Two maintenance employees were assigned a simple task: clean the outside wall at a housing complex. On site, they encountered an unplanned problem: access to an area that needed to be cleaned. That part of the wall was between the first and second stories of the building.
Solution: a scaffold or a basket lift. Take your pick; either would be perfect; neither was immediately available. Nor was the superintendent or the safety inspector for the project.
Given the circumstances, what would you expect a couple of hard working people to do? Come up with an alternative. Far better than waiting around for the boss to show up and solve the problem for them. There was a forklift on site, with an operator. There was a big crate there, as well. Alternative solution: mount the box on forklift. Voila, a basketlift.
Problem solved.
Later, when the safety inspector showed up at the site, he immediately recognized that solution didn’t meet applicable safety standards. When the Construction Superintendent finally arrived, he noted this wasn’t the first time he’d seen these two do exactly the same thing. They’d been told before this was not an acceptable solution.
So, the problem wasn’t really solved, at least not well.
What caused two busy leaders like a safety inspector and superintendent to show up on a mundane clean up job? A phone call from emergency responders. They were summoned to the scene after the box the two were working in had been hoisted up, flipped over, pitching both out.
One of the two survived the ten foot fall.
Work Done Here
Drive through any city or town, anywhere in the world, you are guaranteed to see work done here. Work being done by hard working people, who take safety seriously. Nobody wants to go home hurt. That delivery truck you just passed has a driver. His job is more than just driving: delivery includes offloading the goods and carting them into the building.
Down the street, someone is flagging traffic: a road construction crew is tearing up the street. You drive by a building under construction: there’s a queue of concrete ready mix trucks, waiting their turn. If you had the time to find a parking space, get out and take a picture, you’d see another construction crew, pouring the foundation for the transformation of a building in the historic district.
Everywhere you look, there’s work being done. And people working around things that can hurt them. AKA, hazards.
Nobody who works is immune from working around hazards. They come with the paycheck. Stop by Starbucks for a latte or grab a burger from the local fast food franchise, you’ll find both: people and hazards. The only thing different are the people and the particular hazards they are exposed to.
No matter the person and the hazard: when you’re hurt, you’re hurting. At that point, it makes no difference what caused the pain.
It’s one of the simple truths about hazards.
Improvised Work Methods
If you wanted to see work done at a mill, mine, plant or factory, keep on driving. While there are still a few places where the only thing separating the plant from homes, schools, and businesses is a fence, nowadays, most big industrial operations sit outside city limits.
There you might be lucky enough for someone to give you the plant tour – after you complete the visitor safety orientation. Out in the plant, think you’ll see improvised tools and work methods, something akin to working in a crate hoisted by a forklift?
Of course not. Practices like that have long since been engineered out of existence. Four decades ago, one of the biggest names in the manufacturing quality improvement movement, Phil Crosby, held the view that the job of a manufacturing manager was to mold the operation into ballet – not hockey.
In most well-run industrial operations, that’s exactly what it looks like. When it comes to managing safety performance, don’t be fooled by appearances. Yes, production work may look like ballet, but conveyor lines, production equipment, machinery and robots aren’t the ones subject to getting hurt. If you want to see improvisation, you need to look at the support work required to produce that ballet. That work – starting with maintenance – falls to humans.
The nature of repair work is such that it will always be more like hockey than ballet. It’s non-routine; one of a kind; no two jobs ever quite the same. Every time one of those kinds of tasks are performed, there’s some degree of improvisation required. Improvisation can be the stuff of genius. Consider Apollo 13, and what it took for Houston to solve that problem.
On the other hand, one of the precipitating events of the regulations governing process safety was the improvised solution to the need for additional storage capacity for a hazardous chemical product in short supply. An out of service reactor seemed like the perfect solution. At least until the product started heating up, with nowhere to go but out the pressure relief valve, and into the adjoining neighborhood.
Looking back on that event with the benefit of four decades of hindsight, this improvised solution wasn’t all that much different than putting a crate on a forklift to create a basket lift. Instead of being critical of either event – or any event like these – you need to be mindful of the simple fact that the very essence of improvised is “makeshift, done on the fly, spontaneous, impromptu.”
As a practical matter, improvisation means the probability of a problem is relatively high. And that is something that needs to be taken very seriously.
Connecting The Dots
The world of work is chock full of hazards. As to exactly what those hazards are, it depends on the nature and location of the work being done: construction versus food service; operations versus maintenance; on a busy street versus down in a mine. For each situation, there is a long list of ways and means to get hurt.
You could make up that list up, and hand it to the people doing the work. A better thing to hand the people doing the work would be a way for them to prioritize that long list: what hazards should they pay the most attention to?
And, for that matter, what hazards should you, as the leader, pay the most attention to?
The tragic story at the top the news provides a very useful clue as to one answer: improvised tools and work methods. That’s where the odds of that specific hazard are a lot higher.
Improvised tools and work methods are one example of a class of hazards that deserve special attention. It’s as if an improvised tool or method should be accompanied by a huge warning sign: Danger: Someone working here may very well get hurt!
Read that warning, and heed that warning, those involved will proceed with caution – if they proceed at all.
If those two workers (or, for that matter, the forklift operator) had seen that improvised method as a warning sign, that crate might never have been lifted off the ground.
If that construction superintendent had seen that crate as a warning sign, he might have intervened in a way that would have left those two workers convinced they wouldn’t want to be caught dead doing that.
Paul Balmert
September 2019
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