In workplaces around the world, days are diverse but most typically follow common paths that are absent of injury. Yet sadly, when focus is cloudy or misplaced, these days can deviate from rote (and safe) routine and move into a place where no one wants to go.
I went to the hospital today to see Sandy. Sandy‘s family was there. It was a tough visit. I wished
I had answers to their questions about how could this have happened. It‘s not like I wanted it to happen or planned it. Could anyone really have predicted so many things coming together at the same time and place to lead to this outcome? Sandy‘s leg is shattered; I hope they don‘t have to amputate.Whataflukeevent.
Let me tell you a bit about Sandy. Sandy is, rather was, a foreman‘s dream. Twenty years on the job, one of those employees you could always count on, always on time, first in and last out. I could give Sandy the toughest assignments and Sandy never complained, not once. Sure, Sandy had some injuries and close calls, and you had to be on Sandy about following the rules, but neverbecauseofthewrongmotivation.
This was a non-routine job where we needed to lift a piece of steel deck plate to the second level.
It‘s not something we do all the time. I had a new employee who didn‘t have much experience rigging this type of load, but he was certified. We did find out during the investigation that the sling was bad and shouldn‘t have been in use. Maybe a more experienced rigger would have
caught it, but if we had rigged the load properly I don‘t think the sling would have been an issue.
We haven‘t had a serious injury at this site for 28 months and my department had gone over 4 years. In fact, we‘re known within our company as one of the best in safety and have lots of awards to prove it. Our medical case rate is less than .75 per 200,000 hours worked and has been for quite a while. With that kind of safety record this event should not have happened.
Every single employee at this site has the right to pause work if they believe there is a risk present. That morning in the safety briefing I told the crew how important it was that we get this steel plate lifted into place so we could finish up the work on the compressor below it. I really thought we could beat the schedule. The operations department needed the compressor back up and running to get the plant started. I never would have thought it would lead to Sandy entering into the work area before we completed the lift. Several people had to have seen Sandy enter the restricted area, but no one invoked the pause work policy. Work pauses hardly, if ever, happen anyway, but in this instance you would have thought someone would have stepped up.
We put up a warning sign and told people in the safety briefing we were making the lift our first item of the day. Sandy should have seen the sign and known not to enter. Now I wish we would have put up the barricades, but we told everyone during the job safety briefing what was going on. This kind of lift takes less than an hour, so the barricades seemed excessive.
The story about Sandy is fictional, yet in reading it one can see the many instances where potential became reality. Consider this partial list of factors that were present:
A non-routine rigging job being performed by an inexperienced rigger Production pressure levied to get the compressor online
A foreman who “thought” the crew could beat the schedule Judgment that installing barricades was not needed
A bad sling and a system that allowed its continued use A pause work policy that no one felt compelled to invoke
An employee who had to be repeatedly reminded to follow the rules
Each of the factors above represents potential. Leadership in this organization likely doesn‘t consider potential at all, much less evaluate it on an ongoing basis. As a result, this organization operates with an incomplete and insufficient understanding of their true level of risk, evidenced by their surprise and lack of answers regarding the event‘s causal factors. This fosters leadership that can easily drift into denial and dismiss such occurrences as “a fluke” that “could never happen again”.
There are five mistakes that leaders make that can cause them to ignore or overlook significant potential:
1. Judging an incident‘s potential by the severity of the injury
2. Assuming that lagging indicators show the total potential that exists organization wide
3. Believing that all injuries and exposures have the same potential to be serious or fatal
4. Devoting a disproportionate amount of resources to relatively low value-added injury investigations and not applying adequate resources to high potential near miss events
5. Implementing systems that reinforce focus on measuring outcome instead of potential