Beyond Devil’s Dust: How an “If only…” Event Cascade can result in fiascos like the Ascot Park Primary School asbestos exposure disaster?

Recklessly exposing children to asbestos, or any other toxic substance, is never an “incident”; it is always a disaster!Anyone who believes that that is a gross exaggeration should read the lethal health problems caused by exposure to asbestos that are mentioned later in this blog. WE usually associate disasters with large numbers of people, so please; try to calculate the number of “secondary exposure victims” that resulted from the Ascot Park event and don;t be surprised when you find that the numbers involved are in in the hundreds!

Whether large or small, man-made disasters such as what happened at Ascot Park all share a common characteristic; there is a series of seemingly unrelated events and decisions that collectively lead to inevitable disaster. This process is commonly known as an ‘Event Cascade’ When seen with the benefit of hindsight, these Event Cascades can often be easily identified and then something else also becomes apparent;, any changes in the event cascade could have prevented the disaster. In the case of Ascot Park, the event cascade may have included literally hundreds of decisions and events such as those listed below. This ‘snapshot list’ raises the critical question of just how many schools in South Australia were compromised over a period of almost 2 decades?

 ‘The Events Cascade – the ticking time bombs in South Australia’s schools.’

  1. DECS’s rising $50.000 a day shortfall in funding to address school health, safety and maintenance problems.
  2. A manifest unwillingness on the part of the government of the day to willingly reveal the scale of this problem and to deal with it openly.
  3. In 1992, Peter Lewis (Economic & Finance Committee chairperson) identified a $230 Million OHS&W and maintenance shortfall in funding but never properly followed up and fully investigated the potential real-world consequences of this $230 Million shortfall.
  4. School principals and safety rep’s who relied upon unsubstantiated departmental opinions instead of exercising their Duty of Care by asking for the empirical facts and then using their professional judgement to act in the best interests of their students and staff. 
  5. School communities that failed to acknowledge the potentially lethal risks to children because they were just “too hard to get your head around.” 
  6. The public servants who saw this financial crisis as an opportunity to help the government out whilst advancing their own careers.
  7. The DLI safety inspectors who could only report the problems in schools but could not prosecute DECS and/or SACON bureaucrats for identified violations of OHS&W laws because they were not allowed to do so!
  8. The grossly unprofessional attitude of the teachers’ union leadership who chose to put pay rises for teachers ahead of classroom safety.
  9. The numerous reports in The Advertiser, the Sunday Mail and the broadcast media that looked at the “What” of glaring safety issues in South Australian schools but ignored the “Why” and the chilling downstream “When” implications for school students exposed to hazardous chemicals that have well known, adverse long-term biological consequence.
  10. There is even my own 1993 decision not to use my videotape of the rigging of the safety tests at Cleve Area School and to instead ‘cut and run’ after a 6-year battle rather than see people prosecuted.
  11. Time and time again, the Events Cascade  reveals that the in-loco-parentis responsibility to ‘Care for Kids’ was tossed overboard, and eventually it was inevitable that student safety would eventually be compromised in one or more DECS schools.
  12. Eventually, inevitably, the day came when more than one person who should have known better decided that it was okay put children and asbestos in the same environment at the same time!

Change any one of these events in the Event Cascade and it is highly probable that no child at Ascot Park Primary school would have been exposed to asbestos. The problem is that none of the events were changed and the reality is that almost 10 years ago children were literally placed in body contact with asbestos dust and now a biological time bomb clock is ticking away. Any review of what happened at Ascot Park can be directly compared with what happened at the  same in 3 primary schools in New South Wales in the same week that the Ascot Park fiasco occurred:

  1. Asbestos was found under a school classroom and so a decision was made to evacuate the school and move the children to a nearby primary school until the asbestos could be safely removed.
  2. However, a check of that school led to the discovery of yet more asbestos and so this school was also closed and the children from both schools were temporarily accommodated at a nearby high school.
  3. A Catholic primary school was also found to have asbestos contamination and was closed whilst the hazardous material was removed.

 DECS WAY v NSW AND THE UK WAYS OF HANDLING ASBESTOS IN SCHOOLS.

Compare the way in which the Departments of Education & Children’s Services, (DECS), in South Australia handled the Ascot Park Primary School problem. If I have the facts wrong, I am sure that someone who was present on the day will provide us with the correct details, but what is generally known is as follows.

  1. Removal had begun during the school holiday break but was incomplete when the holidays ended. Instead of sending the students 400 metres down the road to the Marion High School, or even extending the students holiday break until the job was finished, the school re-opened whilst the asbestos was being removed.
  2. It was a grossly reckless decision and the inevitable, easily foreseen happened! According to media reports at the time, 2 students apparently went into a building where asbestos was present and part of the ceiling collapsed, covering them in asbestos contaminated dust . Upon rushing out of the building, other students and school staff rushed to the aid of the frightened, dust covered students and brushed the dust off them.
  3. The 2 students being covered in the asbestos contaminated dust was the initial contamination vector whilst the secondary contamination occurred when others brushed the dust of the 2 children. These secondary contaminated students and staff then spread the contamination into the classrooms, staffroom and administration areas.
  4. Upon leaving the school students and staff spread the contamination even further by taking it home.
  5. With a high school just 5 minutes walking distance away, why didn’t DECS officials do what their NSW counter-parts did and just send the children there until the asbestos was removed? Where they unable to think of such a short-term solution or were they thinking that to so would be a waste of time because the high school was also contaminated?
  6. You have to wonder don’t you? You also have to wonder if you or your children have been exposed in your local school.

SECONDARY CONTAMINATION FATALITIES.

Fatalities caused by secondary level contamination of toxic substances such as asbestos are not uncommon. Anyone who watched part 2 of the documentary drama Devil’s Dust will be aware of the death of the wife of one of the James Hardie executives. She died from Pleural Mesothelioma, apparently caused by washing her husband’s asbestos contaminated clothes. DECS officials tried to play down the Ascot Park disaster as being only a ‘minor incident’ involving a very small amount of asbestos. However, as anyone who watched the ABC’s 7.30 Report interview with Karen  Banton on  November 12th  (2012) will be aware, just drilling a few holes in a bathroom wall to fit a towel rail could easily provide enough asbestos dust to result in a potentially lethal exposure.

 Asbestos has a ZERO Threshold Limiting Value.

There is no such thing as a safe minimum exposure limit and yet DECS officials played Russian Roulette with the lives of students and staff, and by extension, their families, by allowing the Ascot Park Primary School to be open when asbestos was being removed. By 2003, DECS and SACON had a decades long track record of failing to act appropriately to address safety issues in schools.

  1. Part of the significance of the “secret minutes of the meeting that never officially happened” that I posted in the previous blog is who was present.
  2. Department of Labour & Industry safety inspectors probably would have loved to have prosecuted DECS and SACON officials but were unable to so without the Minister’s permission and that was never going to happen because the government was desperately stalling for time to sweep the problems under the carpet.
  3. When you are above and beyond the Law, it tends to breed contempt for the law and such contempt can lead to reckless decisions. Why were students present when asbestos was being removed? Was it because the DECS administrators believed that would not be held accountable for such recklessness?

 I don’t have details of the NSW incidents that occurred in 2003 but the following  BBC report on asbestos found in a school in Wales highlights the difference between the DECS approach to asbestos in schools and that of their peers in Wales: http://www.bbc.co.uk/news/uk-wales-south-east-wales-19962569

 Extract from the BBC report:

The roads leading up to Cwmcarn High School are eerily quiet and empty. Just when the air should be filled with the sounds of children in the playground there is only the hum of traffic from the A465 passing by. At lunchtime, pavements would normally be filled with teenagers in a uniform of red, white and black, milling about, many off to the nearby village to buy snacks from stores and food outlets. But there is only one to be seen: Nadia Yamamoto, 15, out riding her horse, Layla.  “My concern now is will her lungs be filled with asbestos in 40 years’ time” (said) Sally Yamamoto, Mother of Nadia.

 It was not a normal school day for Nadia. But neither was it for the other 900 pupils as their school closed suddenly without warning last Friday after asbestos was discovered following a structural investigation. Pupils and parents have been left mystified and wondering what will happen next. On Monday night, older pupils began receiving a link to homework on Twitter but that has not been helpful to all. “I don’t have a Twitter account,” said Nadia. “I will have to set one up when I get home. Nadia’s mother, Sally, wants all the children to be checked for asbestos. “My concern now is will her lungs be filled with asbestos in 40 years’ time,” she said. The closure of the school has had a significant impact on Cwmcarn and other nearby communities where pupils live.

Okay, this happened in Wales in Great Britain, but asbestos is an environmental health hazard that is not limited by national boundaries and a number of the issues raises in the BBC report parallel the asbestos issues in South Australia and elsewhere. The lethal effects of asbestos may not show up for 40 years and therefore there is the need for expensive long-term monitoring of those exposed to toxic substances with the implied medical and compensation costs.

“significant impact” upon the local community:

At Cleve, some staff opposed my actions, expressing fears that some parents might send their children elsewhere, i.e. to private schools in Adelaide, and that would mean job losses or staff transfers.

  1. In short, the concern was not about the safety of students but the economic impact upon the local community and the inconvenience of teachers being given forced transferred due to declining enrollments.
  2. The current staff and school council at Ascot Park Primary School may not appreciate this blog and its potential impact on the school, but the issue is the welfare of the students, staff and families who were needlessly exposed to asbestos, not the “significant impact” school’s reputation.

 SAFETY FIRST? No, it wasn’t a case of “Safety first” because safety simply wasn’t on the agenda, just Self-Interest.

 DEVIL’S DUST – Have YOU may ever been exposed!

NHMRC QUOTE “…exposure is widespread.”

It is highly possible that you have been exposed and are totally unaware of this due to the secrecy surrounding the role played by schools in exposing children to asbestos. You should therefore read the following information carefully, especially if you are a smoker!

The following health problems caused by asbestos, as outlined in the following National  Health and Medical Research Council article  spells out quite clearly what is really at stake for any South Australian student, teacher, support staff or parent who has ever been exposed to asbestos in South Australian schools. (Article source: http://www.nhmrc.gov.au/your-health/asbestos-related-diseases )

ASBESTOS RELATED DISEASES: Embedded asbestos fibres irritate the lung tissue around them, causing a number of diseases:

(A)  Pleural disease

Inflammation and irritation of the outer lining of the lung, the pleura. The pleura stiffens and thickens widely (diffuse thickening) or in patches (plaques), and can fill with fluid. This thickening can restrict breathing.

(B)   Asbestosis

This is scarring of the lungs: the airways become so inflamed and scarred that oxygen is no longer able to pass from the lungs into the blood. The lungs become stiff and inelastic, making breathing progressively difficult. Symptoms include tightness in the chest, dry cough, and in the later stages, a bluish tinge to the skin caused by lack of oxygen. Asbestosis is usually seen in former asbestos miners, asbestos manufacturing workers and insulation workers, and usually takes a decade or more to develop.

(C)   Lung cancer

Exposure to asbestos fibres greatly increases a person’s risk of developing lung cancer, particularly if they are also a smoker.

(D)  Mesothelioma

Mesothelioma is a cancer of the pleura. It typically grows quickly and spreads widely before symptoms appear, making its early diagnosis and effective treatment very difficult. The average survival time after diagnosis is only 6-18 months. A very small exposure to asbestos can be enough to trigger the cancer, however only a small percentage of people exposed to asbestos develop mesothelioma. There may be a lag of 20 to 40 years after asbestos exposure before mesothelioma results. [5][19][20]

(E)   Other risk factors

Two further factors that increase the health risks from asbestos are:

  • The typical lag of 20 to 40 years between exposure and the onset of symptoms of disease. This can make detection, prevention and risk management for asbestos related health risk very difficult. It is estimated that the peak of the epidemic of asbestos-related disease in Australia will not occur until the 2020s.  [4][5]
  • The extremely widespread use of asbestos in construction in Australia last century means that exposure to it is also widespread. The weathering and aging of asbestos-containing materials and renovation of buildings containing asbestos products may continue to release asbestos fragments for many years.  [4]

Who is at risk of asbestos-induced cancers?

Those who are particularly at risk of asbestos-induced cancers, as noted by the Asbestos Diseases Society of Australia Inc,are people exposed to the loose fibres of asbestos in mining, manufacturing, building and construction or at work, school or in the home; as well as those exposed through asbestos removal, and the consequences of uncontrolled, unsafe removal.

(INSERT) MY TRANSLATION of what you have just read:

  1. Just about anyone who has been exposed to asbestos at anytime in their life is at risk of facing an agonizing death. NASTY; very nasty indeed!
  2. No one knows precisely how many people have been exposed, or the most probable consequences for each individual as a result of that exposure.

 Mortality from asbestos related diseases

Australia and the UK have the highest rates of asbestos-related death in the world. [7] This is understood to be because of the amount of asbestos used in these countries, and the relatively high proportion used of the most dangerous types, blue and brown. It is estimated there have already been at least 4,700 deaths from mesothelioma in Australia since records began in the early 1980s [8], and more than 25,000 Australians will die from it over the next 40 years. [8]

Currently, each year 500 men and 100 women develop mesothelioma in Australia, and this is expected to rise to 900 new cases a year by 2020. [8]

60,000 VICTIMS   “This thing is so huge; you just can’t get your head around it. And so people ignore it instead. But we need to make them look, even if they don’t like what they see!” (Bernie Banton).

With an estimated 20,000 victims in South Australia by 2030, in November 2005, Nick Xenophon (now a senator) described South Australia  as “The asbestos victims capital of the world.”  Clearly the NHMRC figure of 25,000 over the next 40 years is probably way too low but the statement Mesothelioma is a cancer… It typically grows quickly and spreads widely before symptoms appear… early diagnosis and effective treatment very difficult” is a chilling reminder why children should NEVER ever have been allowed anywhere near an asbestos removal site!

In “Devil’s Dust” the claim was made that from diagnosis to death the average time frame is just 153 days.

Once the clinical signs are detected, death comes quickly for many sufferers of this disease. The only chance, slim at best, is constant medical checking to pick up the disease in its very early formative stage. For that to happen, people need to know that they have been exposed and perhaps equally importantly, the medical system needs to be geared up to provide the appropriate testing regimes needed to catch this disease in its most formative stage. Mesothelioma is not something that either the victims or the national community can ignore. As a nation, we have to get our heads around the health problems  caused by asbestos and put in place appropriate support measures.

GET RID OF THE SECRECY:

Across the nation there is a growing awareness of the extent to which schools are STILL contaminated, but the political problem that poses is a massive barrier to effectively dealing with the victims of asbestos exposure because of  the secrecy surrounding the extent to which school children have been exposed to asbestos.

  1. The “secret minutes of the meeting that never officially happened” may involve South Australian schools and South Australian bureaucrats, but given what we now know about the extent of asbestos contamination in Queensland and NSW schools, does anyone doubt that such minutes exist in bureaucrats files in every state?
  2. In South Australia, the methodology of deceit was Stall, Stall, Stall so as to buy TIME; time to shut down and bulldoze the really bad schools and time to then sell of the land and bury official records deep in the massive labyrinth of the state archives at Netley.

HUMANE COMPASSION.

You need to “get your head around it” and make sure that your state or territory government treats asbestos victims in a similar manner that the victims another man made humanitarian disaster, The Stolen Generation, are now asking to be treated, i.e. with humane compassion.

  1. We also need to force politicians, (some of whom are former members of the legal profession who apparently profited from asbestos victims claims by just doing their jobs! Ideally, the tort lawyers should be excluded by introducing a ‘no-fault’ compensation system funded by (appropriately) taxation of shareholder dividends.
  2. Freed of the enormous stresses and strains of complex legal actions and the mind bogglingly huge legal costs, asbestos sufferers may have a far better quality of life, which  in turn may result in a longer life.

IMMUNITY TO CATCH THE FIELD MARSHALS OF MASS MURDER.

  1. The one area where lawyers do have a legitimate job to do, is going after those ‘Field Marshals’ who were ultimately responsible for the asbestos epidemic. If that means drafting legislation that grants immunity to low ranking offenders (as per the South African apartheid hearing example), in order to bring the Field Marshals of Mass Murder to justice, then it should be done.
  2. Every person in the nation has aright to know just how many people have been exposed to asbestos, because the chilling reality may well be that the realistic death toll by 2030 could be rising towards 600,000+ and not the currently estimate of 60,000 mentioned in Devil’s Dust which may be far too low because we do not know how many people have been exposed due to the wall of secrecy surrounding contamination problems.

 SO, ARE YOU A ‘DEAD MAN’ WALKING?

You really do need to “get your head around it” when it comes to asbestos because you too may be a dead man walking and do not know it. As I pointed out in the last blog, at Elizabeth in South Australia, James Hardie’s management built an asbestos manufacturing plant just half a mile (880 metres) west of a  regional shopping centre and residential area where thousands of people lived. How far afield was the airborne asbestos blown on the wind and how many people will eventually die as a result of this factory being located in such a dangerous location?

 Good advice from a very wise old man: The apostle St Paul wrote, “Test everything and only keep what is good.”(1st Thessalonians 5:21)

  1. The starting point is to question EVERYTHING I have written.
  2. Then question whatever you may have been told about safe your school was/is.
  3. Killer classrooms can kill and have killed in so many ways so NEVER assume that the school that you send your child(ren) to is safe.
  4. At Streaky Bay Area School, 5-year-old children sat on an Organo-Chlorine pesticide soaked carpet in the school library while listening to children’s stories.
  5. At Port Pirie, a student died after being electrocuted – an electric stove had been earthed to the drinking fountain.
  6. CHECK IT OUT with your own eyes and don’t accept glib opinions masquerading as facts from school authorities or government experts who, by self-definition, are NOT impartial experts because they are paid by the government and represent the government!


Ronald Medlicott (Christian advocate of welfare justice.)

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