Ken Arnold
TAll too often, when investigating security incidents, we focus on the immediate cause and not the “root cause”. They are not the same. The US Occupational Safety and Health Administration defines a root cause as a fundamental, underlying, system-related reason why an incident occurred that identifies one or more correctable system errors. Finding that cause involves asking hard questions, such as why a
the crew did not see the potential hazard, or there was inadequate training and discussion of the risk by the crew. We also need to ask if the crew was tired or in a hurry, and if so, why? When we ask these questions, we often find that they lead to a discussion about the company or workplace safety culture.
The National Construction Academy defines a safety culture as “a system of beliefs, practices, and attitudes shared by all employees in an organization that shapes behavior and drives the way all work is done.” It is created with a formal safety management system, which addresses key processes and procedures, and a safety climate that defines the mindset and behavior of employees.
Here is an example. This is a fatal crane accident that occurred because a crane support was too close to a 70° slope and the crane fell when it turned. The OSHA inspector cited the contractor for failing to ensure that ground conditions were firm, drained and graded to adequately support the crane. But was this the main cause? Why didn’t the crew see the danger? Was there inadequate training? Did the crew prepare for lift by discussing the risks? The crew members were in a hurry, and why?
There is another incident that illustrates my point. It meant the reform of the facilities of an old offshore oil production platform. On the project, a welder made an arc to create a new tank nozzle, but connected tanks that had been emptied but not degassed. The result was an explosion that killed three people.
When the employer was fined for not following welding safety procedures, the CEO said, “What do you want? I hired people with experience. They all attended OSHA’s mandatory safety courses. I hired a consultant to write a series of safe work practices. I had a construction manager in charge with 20 years of experience. Do I have to personally monitor all workers to make sure they don’t violate safety practices?’
The CEO replaced the construction manager and thought he had removed the bad apple and the project would be safe. What he didn’t do was ask the follow-up questions to understand why the crew acted the way they did, and the answers he would have received would have been enlightening. Workers were in a hurry to finish the job because the job was over-budget, and they knew the CEO didn’t like these jobs because they might limit future job opportunities.
Further investigation revealed other relevant findings. All workers signed a job security review, the same review they had been using for the past month for many different tasks. The operations manager also signed a mandatory document called a “permit to work” that called for the area to be inspected to ensure that potential gas sources were properly isolated, but no one did the inspection.
In addition, a fire warden with a gas detector was assigned to check key points of the task as required by the company’s “safe work” practices. But the detector was not working and the same fire warden was assigned to oversee the work being carried out simultaneously in three widely separated geographical areas.
meIn summary, the safety climate at work was: “We have to follow procedures, but we know what we’re doing, and those procedures only hinder our ability to do the job. The boss wants us to hurry up and get it done.
Is it a surprise to anyone that in some construction projects we let this “macho” attitude prevail? The CEO never realized that his actions were a major factor in the cause of three deaths and that he failed in his job to establish and maintain an appropriate safety culture.
Unfortunately, there are still many more leaders in our industry who believe that safety begins and ends with OSHA compliance and training, have never been exposed to the concepts of a safety culture, and do not know how to develop and maintain one. the bear.
