4 min read
A few years ago I interviewed a worker (we’ll call her Sally) about her near-death experience at a government facility in Western KY. On a bright Saturday morning, Sally went to work at her usual trailer. About mid-morning she collected some files she needed to take to another location and placed them in a small box. Carrying this box in front of her, she decided to exit out of the back door to the trailer rather than through the front where she had entered.
When she opened the door and stepped outside, the box in her hands prevented her from seeing that there was no step there, and she fell to the ground (see the picture). The steps had been removed the previous day by a work crew that was assigned to replace those steps, and they had stopped for the weekend leaving the job only half complete. Sally vividly recalled the horrible feeling of falling face-first into a void and being knocked unconscious when she hit the ground. Workers found her laying unconscious on the ground and bleeding from a cut in the back of her head. And it could have been much worse: Sally was a diminutive person and fell cleanly though the left side of the wood frame (shown in the picture ), which was lined with exposed nails. Blows to the back of the head are very serious, but rather than calling the site Emergency Response Team and sending her to a hospital right away, the persons that found her delayed getting her to a hospital by over an hour while figuring out which hospital accepted her insurance, and while they located her husband to come and pick her up. At the hospital, they also found she had two broken ribs.
At a government site in Eastern TN, I was asked to investigate how a non-qualified electrician cut into a live wire using non-insulated wire cutters. He was part of a crew doing the demolition on a building that was to be refurbished, which called for removing power to all of the electrical connections in the area they were clearing out. However, a safe electrical work boundary was not properly established and there were numerous live electrical wires still running through the conduit. When the worker went to cut one of those wires, he was exposed to a 20 amp, 208 volt current. The arc from the live wire melted the tips of the snips and shocked the worker, who was taken to the hospital.
What is significant about the two examples above is that the root causes for the events could have been identified sooner had the organizations taken a more proactive approach to trend and analyze their “precursor” events (i.e. minor events). What I routinely find when I investigate Industrial Safety events, is that the organizations are largely in a reactive mode.
These and even more serious industrial safety accidents and incidents are taking place every day at construction sites and in places where workers are exposed to high energy sources or dangerous conditions such as hazardous chemicals, working at heights, working in confined spaces, working with radioactive sources, working with nuclear weapons and other explosives, etc.
In the United States, industries where workers may be exposed to dangerous conditions are required to have Industrial Safety Programs, especially if they fall under the jurisdiction of the Occupational Safety and Health Administration (OSHA), a large regulatory agency of the United States Department of Labor. These Industrial Safety Programs are designed to gather information from safety incidents and take corrective actions to prevent recurrence. Where I see these efforts fall short is in their inability to proactively identify and eliminate the latent weaknesses causing these events.
Safety Programs typically include a set of defenses to prevent workplace accidents; administrative requirements and physical barriers such as personal protective equipment (PPE). Robust programs are successful in preventing serious injuries due to the strength of their defenses. But even sites with robust Safety Programs may also be experiencing a stream of low-level incidents (i.e. precursor events) that are indicative of latent weaknesses in those defenses. History tells us that, unless we find and eliminate those latent weaknesses, it is only a matter of time when a unique set of circumstances line up in a way that bypasses all of our defenses and we end up with a more significant injury or even a fatality.
To identify and eliminate latent weaknesses requires insightful data; data that can be trended and analyzed. A qualitative analysis of the Industrial Safety Programs at many of the sites I have visited reveals that most are lacking a methodology that quickly and efficiently investigates even the most minor of Industrial Safety incidents, to the degree necessary, in order to generate the meaningful data that can be trended and analyzed. A typical approach for investigating low-level events includes interviewing the persons involved, a check to see what procedures were violated, and determining what PPE was not properly used. And unfortunately, in many cases, determining who to blame.
Shifting Industrial Safety and other corrective action programs to a more proactive approach is one of the primary goals of BlueDragon Hyper-Integrated Causal Analysis (HCA).
We can enhance our Industrial Safety Programs by improving the early identification of negative performance trends and proactively launching investigations to identify and eliminate their root causes (before a perfect set of circumstances bypasses all existing defenses and results in a major incident).
One of the main benefits of the HCA methodology is that it is scalable and can be used to thoroughly investigate minor Safety incidents in two to three hours. These are called HCA Rapid Investigations and the results provide more accurate and meaningful data that will dramatically improve the quality of existing trending and analysis programs. Once a negative trend is identified, we can proactively launch a HCA Comprehensive Investigation (which covers apparent cause evaluations and root cause analysis) to identify and eliminate the latent weaknesses that we inherently know are there. Trending and analysis can also identify trends that are indicative of programmatic weaknesses. For those, we can also use the methodology to conduct HCA Proactive Program Reviews.
As far as Sally and the construction worker, their injuries were not permanent and both returned to work after proper treatment. And their collaboration in the subsequent investigations were invaluable in preventing future events.
To learn more about how to dramatically improve the effectiveness of your Safety Program investigations, visit us at: https://bluedragon1-ips.com/
