Monday is the start of NYC’s annual Department of Buildings (DOB) Construction Safety Week. This year’s theme is Build Safe / Live Safe. After last year’s great safety numbers – construction-related accidents and injuries declined for the second consecutive year; there were 18% fewer accidents and almost 8% fewer injuries. This decrease came as construction permits rose nearly 8% citywide. This theme had rung of a bright future for construction safety in 2012.
”]But as I write this post, another family of a NY construction worker is mourning a lost loved one. Earlier this month, one worker was killed and four others were injured when a boom crane collapsed at the No. 7 Subway extension project. This latest loss in on top of the bridge worker who fell and the demolition worker killed and two others injured in a building collapse in upper Manhattan both happening in March. This is not a great start for this year’s construction safety stats. This year’s three fatalities happened in the first four months compared to the five deaths in all of 2011.
Is there a pattern to this year’s fatalities and injuries? At first glance, I don’t think so. The three fatalities are from different trades and different construction phases. But could there be? I am a firm believer that when you allow someone to do something incorrectly by not correcting them, you have given them formal permission to do the same thing again in the future
Those of you who know me and others of you who have read by blog posts may have the idea that I am very passionate about safety. I really feel that it is unnecessary for anyone to die or be injured in a work related accident. Just one accident is a sign that at least two different things went wrong – either events or decisions.
What I am about to say is not backed up with statistics but is based on years of anecdotal experience. In all the years that I have been working – as a first line worker, first line supervisor, manager and safety professional – I believe that for every accident that resulted in an injury there have been at least two actions or decisions made led to the accident.
Many accident investigations appear to stop once they find the first “cause” of an accident. That first cause is usually a poor safety behavior or unsafe act by the injured person or another first line worker. Once this first cause is found, many people often fail to look behind it for additional causes. But there are usually (I really want to say always but…) additional causes.
It is unfair to the injured worker and other workers to stop at the first cause. The reason we do accident investigations is to discover the true root cause of accidents and to try to prevent them from happening again. If you stop at the first cause and fail to find the real root cause, the accident will happen again. Sometimes you have to be like that famous TV detective Lt. Columbo who kept on asking “I got just one more question.”
It is often painful to find the real root cause. You sometimes have to ask the same questions of people that you already interviewed. Sometimes you need to listen and understand attitudes and not just actions. Sometimes the real root cause is an attitude or decision made by someone not directly involved in the operation.
”]In the fatal crane collapse, the preliminary investigation by the NYC DOB is indicating that there may have been problems with the crane’s hoist system (see ENRNew York Construction report). This crane was not reported under load when it failed. DOB Commissioner Robert LiMandri urged all contractors operating cranes on any job site to perform daily and monthly checks to ensure their equipment is safe to use. The DOB engineers are focusing on the defects but are they the problem. Should the defects have been uncovered during an inspection? If the defects were uncovered, what would have been the corrective action?
Are the inspections the problem? The DOB commissioner alluded to it in his statement on April 5th. The accidents underscore the need for thorough crane inspections as required by the manufacturer and by regulation. Inspection of any piece of equipment is important in preventing injuries. There are many different kinds of inspections performed by different individuals and all of them are important. But equally important, if not more important, is the actions that are taken once the inspection is complete and defects or issues are found.
There is another newspaper report that focuses on the crane operator in the latest fatal crane accident. This crane operator was reportedly involved in two previous accidents that resulted in injuries. In at least one of those accidents, a safety system was bypassed and the crane operator operated the crane anyway. When the operator was deposed and asked about his decision he replied “I should have looked into it further maybe, but I assumed that it was all right to run it that way. That’s how the other guys were running it.” But why was the safety system bypassed? What were the operators told to do in lieu of the bypassed safety system? Who made these decisions?
Many historical disasters are the result of poor decisions. The loss of the RMS Titanic that lead to many people dying was a result of a series of poor attitudes and poor decisions – from the design of the watertight bulkheads, to the decision not to have enough lifeboats for all passengers, from the decision to operate a high speed in the reported weather conditions. The Triangle Shirtwaist Factory Fire, the Chernobyl accident, the Exxon Valdez disaster, the Challenger disaster, the Deepwater Horizon disaster all involved an accident that was exacerbated by questionable attitudes and decisions. Trial lawyers loved these kinds of cases because these are the cases where they can “prove” something else could have been, and should have been, done.
A good friend of mine named Bill has a great story about accidents, attitudes and poor decisions. At one time Bill was the manager of a nuclear plant. Every day, he visited the control room before going to his office. Bill did not like to see alarms on the alarm board. One day, Bill saw a high level alarm in the low level radioactive waste tank. He questioned the operators about the alarm and was told not to worry because there was a high-high level alarm and they really couldn’t do anything until the plant was taken down for refueling. For the longest time, Bill questioned the operators every day about the alarm. Finally, the operators called the controls supervisor and had the alarm point reset so Bill would not see the alarm light any more.
Well that worked because Bill stopped asking about the alarm and later went on an extended family vacation. While, he was on vacation, the water in the tank spilled out of overflow pipe but there was no high-high alarm that came up. It seems that the high-high alarm was set at a point higher than the overflow pipe. Thankfully no one was injured.
Bill told me that the lesson to be learned from this “accident” was that where safety or any safety system is involved, you cannot ask too many questions. It is a lesson we can all learn. He said he learned to be “aggressively suspicious” when anything involved a safety system or matter of safety. Never take the first answer at face value, probe behind it and keep on asking questions like Columbo until you are sure there is no danger.