Earlier this week, I wrote a piece critical of an article about worker fatigue that seemed to put the blame on workers for being tired on the job, despite the fact that most of the causes of worker fatigue are imposed by management.
Today I continue on my quest to make enemies of every magazine columnist, attorney and health and safety consultant I run across as we look at a Workforce article on “Do You Know What to do When an Employee Dies on the Job?” by Jon Hyman, a partner at Meyers, Roman, Friedberg & Lewis in Cleveland. Workforce describes itself as “a multimedia publication that covers the intersection of people management and business strategy. Our content helps HR professionals approach their jobs from a more strategic, big-picture, business-results perspective.”
If you own or manage a business with hazardous operations, you might interested in this topic. First, it starts off on a shaky foundation:
It’s news an employer never wants to deliver.
“I’m sorry, but your spouse (or partner, child, or other family member) had an accident at work and unfortunately passed away.”
But it happens. In fact, according to OSHA it’s happened 357 times already this year.
A couple of things there. First, the number of times this has happened to employers this year is probably ten times the 357 incidents cited above. Last year, over 4800 workers were killed in the workplace. Hyman’s number comes from OSHA’s Fatality-Catastrophe reports which are a) not up to date and b) only cover those fatalities that OSHA investigates. There are many workplace fatalities that OSHA does not investigate (e.g. public employees in many states, transportation-related incidents, small farms, etc.)
Hyman’s list of nine things to do when one of your workers is killed in the workplace isn’t bad; it’s just incomplete. The article suggests calling 911, then the worker’s emergency contact person. Contact OSHA. Talk to other employees and your HR Department. Figure out who the company’s contact person will be and what you’re going to say to the press. Or hire a P.R. firm to help you.
“Show extreme sensitivity to the family of the deceased.” That’s a good one. And advice that the President could learn from. And get grief counseling for the other employees. Also a good one.
What bothers me is that this is where the advice ends. What’s missing? (Pausing here a moment to let you think about it…………………)
What’s Missing
OK, time’s up. What’s missing here is suggestion Number Ten: “Investigate the root causes of the incident and implement measures to keep the incident from happening again.”
Because the only thing worse than having to call someone’s spouse or parent about the death of their loved one is having to do it twice…or three times.
And that’s what could happen unless management identifies what caused the fatality and implements measure to prevent it from happening again.
So, what to do?
Assign someone on your staff who is knowledgeable about safety and incident investigations to determine the root causes of the incident. (Or better yet, hire an independent consultant who will assign an investigator whose career is not dependent on providing a favorable report to management.) If your investigator comes quickly back with a conclusion that the cause of the incident was “Worker Error,” start over again. (Or, as I said above, hire a real expert…)
Almost no legitimate incident investigation should end with “worker error.” Worker error may be a factor, but that should be the beginning of the process, not the end.
The way to get to the root causes of an incident is to keep asking “why?” Why did the worker stick his head into a machine that wasn’t locked out? Why did the worker close a valve when it should have been opened? Why did the worker step in front of a moving vehicle?
Do you have a lockout-tagout problem? Why? Lack of training? Why is there no training or why is training inadequate? Poor procedures? Are procedures confusing? Why? Are procedures outdated? Why?
Why did the worker step in front of a backing vehicle? Lack of backup alarm? Or just a lot of ambient noise, dust, heat? Fatigue after a long day? Lack of backup camera in the backing vehicle? Failure to demarcate travel lanes?
Keep asking why until you get to a point where nothing can be done to address the cause.
The problem with stopping with “worker error” or stopping before you’ve asked “why?” enough times is that if you don’t get to the root cause, the problem is likely to happen again. And you’ll be making that same tragic phone call once again.
As Andrew Hopkins, Emeritus Professor of Sociology at the Australian National University in Canberra, writes in “Lessons from Longford,”
Human beings inevitably make errors and errors by operators must be expected. Thus, rather than focusing on the operators who make the errors, modern accident analysis looks for the conditions which made the errors possible. It is nearly always the case that there was a whole series of contributory factors which created an operator error and set up the situation which made the error critical. Accident analyses which aim to prevent a recurrence see to identify these factors.”
In other words, worker errors are not the causes of incidents, but the inevitable result of other conditions.
Conclusion
If Mr. Hyman and Workforce really want to help “HR professionals approach their jobs from a more strategic, big-picture, business-results perspective” — and more specifically guide them through the difficult process of dealing with a worker’s death — they should focus on why that death occurred and how to prevent similar incidents from happening in the future.
And finally, stop using the word “accident” in these situations. An accident is an event “that happens unexpectedly and unintentionally” or “that happens by chance.” Most workplace fatalities occur as a result of unsafe workplace conditions. Where you have unsafe conditions, an injury or fatality is predictable, or even likely. These aren’t accidents; they’re incidents. They aren’t “unexpected” and don’t “happen by chance.”
Next thing you will hear from Mr. Hyman was that he was addressing the HR staff. Incident investigation and prevent is the safety department’s job and I don’t want to tell them what to do.
The only problem I have ever had with root cause analysis (political) is trying to explain what it does (without over promising) and knowing that ultimate cause is going come back to some business decision that resulted in a cascading series of events leading to the incident. Sometimes those business decisions are unforced errors but mostly they are a function of the business model, a function of the specific project environment (low budget, behind schedule, client over promised) or a function of the background, prejudices and fears that were brought into the workplace at all levels. Some of these are tough to fix. Don’t worry about pissing off the Philistines…comes with the territory.
You’ll get no argument from me, I’ve included the critical root cause analysis step and avoiding a “blame the victim” mentality whenever I train in effective incident investigations.
A couple of comments. Having tracked every workplace death in MA since 1987, I have thought a great deal about what actually happens to the workers who witness these incidents. I have seen employers who tell their workers just to keep on working and others who are devasted by the loss of long time employees. As far as I can tell, the law is silent on surviving worker rights in these cases. Do they have to keep on working? Are they paid if sent home? What about critical incident debriefing? . I have seen co workers of victims hospitalized for mental health problems and others who’ve experienced heart attacks following fatal incidents. So in addition to root cause analysis to prevent future deaths, which is absolutely essential, employers also need to take care of the surviving employees and their responsibility to do so needs to be made clear. …