Construction Failure Causation

Case in Point

One safety manager of a fairly large construction company told me a story that is somewhat representative of many of those situations. Not only did they require their subcontractor to conduct a regular weekly safety meeting with written minutes, copies of which were submitted to the general contractor (GC), but the GC conducted an all-hands safety meeting involving all of the workers on site on a somewhat semiregular basis usually falling at an approximately 2-month, or so, interval. These safety meetings were mandatory, could take about 30 minutes, and were driven by the changes in that state of the work that potentially reflected a change in the risks faced by a substantial segment of the workforce.

In this case, the structural frame had reached the seventh or eighth floor, and they had poured the concrete on the metal decks on the lower floors. The installation of the curtain wall of the building was commencing on the second and third floors. The all-hands safety meeting was scheduled to address the recent changes that required working at the building perimeter with a potential fall exposure as well as things possibly falling off the building and injuring workers moving around below. The all-hands meeting was held to discuss the risks involved and the protective equipment to be used. Possible areas below that would be cordoned off due to possible falling objects as well as the procedures and practices the workers had to follow to avoid potential injury from the "new" activities. They even had a few pages of handouts that were distributed to all the attendees. All of the key points were reviewed at the end of the meeting to ensure everyone had a clear understanding of the risks and protective methods required.

About an hour after the meeting, one of the curtain wall installers went up to the second floor, went outside the protective cables to work on the curtain wall anchors, did not tie off, and fell off the building, sustaining severe injuries. The GC's safety manager bemoaned this by saying how stupid does a worker have to be to fail to tie off when going outside the perimeter protection and then proceed with his work in such a manner that he fell off the building after all of the discussion at the all-hands meeting just an hour or so before.

Missed Opportunities

Was the worker stupid? Maybe. Was he forgetful? Possibly, but then someone at the curtain wall company hired that "stupid" or "careless" worker. A more robust hiring practice could have more than likely avoided that particular problem. Was the worker negligent or ignoring safe work practices? Possibly! That worker worked in a crew that had a foreman overseeing the work. The foreman should have ensured that everyone understood the importance of tying off and also provided greater oversight during the first few days to ensure that workers did not violate safe practices. He should have reinforced the fact that failure to tie off would result in termination. This work was planned by the curtain wall company days in advance of the start of work, and knowing the conditions, they could have selected a crew that was more likely to tie off than not and lightened the foreman's burden of dealing with a noncomplying crew. The GC knew of the potential risk before any construction started and could have asked the steel erector to place the perimeter cable on the out-board side of the columns to possibly address this potential risk. Knowing this risk existed, the GC could have also visited the curtain wall crew during the first few days to ensure that they were following safe work practices.

At that point in time, the curtain wall work had been going on for a little over a week. This worker had been on the job from the start of the curtain wall work. This worker had to have stepped outside the perimeter protection multiple times during these days. In all likelihood, this was not the first and only time he did not tie off. So, the question is: why did the foreman not ensure that every worker tied off each and every time they had to step outside the perimeter protection in performing their work? The foreman could have made it a point to observe this effort carefully multiple times in the first week to ensure that everyone was complying with the "tie-off" requirement to ensure that it was diligently performed. Also, the GC had supervisors walking the site; they could have made a point of ensuring that the curtain wall workers tied off regularly as well.

This GC almost always engages in negotiated work and provides value-engineering services. Should they not have identified this potential exposure and had the structural engineer design the curtain wall imbeds and attachment process in such a way that workers would not be required to work outside of the perimeter cable? And if all this effort could not have eliminated the risks involved with the operation, then why didn't project management staff make sure that the perimeter cable was installed on the out-board side of the columns thereby reducing the distance to the imbeds from the protective cable? This simple action could have significantly reduced the risk involved in the work. If this did not completely eliminate the associated risks, then supervisors could have alerted the workers to the residual risks and provided procedures for executing the work in a safe manner. This concern should have been supervision's primary responsibility—to make sure that the workers carefully followed tie-off procedures—and rigorously enforce this practice.

Finally, why wasn't the GC supervisor paying greater attention to this known risk and making sure the workers clearly understood the risks? The supervisor should also have stressed to the foreman, as well as the workers, that there were procedures in place to deal with the known risk, and workers were required to adhere to them. The workers should have been given to understand that failure to follow protocol would result in severe consequences. On top of that, the supervisor should have spent some time observing the workers to make sure that everyone was adhering to the rules all of the time. This would have made it more unlikely that the workers would not have tied off when they stepped over the perimeter cables and fell off the building.

Yes, there was an element of worker failure, but the supervisor bears some responsibility, as well as the project staff and the organization as a whole, for the adverse outcome in this case. Management, as a group, failed as they bear greater responsibility because they have more opportunity to manage the risks involved, they can and should control the work process, and they have the responsibility to inform the workers of any known risk and provide the necessary education as to the most appropriate ways of dealing with them, as well as conveying safe work practice expectations. They should make sure the workers clearly understand the risks and the consequences if they do not follow project expectation, resulting in appropriate sanctions.

Organizational Weakness

That particular company and many more that I dealt with over the years have an organizational weakness that requires serious attention. This is understood by some of them and how they go about correcting this deficiency is in many cases the wrong approach. Some organizations try to fix symptoms rather than the underlying drivers of the problem. Other organizations try to focus on elements of the safety program to correct the outcome. This too is doomed to fail because it does not address what actually drives the outcome. What is required is a focus on the organizational practices, processes, and procedures so that the safest possible means and methods are selected prior to the start of work.

In construction, management generally bemoans the fact that at times workers do not seem to do what they are supposed to do, sometimes make choices or decisions that lead to adverse outcomes, and more importantly fail to recognize that working safely is a personal responsibility. People on site in management positions must shoulder a good bit of the responsibility and part of the blame as well. Generally, employees want to succeed at work so as to stay employed. It is hard to believe that any rational person will come to work with the intent of getting injured that day. If they have bad habits, their supervisors should pick that up on the first day while observing how they perform. This should lead to some form of intervention. Workers generally fail because of weaknesses in the organization's management system.

Ultimately, this is not a safety problem that needs to be "fixed" by the safety function of the organization. It is an operational as well as an organizational problem. The only way to solve this is to do a robust analysis of all of the systems as well as subsystems and their interfaces to identify the underlying drivers of loss. The question is what is causing the employees to make decisions that lead to discrepancies, incidents, and losses? This will then lead to a re-engineering of the policies, practices, and procedures utilized by employees to accomplish their daily work with most of the risk eliminated or effectively addressed before the work commences.  

Superintendents or foremen are usually responsible for production and quality while the safety practitioner is responsible for dealing with worker safety. This does not make any logical sense whatsoever. If the superintendent plans the work in such a way that there is inherent risk in performing it or selects means and methods that have built-in risks, how is the worker or safety practitioner supposed to somehow magically eliminate it? Herein lies an inherent problem in the way many construction firms are organized. The safety practitioners generally cannot magically remove these risks without impacting the level of productivity. So, such management systems are flawed and are bound to put workers in situations where they may have to choose between production and protection.

Conclusion

Enlightened management does not look at the supervisors as being responsible for production and quality, while the safety practitioner acts as they catch workers violating safety rules. The company requires an enlightened management to set the stage where the CG's staff, as well as the safety practitioner work cooperatively as a team to find the most effective way to finish the work in such a way that is not only the most productive and minimizes waste, but also in the safest way possible. This would seem to be the more logical and productive way to address field operations as a team rather than working at loggerheads.

This will require six critical management systems. (It also assumes that the organization will hire competent, knowledgeable, and capable workers. If that is not practical or possible, then substitute foremen for workers below.)

Clearly articulate plans and goals for the work.

• The vision will have to be in alignment with organizational goals as well as relate to those of the employees to garner participation and buy-in.
• Ensure that goals are achievable and resources are available.
• To some extent, invite employee participation in goal-setting and problem-solving.
• Set measurable goals and objectives so that progress toward goals can be measured and, if needed, improved.

Delegate project's review progress.

• Allow employees to set goals, make plans, and solve problems under the supervision of management.
• Clearly define deliverables.
• Establish key success factors.
• Regularly meet to review progress and deal with issues.

Develop management systems: training, education, and development.

• Provide training and education.
• Coach and counsel as necessary.
• Aid in skill development.

Provide recognition and reward.

• Provide recognition that is timely and that reinforces employee-learning and goal accomplishment.
• Recognize employees for doing what you want them to do.