In the first part of this two-part series, Paul Verrico CMIOSH and Sarah Valentine set out a new safety theory that uses a ‘story’ to illustrate the need for rest, observation, planning and empowerment (ROPE).
When the focus is on workers as the problem in a drive towards perfection, factors such as fatigue, accumulated stress and family pressure are often ignored. An ascent of Mount Everest is a useful analogy for safety professionals in giving a context to directors and managers to explain this phenomenon.
It is only 70 years since Everest was first scaled. Sir Edmund Hillary recorded his account of the climb: ‘After an hour’s steady going we reached the foot of the most formidable-looking problem on the ridge – a rock step some 40ft (12m) high [now known as the Hillary Step].
‘The rock itself, smooth and almost holdless, might have been an interesting Sunday afternoon problem for a group of expert rock climbers in the Lake District, but here it was a barrier beyond our feeble strength to overcome… Despite the considerable effort involved, my progress although slow was steady, and as Tenzing paid out the rope I inched my way upwards until I could finally reach over the top of the rock and drag myself out of the crack on to a wide ledge… As I heaved hard on the rope Tenzing wriggled his way up the crack and finally collapsed exhausted at the top like a giant fish when it has just been hauled from the sea after a terrific struggle’ (Hillary and Hunt, 1953).
An unaided Hillary Step climb in isolation was rated as a ‘Class 4’ – the Yosemite system for climbing difficulty describes such a climb as ‘simple climbing, often with exposure. A rope is often used.’ A fall on Class 4 rock could be fatal but is rarely so – in different circumstances.
The importance of sleep: Sleep deprivation study results
Sleep deprivation slowed reaction time. Participants, for brief moments, would stop responding all together. What Van Dongen et al (2003) discovered was that slowness wasn’t the most telling sign of sleeplessness but, rather, complete lapses (which we now call microsleeps).
Kept awake for 72 hours, (no sleep for three days)
After 24 hours of no sleep, missed response rate increased by more than 400%; after three nights subjects had catastrophic impairment. Deterioration continued and showed no signs of stabilising.
Allowed four hours of sleep per night
After six nights of four hours’ sleep, they performed as poorly as Group 1 after 24 hours; after 11 nights of four hours’ sleep, their performance was equal to someone going 48 hours without sleep.
Allowed six hours of sleep per night
After 10 nights of six hours of sleep, they performed as poorly as Group 1 did after 24 hours.
Allowed eight hours of sleep per night
Maintained a stable, near-perfect performance for two weeks.
Worryingly, all the groups apart from Group 1 had no perception of how poorly they were performing.
Why so difficult?
The summit of Everest is 29,028ft (8849m) above sea level. The Hillary Step is the last challenge before reaching the summit; climbers will have spent weeks ascending and descending to acclimatise. So, by the time they reach this final obstacle, they will be exhausted.
In his book, Into thin air (2011) journalist Jon Krakauer describes his experience of the 1996 expedition during which six climbers died. He remarks that ‘people’s perceptions of their own abilities are amazingly far off the mark’ and ‘one teammate, for example, was reduced to a helpless, infantile state by his infirmities and needed extensive help to make it down to the South Col. And yet he doesn't seem to remember this; his view is that he was just fine, that he didn't need any help.’
A little nearer sea level, and on another continent, the civil case of Michael Eyres in the UK (EWCA, 2007) highlights the risks of fatigue. On the day of a road accident that left him paralysed, he had arrived at work at 3.30am after four and a half hours’ sleep, setting off with a colleague to fit a kitchen in Swindon, 111 miles (179km) away. The pair shared the driving and work, which was finished at 2.30pm, when the colleague said they had another job in Sidmouth, Devon, 122 miles (196km) away. The accident happened in the evening while Eyres was driving from Devon to the company’s base in the north of England. Lord Justice Ward, who gave the ruling of the Court of Appeal, said Mr Eyres, who was 20 at the time, was ‘in that predicament because his employers had put him there’.
The judge added: ‘This case is a strong financial reminder to employers of the need to manage occupational road risk. Companies need to be sure that their employees are in a fit condition to drive and have had adequate quality sleep before getting behind the wheel.’
Rest – the R in ROPE
Van Dongen et al (2003) published research in 2003 on ‘the cumulative cost of additional wakefulness: dose-response effects on neurobehavioural functions and sleep physiology from chronic sleep restriction and total sleep deprivation’.
A group of 48 healthy adults were separated into four groups. Each subject was asked to complete the following task for a 10-minute period every day for 14 days: press a button, whenever a light appeared on a computer screen, within a set period. The results were staggering (see Sleep deprivation study results above).
Fatigue is a reason we struggle to perform tasks safely. And, just like Sir Edmund Hillary, what looks like an easy job is anything but. Rest, therefore, forms the first element of ROPE – ensuring teams have adequate opportunity to recover and take appropriate breaks.
Case Study:Fatigue: why workers need rest
Many construction workers travel to secure employment, often staying away from home during the week and working long hours to ensure an early finish on a Friday – sometimes with dangerous results.
A worker who lived in northern Scotland secured a contract in Teesside. The worker had been involved with the project for seven months, completing the same routine each week, leaving home at 1am on a Monday and leaving work at lunchtime on a Friday. He was an experienced piling operative and the designated safety officer.
The incident occurred at 11am on a Monday while piling an outline for a tunnel. He was working with the same site team, had completed the morning briefing and eaten his usual breakfast. There was nothing out of the ordinary.
However, he became trapped between concrete posts, sustaining life-changing injuries. The subsequent investigation attempted to determine why he deviated from the site-safe procedures he had previously followed.
Application of ROPE theory
While fatigued, the worker struggled to perform a familiar task safely. Fatigue causes us to not fully think and consider, and to cut corners. This scenario was exacerbated not just by the early start, but many months of lack of sleep.
The organisation must have been aware of the worker’s home address and should have made sure suitable control measures were in place to manage the fatigue risk. The investigation found that no enquiries had been made – if they had, safeguards could have been introduced.
A full work schedule was allocated each week. The worker completed long days to ensure an early finish on Friday. This, on top of a 20-hour day at the start of the week, would have exacerbated his tiredness. Setting realistic work schedules is key. The organisation expected its contractors to adhere to unrealistic timescales, which created additional stress. Organisations need to take the time to properly plan work activities to ensure they provide realistic deadlines.
Organisations should also have regard to roles and responsibilities. In this case, the worker could have been placed on office duties on the Monday rather than a pivotal role in the piling operations. Planning considerations should also extend to competence and resourcing of work teams.
The worker’s fatigue could have been identified as a risk indicator through site observations, monitoring and oversight. These are effective safeguards to ensure safe systems of work are followed and take into account site-specific hazards. Site observations allow work to be paused or stopped if the control measures are not in place. Supervisor observations should have identified a failure to follow the safe systems of work, and highlighted that workers were suffering from fatigue. Organisations need to understand the importance the middle management tier has in achieving safety assurance.
A key question in the investigation was ‘Why did no one say anything?’ It is important in an organisation for workers to feel empowered (the E of ROPE) to highlight safety concerns. A failure to encourage workers to speak up leads to a disconnect between management and workforce. It prevents an organisation taking proactive steps to improve safety systems. It can also drive negative behaviours from workers, who form the view that management does not care, making workers more likely to cut corners and take on tasks they are not competent to perform. It will also lower morale.
Observation – the O in ROPE
A second factor is the importance of supervisor observation of workers. We often overlook the stress that accumulates during work. Jay Kaplan’s (1991) work with macaques gives us a clue as to how office politics can create a Hillary Step moment. In the late 1980s, the US changed guidelines for the care of laboratory monkeys. They had been kept individually in cages, but a new, required weekly meeting became a brawl, which induced heart problems. Kaplan mimicked this in controlled conditions. Lab monkeys were socially disrupted. Male monkeys swiftly developed worsened coronary atherosclerosis relative to control animals housed in groups of fixed (stable) membership.
When the same experimental procedures were applied to males fed a diet low in saturated fat and cholesterol, the manipulation of group memberships similarly led to development of greater atherosclerosis in the coronary arteries. Robert Sapolsky (2001) found increasing levels of the stress hormone cortisol accelerated ageing of the hippocampus – the area of the brain that helps keep track of events and remember what happened.
Those who try to get up the Hillary Step face the danger of falling 10,000ft (3048m) on their right and 8000ft (2438m) on their left. Stress is high. There is not enough oxygen for humans to live for long. Yet those who summit the mountain have acclimatised to those pressures.
We can find ourselves in a job or completing a task that would have seemed beyond us when we started our careers. We take on responsibilities that may seem crushing.
When we are under enormous stress, it feels like we are out of oxygen.
For the climber, altitude sickness can strike in the death zone. Severe altitude sickness is a medical emergency that requires immediate descent and medical attention. But doing so can be challenging – climbing downhill is harder than trekking uphill.
This is a key consideration in ROPE theory. Helping an individual ‘move down the mountain’ by reducing their responsibilities could be difficult as the individual may fear losing status (altitude). Observing the behaviour of our teams is very important if we are to best help them perform. To understand and enhance mental health, it is essential to bring together aspects of the person and the environment – rather than examining both separately.
The ROPE theory suggests completing the same tasks repeatedly under different conditions can be more difficult when suffering from fatigue, stress or anxiety, and this can lead to a disaster.
Case Study:Stress, anxiety and effective observation
Without support and supervision, even experienced workers are at risk of lapses when their personal and work conditions change.
An experienced operative in a food production firm had been working on a production line, next to her usual line. She had been promoted during the pandemic to a senior operative as her colleagues were shielding. The line was automated, but cleaning and product-changing were done manually. Her shift patterns now accommodated social distancing, including split shifts, and her partner had been unable to work and was not eligible for furlough, leaving her responsible for household income. In addition, her mother had COVID-19 and she was delivering essential supplies to her daily.
The operative worked six days a week, including some night shifts, and was responsible for training colleagues. While she was one of the most experienced team members, she found the new role challenging. She had received relevant training and reviewed the risk management documentation. The organisation considered her one of their best operatives but management failed to check to see how she was. There had been very little dialogue with her manager.
In addition, the organisation’s wellbeing policy was not embedded. The workforce felt lucky to have a job; the organisation's ethos was that the work had to be done and that mental health concerns were a waste of time.
The incident occurred just after 9pm. A junior operative caught their fingers in the belt rollers, sustaining life-changing injuries. Although the experienced operative supervised a product change, she failed to check the replacement of the belt guarding. The shift had been running to plan, with no faults or issues noted. She had changed products several times that week and hundreds if not thousands of times in total.
So why had she failed to follow the most basic of tasks on the line?
Application of ROPE theory
Everyone experienced challenges during the pandemic. However, that evening the operative’s concentration had lapsed. Stress and/or anxiety can affect performance and judgement. Lapses of concentration, panic and lack of confidence can occur.
Some individuals can work without showing that they are struggling, but eventually burnout will occur. The organisation failed to check in with the worker, and did not track and monitor overtime sufficiently.
Check-ins are important as they allow management to ensure the wellbeing of the workforce and that the framework, documentation, signposting, and services and guidance are sufficient. Observations must be more than simple interactions – management should be trained to identify when someone is facing stress and understands the support available. The worker could have been signposted to external agencies to assist with financial matters, childcare support and so on.
This framework, alongside an ethos to ‘look after each other’, is important. It will empower employees to speak up if they or others are struggling. A chat with her manager could have helped and ensured operations were completed safely.
Coming up: In the next issue
In part two, Paul Verrico and Sarah Valentine discuss the vital planning and empowerment components of the ROPE acronym, which hold a safety management system together.
Climber.Org (2022) The yosemite decimal system. (accessed 5 September 2022).
Hunt J, Hillary E. (1953) The ascent of Everest. Hodder & Stoughton: London.
Kaplan JR, Pettersson MK, Manuck SB et al. (1991) Role of sympatho-adrenal medullary activation in the initiation and progression of atherosclerosis Circulation 84(6 Suppl): VI23-32.
Lee AL, Ogle WO, Sapolsky RM. (2002) Stress and depression: possible links to neuron death in the hippocampus. Bipolar disorders 4(2): 117-28.
Krakauer J. (2011) Into thin air: a personal account of the Everest disaster. Pan Books: London.
ECWA. (2007) Michael Eyres v Atkinsons Kitchens and Bedrooms Limited. (accessed 5 September 2022).
Sapolsky RM. (2000) Stress hormones: good and bad. Neurobiology and Disease 7(5): 540-2.
Sapolsky RM (2001) Depression, Antidepressants, and the Shrinking Hippocampus. Proceedings of the National Academy of Sciences of the United States of America 98(22): 12320–2.
Van Dongen HPA, Maislin G, Mullington JM et al. (2003) The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 26(2): 117-26.
Paul Verrico is head of the global EHS team at law firm Eversheds Sutherland. Sarah Valentine is a senior lawyer in that team and an assistant coroner.
Image Credit | Shutterstock | iStock
Free workshop on the ROPE theory
If you would like to attend a workshop (either in person or online) to learn more about how fatigue management, supervision, pre-planning and worker empowerment can be better used in different industries to improve safety performance, please register here.