisation. Today we are at a point where these practices are almost inexistent and hugely contributed to the death of a worker. Introduction The first aim is to determine the liability of the company in the accident and potential legal consequences. This will be done by identifying the root causes of the accident, and potential infringements to laws and regulations which provoked these root causes and the potential penalties. Secondly, a risk management framework which could have prevented the accident is to be proposed. The ‘Risk Assessment Guideline’ by the Ministry of Labour, Industrial Relations and Employment shall serve as a proper backbone to devise this framework. Finally, the culture of the company is to be assessed to determine to what extent it could have contributed to the death of a worker. To achieve this, information from the Reflective Learning outcomes by 3 employees following the accident and evidence from the site will be considered to have an insight into the company’s culture. The extent of Liability of Company To be able to situate responsibilities in this accident, the Ministry of Labour, Industrial Relations and Employment launched an investigation. An effective way to identify the causes of the accident is through a root cause analysis (RCA). Afterwards the owners of the risks for each potential cause and associated potential legal consequences were identified. To help with the investigation, the officers of the Ministry requested all Safety and Health records to be provided to them. It was found that in the absence of a Safety and Health Officer, the Site Manager who was supposed to assume this responsibility did not have absolutely any record except a checklist which was inaccurately filled when works first started on the site. This was already very damning to the company. Moreover, reflective learning outcomes with some employees provided some more details which may help to establish the causes of the accident. Root Cause Analysis A RCA is a systematic way to work backwards the causes and effects which lead to an event. Using the cause and effect technique the root causes can be identified and presented in a fishbone diagram as illustrated below. Worker Stressed Negligence Too much work Too tight deadlines Re-bars Protruding No Barriers No Safety & health Officer No Safety & health Officer Only Worker Speaking English Site Untidy Imprudence Kickers exposed with no warning Worker Tripped Flu Epidemic Working while Ill Negligence No regulatory authority to enforce regulations Worker died falling in stairs Did not get Sick Leave Work tatgets to be met Figure 1: Fishbone Diagram for Fatal Accident Root Causes: • Negligence • No Safety and Health Officer • Sick leave was not approved • Flu epidemic • Work targets and deadlines were too tight • Absence of visits by Regulatory Authorities • Work site was untidy • Only one Migrant worker speaks English • Kickers were exposed with no sign Liabilities In this case, the Company, as an entity employing the migrant worker may be held liable for the accident and/or the Site Manager, who represented the company on site and the one officially responsible for the site, will also be held accountable. It is very unlikely that the Junior QS will be held accountable for responsibilities not within his scope of duties. Any employer who commits and an offence under OSHA shall, upon conviction, will be liable to a fine not exceeding 75,000 rupees and to imprisonment for a term not exceeding one year, as per section “94. Offences”. Any person who commits an offence under the ERA shall, on conviction, be liable to a fine not exceeding 25,000 rupees and to imprisonment for a term not exceeding 2 years, as per section “67. Offences”. As there are numerous offences, in this case, legal actions may be undertaken on several grounds by the Ministry of Labour, Industrial Relations and Employment and there is a high risk of multiple fines being applied as well as terms of imprisonment. Moreover, as there has been a fatality, in this case, the Ministry may also sue the company and/or the site manager for involuntary homicide due to negligence. Compensations under the ‘Code Civil’ for such instances, may amount to several millions of rupees. This may provide a glimpse at the magnitude of the financial impact this accident may have on the company. In light of the above, it is clear that our company and/or the Site Manager will stand no chance in any court of justice to be cleared from responsibilities in the death of Mr the migrant. Prosecutions may take place against both the company and the site manager or only one of them, as barristers of the appellants may deem fit. Framework for Risk Management Risk management is an important factor in any type of organisation. The construction Companies are usually faced by a number of risks and therefore requires a serious risk management plan. If there could have been a proper risk management plan by this construction company then the death of this immigrant worker could have been avoided. Proper legislation is also vital and could have saved the life of this immigrant worker. Legislations are important tools that can be used to help in controlling various risks. The Employee Act legislation described very well of how sick employees should be treated in any organisation. Under the Employee Act, employees need to be given off or even leave when they are sick. Once they are away from the job premises to seek medical care and rest at home, their payments should be made as usual. This payment is known as the sick leave and employees are entitled to it. If this could have been in place then the immigrant worker who died at the construction site could have been excused and sent home to seek medical care and relax while at the same time paid as usual. Risks are all based on uncertainty and this means that if an appropriate framework is put around this uncertainty then people can easily do away with the risks in their projects. The framework for risk management that could have been in place for this construction company entails five (5) major steps. These are steps that when followed then risks will be identified earlier and mitigation strategies put in place so as to avoid them. These 5 steps are Identification of the risk – The organisation and the management team should recognize and describe some of the possible risks that might take place within the organisation. These are things that might the project as a whole or the outcome of the project. Various methods can be used to come up with possible risks and an example is the preparation of the Project Risk Register. Analyse the risk –After identification of the risks, the likelihood and consequences of the risks will be determined. Understanding of the nature of the risks and their potential effects on the goals will be developed. Rank or evaluate the risk – The risk will be evaluated and ranked by determining their magnitude which is obtained by addition of likelihood and consequences. A decision is made at this point whether the decision is acceptable and needs serious treatment. Treat the risk – it is also called risk response planning. In this stage, the highest ranked risks are assessed and then a plan is set out to modify or treat them so that the goals and objectives are met as planned earlier. Monitor and review the risk – at this stage, the Project Risk Register is taken and used to track, monitor and review the risks. If all these steps of risk management framework could have been used then, the death could have been avoided. There were various risks at this construction site and these are some of the reasons that also contributed to the death of the immigrant worker. The reinforcement rods were just left naked without covering and these are metals that can cause harm to workers. There are possibilities that this could have led to a fatal accident that led to the death of the worker. There were also accumulated rubbish at the construction site and this was another potential risk to the operation and health of the employees at this construction site. The employees are entitled to a safe and healthy workplace. This means that they should be provided with the right working gear and also ensures that where they are working is safe without many risks. The sharp metal rods could have been covered or signposts written to act as a warning to the workers. Garbage is connected to a number of diseases causing micro-organisms. Maybe, this is what could have caused or accelerated the health issues of the worker who died. In order to control risks in this construction site, the organisation needs to set some policies and follow them to the latter. One control is to maintain a healthy working environment which can be done by ensuring that the construction site is clean and garbage collected regularly. This will help in keeping the good health of the employees. Various warning signs should be used to label dangerous areas or things such as sharp metal rods. The workers also need to be provided by protective gear to put on whenever they are working or within the construction vicinity. These will ensure that the health of the employees is valued and at the same time, they are also safe within the working environments. Safety and Health Culture within the Organisation From the reflective learning outcomes of three employees of the company and evidence from the site of the accident, the least that can be said is that the Safety and Health culture is very poor within to company. It can conclude that safety and health norms are being blatantly ignored on this site. The Site Manager either overlooked or had no consideration for keeping a site clean and safe. Random objects are seen lying around, the stairwell full of rubbish, steel rods protruding dangerously, no barriers around voids, all these are items which should have been reviewed and rectified by the Site Manager and could have prevented this fatality. Moreover, when workers let the worksite become a mess and pay no attention to safety and health, it may be due to; 1) A lack of information regarding the risks for their own safety, 2) Bad example from the upper hierarchy, or 3) They are encouraged not to prioritise safety and health over work progress by the company. Despite having more than a hundred employees, the company does not have a Safety and Health Officer (SHO), not even a part-time one. A SHO would have played a crucial role in implementing good Safety and Health practices on site. A SHO would help in carrying Safety and Health Audits, set up preventive measure where there are risks, advice the employer and train the employers about good safety and health practices and address complaints from employees, amongst others. As at now, it is the Site Managers, who are responsible for safety and health on our sites. However, as witnessed good safety and health practices are almost inexistent on the site of the accident. Some possible reasons could be: 1) The Site Manager is not properly trained/qualified, 2) The Site Manager overworks as he has several sites to manage, 3) To catch up with the schedule, the Site Manager overlooked safety and health, 4) There is a lack of leadership form higher management to implement good safety and health practices, or 5) The financial situation of the company does not allow for any expenditure on safety and health. The higher management of the company showed absolutely no concern for anything other than getting the job done. Work progress, catching up with the schedule and getting cash was the only priorities of the management of the company. Such behaviours set very bad examples for the staffs of the company and may have also contributed to the fatality. Conclusion Liability of the company The company, represented by the Site Manager where the accident occurred, breached numerous rules namely under; • The Occupational Safety and Health Act (OSHA) and • The Employment Rights Act (ERA) Infringements to the OSHA relates to the following: • Failure by the employer not providing safe working conditions, • The absence of barriers on a working area higher than 2m, • Failure to maintain a clean work area, • Failure to carry proper and timely risk assessments, • Failure to employ a Safety and Health Officer and • Failure to set up a Safety and Health Committee within the organisation. Infringement under the ERA relates to not providing assistance to a sick employee. Instead, he was requested to continue to work. The Ministry of Labour, Industrial Relations and Employment, can and most probably will take the company and/or the site manager to court under a criminal case (involuntary homicide due to negligence or non-observance of regulations), breaches of OSHA and ERA, where huge fines and potentially terms of imprisonment may be applied. Risk Management Framework A 5-stage risk management framework that could have surely prevented the accident has been devised. It is based on a Risk Assessment Guideline published by the Ministry of Labour, Industrial Relations and Employment in line with the OSHA. For this framework to be effective, the pre-requisites are that the company should employ a Safety and Health Officer on at least a part-time basis and there should be deep changes in the company’s safety and health culture. Also, any requirement under various laws and regulations shall be strictly abided to. Culture of the Organisation Taking into consideration the evidence from the site of the accident and reflective learning outcomes from several employees, the safety and health cultures was investigated and analysed. It was found that at every level of the organisation, good Safety and Health practices were blatantly ignored. The focus of the whole company was towards getting works done in impossible delays to resolve financial issues. Although lower-level employees have absolutely no gain in these bad practices, it can be explained that they are part of this poor culture due to bad leadership example form the company’s management. The management of the company should, therefore, take drastic measures to improve the organisation’s culture towards good safety and health practices within the shortest delay possible and afterwards implement a Risk Management Framework.
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