|
|
Injury timeline
August 13, 2008 By: Carl R. Metzgar, CSP Pit & QuarryIn 1931 an unsupported, misguided idea was published in Heinrich’s “Industrial Accident Prevention.” Management has been enamored of it ever since. In a contrived exchange, Heinrich has an insurance manager say, “These causes of accidents, as I said before, represent man failure. I propose to put the responsibility for their elimination squarely up to my superintendents and through them to the individual foremen, who in the final analysis are paid to handle men [page 5, remember this was 1931].” Note the vice president of manufacturing should have said it, not the insurance manager.
Then on page 143, Heinrich states, “From this study of 75,000 cases it was determined that dangerous machines and other faulty mechanical conditions could properly be charged with only 10 percent of all accidents and that 88 percent were due to moral or supervisory factors [moral was not defined].”
No less a safety guru, Dan Petersen reported, “that was his [Heinrich’s] first axiom and was something that he just made up. There was no research behind it.” The idea that 80 percent of injuries are caused by unsafe acts and 20 percent by unsafe conditions evolved from Heinrich’s uninformed, hackneyed pontification. But management clings to this debunked notion because it relieves it of responsibility, and blame can be attached to the worker.
Going forward
Consider an injury timeline. Three hundred million years ago coal beds were formed. In the process kettle bottoms were formed. A kettle bottom is a smooth, somewhat conical piece of rock that can drop out of the roof of a mine without warning. The origin of this feature is thought to be the remains of a tree stump that has been replaced by sediments – so that the original shape has been preserved with the potential to cause a 21st century death from a 300-million-year-old cause.
A 2008 newspaper headline said, “Civil War cannonball kills Virginia relic collector.” Even closer, the Belgian army has a special unit whose job is to find and disarm World War I unexploded ordinance. Tourists and farmers are still being killed by old, unexploded shells. Old hazards are killing new people.
Going backward
If only the last few seconds or minute before the damaging energy exchange in an injury are analyzed, the worker can comfortably be blamed. “Last-minute” investigation demonstrates that the worker had the last clear chanceto avoid the incident, and therefore it was all his/her fault.
The investigation report should answer the question, “What happened or failed to happen 15 minutes before the damaging energy exchange?” That might uncover wrong or incomplete instructions from a supervisor, an incorrect setup or undue, overemphasized haste. Next there should be a question, “What happened or failed to happen 30 minutes before the energy exchange?” That might show that the area manager projected an uninformed request for something that required more consideration and more detailed preparation.
“What happened or failed to happen four hours before the energy exchange?” This could involve decision making by a vice president. Considering what happened or failed to happen six months before the incident might very well involve action or failed action by a division president. What happened or failed to happen a year before the incident will probably involve budget preparation, reviews and board of directors’ decisions.
Rest assured, no report prepared by a supervisor or loss-control specialist is going to report that the president or members of the board of directors failed in their responsibilities. The miner might very well have had the last clear chance to avoid the damaging energy exchange. But it was multiple failures long before the incident that left him/her unprepared for thelast clear chance.
Please send any technical comments or questions to our webmaster.