System creep is something to fear and critical to recognize. The space shuttle Challenger is the classic example of where previous successful launches did not go according to plan. Rather than correct the unanticipated hazards encountered, they were allowed—at the cost of the crew and the shuttle.
The idea of system creep, where one allows a system that became loose to continue unchecked until catastrophe, is now tagged as "the new normal." Anyone doing an investigation should consider the Challenger report as the model to follow.
Over my career, I have run across examples in safety where making changes for the better, for profit, or as technology evolves has increased risk. A quick example will illustrate. It was well over 90 degrees in Pensacola, Florida, at the naval base. We are working in the sun, on a dock, wearing life jackets. Everyone but me (safety manager) was wearing a reflective safety vest under the equally reflective and hot life jacket. When I mentioned they should shed that extra layer of clothing, the response was "We have always done this. We do have a 100 percent vest policy, right?"
From wearing hard hats to installing carpeting to using cut-resistant gloves when painting, more often we worry about the perception (if one guy doesn't wear a hat, everyone else will stop) and not what's best for the worker. At times, safety managers need to be risk managers and fortune-tellers.
Emergency Exits and Retractables
A retractable device allows the user to be protected at height. Like the mechanism on a seat belt, it will lock if you fall or walk too fast. It's not unusual in a fall investigation to hear "I was walking, moved quickly, and the retractable locked up, and I fell." The remedy is often retraining the worker to make allowances for the design. So, we coach them on walking slower and not to make quick movements. That is system creep in construction.
While flying, I often look at the exits to ensure I can get out in a crash. I envision myself throwing open the door and stepping aside to help everyone else out. I would leave last with the pilot. But as I started looking, I noted system creep. An exit that would not be acceptable in a restaurant or church is allowed on an airplane. On some of the larger planes, they do leave plenty of room to flee, but in most domestic planes, no. In fact, seats now are placed so close to emergency exits that the armrest is on the emergency exit door. Functioning tray tables further provide a barrier to exits.
After collecting photos from several plane designs, I called the Federal Aviation Administration (FAA) and spoke with their safety manager. I sent her a note with the photo below showing three large guys sitting in front of an emergency exit with the tray tables down. I asked, "In a crash, where this is my only exit, and these three guys have been knocked out, how do I get out of the door?"
Her answer was to pull them from their seats to clear the exit. I reminded her that the rest of the passengers would be looking to get ME out of the way.
Later, after reviewing the considerable data sent by the FAA and more conversations with the agency, I dropped this battle. They sent me enough data on mock-evacuations to confirm escape times and some great info on how they time escapes with college students. Also, assurances that having these exit configurations had never been a contributor to prompt evacuation in a plane crash. I suspect this was only based on survivor accounts.
Hand Protection—the 100 Percent Glove Policy
As a young farmer, my not wearing gloves would have been folly. From tossing bales of hay to replacing razor-sharp knives on a haybine, we needed that protection. After a while, the gloves would wear through, and we would try a different type. Goat worked best.
Over the last decade or so, the construction industry, in an effort to reduce hand injuries, has focused on gloves rather than work harder on what was cutting our hands. A great example is the edge on the valve cover below. This was razor-sharp and serrated when fabricated. A worker grabbed the cover to twist it into place and off he went to the emergency room.
Of course, the worker was blamed for not paying attention, and the safety managers "fix" was to require cut-resistant gloves for the remaining crew who still had all of their fingers. So, I called the manufacturer and asked if they could just remove that sharp edge. They said yes, in fact, some of their larger contractors required the edge deburred. This was not done routinely though the hazard was recognized. And "no, there was no additional cost." In a perfect safety world, we need to evaluate the risks, remove the hazards, and not just hope to protect the workers.
The National Safety Council estimates that 60 percent of hand injuries could be avoided by wearing gloves. Most construction firms now have a 100 percent cut-resistant or some type of glove policy. This is one of the greatest ideas in a while, and I am confident that these policies have prevented many injuries.
How good are they? Here is a simple test I did comparing gloves. Common exceptions to the glove policies are for doing fine work such as circuit connections or some clean room settings.
A unique but overlooked or unknown hazard of this incredible hand protection is its reluctance to fail. The material is extremely durable, often with Kevlar and steel wool fibers within the fabric. It has a rubberized face and, when coated with nitrile, provides chemical resistance and a great gripping surface. We have one glove in the kitchen for opening jars, and there is no better glove for weeding.
The consequence of these new materials and 100 percent glove policy is that most workers and those managing them do not understand how gloves can hurt.
- Strength of the fabric. Since the material will not easily tear, it may pull your hand into the tool rather than fail. Conventional gloves may rip, but this next generation of glove is made to hold together. In one glove accident I investigated, the finger inside was severely damaged, but the glove was perfectly intact.
- Treated glove faces. The rubberized surface on a cut slip-resistant glove is a heat sink and brutal to wear in the cold. Within seconds, the cold passes right through. I have encountered workers using these gloves in the cold to comply with the policy. Allowances were made to outfit these crews with a Kevlar cloth liner inside warm winter gloves. The workers were needlessly affected by the cold due to a strict policy. The industry is producing a lot of new glove designs for differing materials, hazards, and conditions, so safety managers need to step up and find practical solutions for hand protection, not just hand out the gloves.
- Flexible fabrics. The combination of these fabrics, with their more durable materials, gripping surface, and a tight fit, create a classic Chinese finger trap. If you try to pull off a pair of these gloves, it is immediately obvious. They fit (and stick) like those rubber gloves under your sink.
A worker recently shared a story where his friend was in a metal shop rolling steel sheets. As he fed in a sheet, he was distracted, and the tip of his glove got into the roller. As he tried to pull his hand out, the rubber surface gripped and the fabric tightened. His hand went into the roller wearing 100 percent protection. In a second case recounted to me, a worker was using a conventional bench mounted drill press. He reached to slow down the drill after shutting it off to change bits and rather than slip through his hands as expected (we have all done this), it grabbed his glove and pulled his hand around the shaft.
When a firm has a 100 percent glove policy, it must be clear to those doing the wearing when it is appropriate to wear them and when it's not. Clear communication is critical, prohibiting the use of any gloves under a few conditions. This allowance is a best practice and, often, the law.
- State of California—"(b) Hand protection such as gloves, shall not be worn where there is danger of the hand protection being entangled in moving machinery or materials."
- Department of Energy—"Important do not use gloves when operating rotating equipment such as a lathe, drill, or drill press."
- Tool manufacturing—"Danger do not wear gloves when you use (sic) operate the equipment."
- Occupational Safety and Health Administration—"Instruct employees not to wear gloves, jewelry, or loose-fitting clothing while operating a drill press and to secure long hair in a net or cap."
- Army—all workers feeding brush into chippers shall wear eye protection. Loose clothing, gauntlet-type gloves, rings, and watches shall not be worn by workers feeding the chipper.
In our shop, we have a drill press, and the user warning is on the side, well out of sight. Rather than hope operators can find these warnings, we reproduced the warning label and posted it over the machine—after explaining to the users why.
Summary
System creep may not be obvious to those within the system, and system users get comfortable with hazards for many reasons. Often, it is because they have not been harmed by the condition or event.
When a mandatory policy is in place for a while, examine it. If injuries are still occurring to hands, look at what's doing the damage, not why the team isn't wearing gloves. Some steel studs for walls in the building trades are now being produced with the razor-sharp edge rolled-over to eliminate the hazard.
And it's time to stop protecting the worker. The primary focus on personal protective equipment (PPE) over the decades has allowed unsafe conditions or materials to remain on worksites hurting our sons and daughters. As technology evolves, let's focus on opportunities to relieve the burden of PPE on some good people and remove hazards rather than manage them.
If you see something that seems unsafe, it typically is. There may be a justification by others to allow the condition to exist, but it's still unsafe. Listen for "We have been doing it this way for years" or "That's how we do it here." Recognizing the signals, understanding the risk, and adapting and making provisions for your safety is why we remain at the top of the food chain.
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