In a very real and practical way, safety begins and ends with hazards. A hazard is a source of danger. Successfully keep everyone from being harmed by the hazards, they’ll all go home, alive and well at the end of the day. Fail and you will find a hazard was responsible for causing the harm.
All rather obvious, I know.
What might not be quite so obvious is the inescapable truth that everything on the planet is perfectly capable of becoming a hazard. Like that cup of coffee you’re drinking as you read this month’s edition of the News. You need not take my word for it: the one I’m drinking at this very moment came with a warning label: “Caution. The beverage you are about to enjoy is extremely hot.”
It better be: I do not like my coffee lukewarm.
Understanding this points out a significant flaw in the logic underpinning hazard recognition programs, systems, processes and procedures: all are well-designed to recognize a select few hazards. They have to. But leaving out all other hazards does not mean they cannot be present.
Serving as an illustration of this point are two hazards responsible for producing serious harm to two followers of mine, back in the day when I was responsible for a small army of maintenance team members in a big chemical plant: an elbow on a scaffold handrail and a door jamb.
A forty-something year old machinist apprentice stuck his hand in a door jamb at exactly the same time as a gust of wind blew the door shut. The damage to his hand was roughly the same as slamming a car door on your fingers.
Worse was the elbow: it fell ten feet and the scaffold builder standing below took a direct hit to the jaw. What caused the part to fall down? Gravity. What caused it to go up? It was thrown: the guy who was supposed to catch it didn’t, and then it went straight back down. If this were baseball, it would be scored an error.
Figuring out how things like these happen is easy: it’s like running an experiment in a high school physics class. The problem is that everyone wants to also know why things like these happen. Otherwise known as the root cause. Quarter of a century later, I’m still scratching my head as to why these two would deliberately put themselves in harm’s way the way they did.
The answer may be stunningly obvious to you: common practice, culture, management system failure. In a hurry, frustration with the task. Poor supervision, lack of supervision. Normalization of deviation. In a roughly analogous situation, the case was made that the root cause was the failure to recognize the hazard in the first place. That’s why there is now a warning label on every coffee cup sold by Starbucks.
What I can tell you with certainty about my two cases is this: in the opinion of the machinist apprentice, the reason was seniority. More precisely, his lack thereof. If he hadn’t been an apprentice, he would not have been the last crew member in line going into the building through the doorway. That was when the wind decided to knock over the piece of wood propping the door open, slamming it shut on his fingers, which he just happened to have positioned in the door jamb.
As for the scaffold builder, in his view he was doing management a favor by throwing the parts. It was an overtime call out job, done in the wee small hours of the morning; he knew for sure just how important it was to get the scaffold built fast. Carrying all those parts up the stairs would have taken a lot longer.
I suppose that reason would be called “production over safety.” For some reason, I didn’t buy it.
One thing to be said on behalf of hazards is that they are always real. That fact allows most hazards to be recognizable by the senses. A hazard can be visible to the eye: a skill saw, for example. Or the nose: the odorant added to natural gas to make it readily detectable. Carbon monoxide may be odorless and colorless, but exposure at low levels will make you feel sick to the stomach. There are hazards like the COVID virus that are too small to detect by the naked eye, making it necessary to assume its presence.
At the other end of the spectrum, some hazards would seem too big to miss. Consider a locomotive for a freight train, barreling down the tracks at 62 miles an hour, horn blasting as it approaches a rail crossing, where a crossing gate is closing, bells are sounding, and lights are flashing. How many warning flags announce the presence of that hazard?
A lot. But not enough to guarantee that everyone always stays out of harm’s way.
A decade ago, a commercial truck driver pulling a flatbed trailer on which twenty-four people were seated on folding chairs drove his rig through a rail crossing in exactly that set of circumstances. It happened during a parade in Midland Texas. The train struck the trailer. The force of the collision caused the trailer to demolish the police escort vehicle waiting on the far side of the tracks. That only four people perished seems almost as improbable as the event itself.
As you would expect, an accident of this magnitude was investigated by the experts: the National Transportation Safety Board, the independent and unbiased experts who do this sort of thing for a living, trained to focus on the facts and evidence in an objective and scientific way, unperturbed by emotions and excuses.
In other words, “Let the axe of truth strike the tree of reality, and let the chips fall where they may.” You can find the axe and the tree on the internet by searching “Highway-Railroad Grade Crossing Collision Midland, Texas November 15, 2012.” Good luck finding the chips on the ground.
Yes, the NTSB did the relatively easy part, figuring out how – the science of the tragedy – well: nothing wrong with the operation of the locomotive, the train tracks, the rail crossing gate, the lights, the bells, the truck, the trailer, or the commercial driver of the rig. All functioned as designed. Well, except for the driving.
So, why did a professional truck driver drive his truck and flatbed straight through a rail crossing with lights flashing, bells sounding, crossing gate closing – and a high-speed freight train approaching?
Peering Inside The Human Mind
Hazards exist in the real world, but recognizing them takes place in the five and a half-inch space between the ears. If you really want to know why someone would fail to recognize a hazard, you have to go there. Problem is, you can’t.
You can only ask. The truck driver told the investigators he saw the train, but didn’t think it was moving. He didn’t hear the horn because of all the other noise from the parade. Yes, he did see the flashing lights; a lot of flashing lights the whole time. He explained his focus was on the side view mirrors, checking on his passengers as he drove over the tracks. It was bumpy and they were sitting in folding chairs.
Besides, there was a police escort for the parade.
You now know what the Board knew. If you were investigating that tragedy, what would you conclude as to why?
One Board investigator attached to the final report what he called a “concurring statement.” In it, he wrote that commercial drivers “are expected to be safer drivers; they are held to a higher standard regardless of the driving environment.” Moreover, “… it bears emphasizing: the responsibility for safely operating a motor vehicle first and foremost, rests with the driver.”
Sounds reasonable, and roughly what I said to my two followers after they were hurt, albeit without the benefit of the wisdom and experience an independent and professional investigator would have. “Look, guys: nobody has a greater interest in your safety than you. First and foremost, you have to pay attention to what can get you hurt – so you don’t.”
The NTSB would have done well to have written that, and declared case closed. But no, they felt compelled to answer the why question: to decide exactly what took place in the five and a half-inch space between the driver’s ears.
Impossible, you say? Correct. That did not stop the NTSB foolishly rushing in to stake out what they called the “probable cause.”
In the Board’s opinion, this was the City’s fault. Some clerk at City Hall authorized a route that crossed a rail line without identifying and mitigating the risk.
So, a crossing gate, bells and whistles and lights, isn’t enough to alert a professional truck driver to be on the lookout for a train?
Worse, in the Board’s view, providing a police escort created what they called “an expectancy of safety.” A newspaper reporter called that “a safety bubble.” No need for the driver to have to think a thing about driving safely. That was the job of the police and the permit issuer.
Putting Axe To Tree
Time to let the chips fall where they may. Investigating safety incidents is serious business. Facts always need to be put to the test: do they add up? So do conclusions: do they hold up?
These do not. My theory is that’s what prompted one board member to write what he did about the professional responsibilities of the driver. He probably saw where this was headed. But that’s just my hypothesis. Better to ask him and see what he has to say….and if it holds up.
At best, an “expectancy of safety” is a hypothesis. Personally, I can think of a far more useful theory about human behavior that would better explain this tragic failure to recognize a hazard.