“I had to watch this poor kid’s head get crushed”

Common procedure for a workplace fatality: Blame the worker. Then blame the guy who warned that the workplace was dangerous. And fire him.

Problem resolved. Case closed. Move along.

This seems to be the practice of Goodwill Industries in Sacramento that was fined over $106,000 after Abraham Nicholas Garza’s head was crushed in a trash compactor, according to the Sacramento Bee. CalOSHA issued a willful and several serious citations against Goodwill, finding that the company had not developed operating procedures, had not installed machine guards, had not installed controls to ensure the equipment could not be activated if an employee is in a position to be endangered, and not trained employees or corrected unsafe conditions as required by CalOSHA’s Injury and Illness Program standard.

Garza was 26 years old and the father of a 7-year-old child.

Garza was working with another Goodwill employee, David Goudie.  Containers were filled with items that Goodwill couldn’t sell, then compacted and taken to another location several times a day. Gould and Garza were working to align a container in the compactor. Garza stuck his head inside the compactor just as the driver release a cable holding the bin, crushing his head.

Goudie had previously warned the company in writing about a variety of dangerous conditions related to the company’s failure to train employees who were operating the compactor.

Goudie, a commercial driver, said he had an “intuitive sense of urgency” weeks before Garza’s death. He said he began complaining verbally in August about unsafe conditions and risks to untrained employees. On Aug. 25, five weeks before the accident, he put his fears in writing, giving his memo first to his immediate boss on Franklin Boulevard, then forwarding it a short time later to the corporate safety officer at headquarters, he said. He titled his memo “Employee Workplace Safety Hazard Notification.” At the time of Garza’s death, he had been working for Goodwill for about six months and was on the waste management team.

“Based on my personal observations, most employees now operating compactors at each plant have not received the required training,” he wrote in the Aug. 25 memo. “This exposes Goodwill Industries to fines in the tens of thousands of dollars from Cal-OSHA and, should an employee become injured or killed as a result of this lack of training, civil damages could climb into the millions.

“All of that massive liability exposure is completely UNNECESSARY if the required training is made mandatory by company leadership and reporting supervisors are held accountable for failures to do so.”

The state’s proposed penalties total $106,675. The most severe citation, which came with a $70,000 fine, was deemed to be “willful-serious” – meaning the employer was aware of a hazardous condition and did not take reasonable steps to address it. In California, a citation categorized as “willful” exposes an employer to possible criminal prosecution.

“None of the authorized employees including (Garza) were provided training in the safe operation of the compactors at the front and back loading dock areas,” Cal-OSHA concluded in its report.

The Cal-OSHA report also said the charity failed to correct “unsafe or unhealthy conditions,” left dangerous moving parts of machinery unguarded, and had no written procedures for the safe operation of the compactor and mobile collection equipment.

The Sacramento Bee notes, however, the company is doing quite well despite these problems:

Aside from the fine, the company seems rather upset about its image. “Goodwill does a lot in this community,” she said. “We grieve, obviously, over the employee’s death. The additional tragedy is that this is a diversion of community funds. I hope it can be resolved without the fines.”

Perhaps the headline should have read “Employee dies, causing tragic diversion of community funds”

Blame the Worker OR Prevent the Next Death

A little background here. It is often management’s first impulse to blame the worker any time someone gets hurt.  (Or in this case, to blame the employee working with him.) And often, a very superficial investigation will find that a worker had done something “wrong” or in violation of the rules. But if you stop there, you won’t identify the root cause of the incident and won’t prevent the next incident.

The fact is that human beings inevitably make errors. In fact, errors should be expected. But rather than focusing on the workers who make the errors, effective accident analysis – analysis that actually wants to get to the root causes and effective solutions — looks for the conditions that made the errors possible.  Root cause investigations can be complex, but getting to the deeper causes of an incident can also be as easy as asking “Why” over and over until you get to the root causes.

Why did an employee stick his head into a compactor?  Because he was dumb or disobedient? Or because he didn’t know any better because he wasn’t trained? Why wasn’t he trained? Were others not trained, or was he an exception?  Were there written procedures? If so, why weren’t being followed? If not, why not? Were there physical guards or controls that would have prevented the equipment from activating? If so, why weren’t they engaged? If not, why not?

The problem is, if the root cause is lack of training or lack of safe procedures or faulty equipment, then it doesn’t do any good to punish the worker who did something wrong (assuming he is still alive.) Because the next untrained worker, or the next worker who has not procedure to follow will do the same thing. Worker blamed, but problem not solved.

In addition to not learning the lessons that can prevent the next injury, punishing workers for getting hurt, or for reporting unsafe conditions creates a chilling effect on other workers who may have identified unsafe conditions.  Again, this does not lead to a workplace where problems are identified before workers get hurt.

OSHA’s best practices recommend that employers adopt a health and safety program that will prevent injuries and illnesses by implementing the following elements: management leadership; worker participation; hazard identification and assessment; hazard prevention and control; education and training; program evaluation and improvement; and communication and coordination for host employers, contractors and staffing agencies.