Construction Killing Conditions

System Creep

When looking at contributors that allow killing conditions on your project, you don't need to look far. Over the years, all safety systems will creep from what is right to what is allowed. This was recognized as a contributor to the Challenger disaster. Although there were incidents (foam routinely striking the orbiter), the launches went okay until they didn't. That anomaly was accepted—foam strikes on the shuttle continued, and that became the new normal. System creep.

Recently, I was traveling down the New York State Thruway, and a crew was clearing trees and brush from along the edge of the highway. Some of the trees were only about 20 feet from the travel lanes, while the original fence line was 40 feet from the edge of the road. Over the years, a tree likely grew on the traveling side of the fence, so they mowed around that one, then another grew next to it. They mowed around that one, and the forest crept closer to the lanes. Before long, the trees were too hazardous and too close to the cars. That system needed to be reset by cutting the trees back. That is a good example of system creep. In construction, that is easily recognized as a messy site.

A second contributor is a hazard that is unrecognized or does not cause an incident until late in the game. At that point, it is discounted, or, when the hazard kills, it is considered a rare occurrence. Consider this dated but great example from California. The bottom line exemplifies our tendency to study rather than accept the obvious.

1997-12-22 04:00:00 PDT SAN FRANCISCO—A 2-year-old girl stumbled while walking on the Golden Gate Bridge with her family yesterday, plunging through a narrow gap 167 feet to her death on the ground below.

The girl, identified as Gauri Govil of Fremont, fell through a 9 1/2-inch space between the sidewalk and the traffic lanes. The gap runs along a metal barrier that separates the sidewalk from the roadway, and is barely visible to pedestrians.

Although more than 1,200 people have jumped to their deaths from the world-famous span since it opened in 1937, bridge officials last night could not recall a similar accident. "This has not been viewed as a risk for children to fall through," said Mervin Giacomini, chief engineer for the Golden Gate Bridge Highway and Transportation District.

"We will certainly be looking at that space in a new perspective. If there is a potential for accident, we will take whatever action is necessary."

"Geez, TJ, if you drink too much water, that will kill you. Where do you draw the line?" Safety professionals often hear such chatter, for we are often an obstacle and barrier to the good people who build our buildings. Our role is typically unseen. In most cases, our success is measured when nothing happens. In the book, The Black Swan: The Impact of the Highly Improbable, Nassim Nicholas Taleb helps explain the frustrations of why workers can get killed on a safe site (randomness) and provides a compelling observation on those who avoid wars and hazards—and why they get the short end of the stick.

It is the same logic we saw earlier with the value of what we do not know; everybody knows that you need more prevention than treatment, but few reward acts of prevention. We glorify those who left their names in history books at the expense of those contributors about whom our books are silent. We humans are not just a superficial race (this may be curable to some extent); we are a very unfair one.

The tendency to overlook or soften our views of a hazard during inspections is ours (the inspector's) alone. Everyone sets his or her limit of hazard tolerance based on what one knows, experienced, and fears. I do the same, and so do you.

Be Honest and Nice during Inspections

When having a correcting conversation as you inspect, try using real examples, be blunt, and be honest. Speak as you would to your son or daughter. Consider this scenario. You are approaching a crew rigging precast panels and need to tell the foreman to stop the pick, suspecting a poor strap. That requires some finesse—but do not let them make that pick. Here is how you might do this.

Just checking on rigging today. How many panels do you need to set? Well, no need to shut this down, guys, but let's take a quick look … make sure you can keep this going smoothly.

You have identified both the hazard and the value of the inspection (keep production going), and you included the entire team in the learning ("let's"). Plus, you never asked them to stop. But they will, for you have answered their question of "What's in this for me?"

Highlight Killing Conditions

As you tour a work site, you will see conditions that have killed in the past—from cords missing a ground to scaffolds without rails. Finding these conditions is relatively easy, but getting the user to understand the threat is the challenge. Another example: You are inspecting a work site and see some scaffold similar to that shown in Figure 1.

Figure 1: Shoddy Scaffolding

Can these conditions kill? Certainly. The material is good but the erection shoddy. One can see the chance to fall from the scaffold (no rails) but also the potential for someone to step on the Styrofoam on the top levels thinking there are planks underneath.

First, keep in mind that, although many competent persons are appointed, they may not be as competent as needed. Just the right person in the right place at the right time can result in disaster. The disaster is not his or her fault but is evidence of system creep. You can focus on what you see, but the goal is to avoid those killing conditions.

So, take the time to tie in some real-life examples as you discuss the need for some additional training. Let the workers on the planks know that you just read of a student slipping off some scaffolding, falling head first into an open barrel, where he died. Focus on "What are the odds?" This confirms to the user that this is indeed a killing condition. By doing so, the workers will understand how their work could kill someone. Bringing the news clipping along proves you care.

Seeing Is Believing

During a recent inspection, I noted an ironworker whose leg straps on his harness were extremely loose. As we watched him set a piece of steel and come back down in the scissor lift, I asked the crew who had gathered, "Did you guys ever see what happens to a guy when he falls, and his leg straps are loose?" No one knew the damage that habit could do to men only. I later brought back a photo of what had actually happened to someone else and left it with them. When we went by later in the day, each and every leg strap was tight. Teach by example.

Encountering a Killing Condition

When you spot a killing condition, your first role as an inspector is to immediately protect it. That may require standing in the same spot for a few hours until the threat is gone, but never leave a killing condition without addressing it. If the power cord is bad, find the owner and take it out of service. If the scaffold is unsafe, get the people off, and find the person in charge. Regardless of the pushback later, if what you see could kill someone, and you continue on—shame on you!

In the photo shown in Figure 2, some borings had been augured for goal posts. When these were discovered unprotected at the ends of the playing field, there was no immediate threat—except to me. But the field was also in a nice neighborhood surrounded by nice kids. These holes had been left open for 2 days. So, I called the foreman over and stood by this particular boring until he gathered a crew and a machine and brought over some nice pipes that looked a lot like the goal posts. They were rigged and loosely placed in the hole, thus eliminating the killing condition. That threat had existed for 48 hours and was corrected in 30 minutes. The safety program clearly stated that no holes could be advanced until covers were staged and ready. Not done. System creep.

Figure 2: Open Boring

As the corrections were being made, the foreman started the "What are the odds?" conversation, so I recounted what happened to Joe in Southern California, detailing how the late Joe could only take one breath as he fell into the boring and probably died holding his breath, for he could not exhale. That's paints a picture. From that point on, the foreman and I had an understanding that lasted.

It is critical that safety professionals recognize and react, but it's just as important that they move from telling people to providing a lesson and simple examples of similar conditions that actually killed someone.

Tirelessly Praise Elimination

The safety professional recognizes it is important to praise any progress or achievement no matter how small. Should you recognize that a crew has taken on the elimination of a hazard or brought one to your attention, make a big deal of that. Spotting a killing condition that has not killed—that is everyone's gift.

Take the time to capture a photo of the worker who spotted a hazard. Write up a lesson learned or the best practice that resulted and post it for everyone to see. Recognition of what is done right and done well trumps discipline every time.

A Resource

My friends describe me as a storyteller, and that is accurate, for I have the ability to remember incidents and details that bolster most of my arguments with the "what are the odds" folks. When I read the article detailing how they found Joe Alamillo stuck in a hole, I filed that away. Joe was a father who did not just pass away—he was killed. That was not an accident but the result of system creep.

One of the best resources to find examples of killing conditions is a summary of incidents compiled by a Bryan Haywood. Bryan is one of the top safety professionals in the county and my "go-to" guy for questions on confined spaces, as that's his expertise. Bryan publishes a roster of recent industrial, construction, and other accidents you can access from www.safteng.net. These are quick summaries and links to real cases where killing conditions were encountered. Though not everyone died from the condition, that was just luck. Tie one of these examples to what you see in field and share these as near misses. Find a crew in a 6-foot trench "just for a few minutes"? Here are some examples from that website, which are provided at no cost every week or so:

Construction

EXCAVATOR on BARGE FATALITY Delta barge worker dies in accident (a construction worker, 49, was killed after a piece of equipment he was working on fell into the delta - he was operating an excavator from a barge around 1 p.m. when the machinery fell into the water - he was trapped inside the submerged excavator and was pronounced dead at the scene)

WORKZONE FATALITY Construction worker killed on Selmon Expressway (a construction worker died after he was hit by a dump truck - he was working in a construction area of the expressway at about 4:44 a.m. when he was struck - he was taken to a hospital, where he later died)

TRUCK FATALITY Construction Worker Killed In Nevada (a man was killed at a construction site - he was run over by a water truck and pronounced dead at the scene)

SCAFFOLDING COLLAPSE 3 workers injured in BGC construction site accident (a structure that was supposed to ensure safety at a construction site instead sent three workers to the hospital - a heavy meshwork of steel and wire designed to protect pedestrians from falling debris gave way at the hotel worksite around 1:30 p.m. - three men suffered injuries mostly on their arms and legs and were brought to a nearby Medical Center - four other workers were then under the structure but were able to run away as it gradually fell to the ground)

TRENCH FATALITY Man killed when trench collapses (workers were working in a six-foot trench and installing an electrical conduit when a wall on the trench collapsed and buried a worker, 35, - by the time he was uncovered by emergency personnel, he had passed away due to the injuries sustained in the collapse)

SCAFFOLDING COLLAPSE Two men taken to hospital after scaffolding accident in Northampton (two men were taken to hospital after scaffolding collapsed - the men were both at the top of the scaffolding and fell from a height of up to 15 metres - one patient, a 55-year old man, sustained serious chest injuries as well as a potential head injury - the second patient, 42, sustained injuries to his lower back)

Conclusion

As safety professionals, we have the ability and opportunity to help reset system creep and guide those allowing that creep. Often, we can help those in charge recognize that creep. Like the trees growing too close the highway, it can be corrected. Work with the crews so they understand that the same hazard you are looking at killed someone before, and then provide what happened as a lesson. The goal is to make someone so uncomfortable with an obvious hazard that he or she is forever compelled to correct it.

A safety professional's success will be measured when those you have taught come back and show off what they have done. That is a system being reset.