Saturday, September 1, 2012

“Best Practices”? Or Safety Run Amuck.


Occasionally I am asked by attorneys to serve as an expert witness on lawsuits involving workplace injuries and fatalities. One of the most fascinating cases I worked on involved an office worker suing her employer for gross negligence because a maintenance man operating a scissor-lift ran over her foot as she exited her cubicle. Now why, you may wonder, would a scissor-lift be traveling down an aisle way in the office? The short answer is, the company was following the “best practice” for changing a light bulb. Perhaps I should back up several years to explain how this accident came to be. But be warned, while reading this story you may not know whether you should laugh or cry.

Quite a few years before this accident occurred, another maintenance man working for the same company had set up a 20-foot metal extension ladder against the exterior of the building to change a burned-out bulb that provided light to the parking area. Apparently the light fixture was mounted about 23 feet above the ground, and the soil was soggy from a leaky sprinkler pipe. You can probably see where this is headed, so to make a long story short; the maintenance man was standing on the next-to-the-top rung of the extension ladder, stretching to reach up over his head to change the bulb, when he received a small electrical shock that caused him to recoil. And that in turn caused him to fall off the ladder to the ground below, where he was seriously injured.

As a result of this accident, the owner of the business insisted that the safety manager implement “best practices” for ladder use to insure something like this never happened again. “Best practices” was the new buzzword in corporate America at that time, so everything the company did, the owner insisted be done in line with “best practices”. Personally, I get tired of hearing people, including safety professionals, pronounce every single policy they implement as a “best practice”; in fact, I’d guess you have to say it is one of my pet peeves. But none the less, it is something that is firmly entrenched in business vernacular, even though there is no organization or mechanism in place to validate most of these claims.

Back to my story; as you can probably guess, the safety manager quickly developed and implemented a comprehensive ladder safety program that included written policies on the proper selection and set-up of ladders, followed by training for affected workers. But the safety manager did not stop there; he decided to go above and beyond to mandate that employees always wear a fall protection harness attached to a lanyard or safety line before they set their foot on a ladder. One hundred percent fall protection all the time. No exceptions. Period!

Apparently the safety manager did not give deep consideration to the potential ramifications of this new policy. So it’s no surprise that the poop hit the fan a few months later when the company owner stopped by the safety manager’s office and chewed him out because he saw a (different) maintenance man who had climbed onto a step-ladder in the office lobby area, and he was not following their established “best practice”. So the safety manager responded by running downstairs to the scene of the crime and sure-enough, there was the worker standing on the third rung of an eight-foot stepladder changing a fluorescent light bulb, and he was not using fall protection gear. The safety manager chastised the worker for not tying off, and you can probably guess what the worker’s response was; “exactly where the heck do you suggest I tie off?”

The safety manager grabbed a broom from a nearby janitorial closet and used the handle to push over some ceiling tiles. Then he shined a flashlight into the hole so he could see up into the area above the ceiling grid. He was trying to find a suitable tie-off point for the safety line, but all he could see was a bunch of conduit, sprinkler pipes, and a flimsy-looking bar joist. Then the maintenance man told him to quit wasting his time, because even if he could find a suitable tie-off point, they had no way to climb up there to connect the safety line because they were not allowed to use a ladder unless they were already tied off!

So the safety manager told the maintenance worker to put off changing light bulbs in the office area until he could come up with something else that would work. And after racking his brain for a couple of days, the safety manager implemented a new “best practice”; from now on, workers must utilize a scissor-lift when changing light bulbs inside the office building.

Over the next few years they discovered a few bugs in their “best practice” that required the procedure to be further revised, such as on the day they realized they needed to change a light bulb on the second floor of the office building. Their elevator was too small for the scissor-lift to fit inside (and the lift was probably too heavy). So they ended up purchasing another scissor-lift to use on the second floor, disassembled and transported it upstairs in pieces, and then reassembled it, where it would remain exclusively for use when a light bulb needed to be changed.

Of course, the Fire Marshall had to express his displeasure when, during his annual inspection a few months later, he found the scissor lift parked in an aisle-way in the back corner of the office area, blocking access to an emergency exit. Due to a lack of an adequate parking spot for the scissor-lift, the company decided their only choice was to have someone move out of one of the offices situated along the outer wall, and then use that office to store the lift. But it couldn’t be just any office; clearance restrictions created by the rows of cubicle wall panels adjacent to the offices required them to park the scissor-lift in one of the corner offices; the Vice President of Human Resources was not pleased! So she booted the safety manager (who happened to report to her) out of his office and into a cubicle, and she relocated to his old, smaller office. Not the ideal situation, but a sacrifice that had to be made for the sake of “best practices”.

Over time, other challenges resulted in the evolution of their “best practice" for changing a light bulb, such as the time when the scissor-lift was being driven down an aisle-way and one of the carpeted floor panel that was situated over a hollow chase for computer wires collapsed. That resulted in the need for the revision of office floor plan maps, originally created for displaying their emergency evacuation routes, so they could also pinpoint where similar false floor panels were located. Then they fabricated special “floor plates” out of sheets of precisely-trimmed 1-inch thick plywood that they would place over portions of the floor with a void beneath when they drove the scissor-lift over them so they could prevent another collapse .

But a couple of years after that, they had to go back and bevel the edges of the sheets of plywood and paint them safety yellow, because a worker stubbed her toe on the edge of one of them as she was walking over it to get to the copy machine and split a toenail. Then about two years ago, the company had to revise their “best practice” once again, this time to require the placement of orange traffic cones to block off all pedestrian traffic in the area when the plywood sheets were laid down because an employee claims to have jarred his back when he stepped off of a piece and had to have surgery.

So now we approach the day of the accident that resulted in the lawsuit I told you about. In spite of the company implementing the “best practice” for changing a light bulb (a procedure that had been developed, formalized, and refined multiple times into a seven page document and an investment of thousands of dollars for equipment, materials, and labor), it became apparent that their procedure did not address one other potential hazard. As the maintenance man was backing the scissor-lift down an aisle-way and around a corner, he accidentally struck one of the cubicle walls, causing it to collapse.

Luckily nobody was inside that particular cubicle at the time, but it did create quite a racket. And a brand new laptop computer and printer were trashed when they were struck by the falling wall. As soon as he realized what he had done, the maintenance man shoved the scissor-lift into the opposite gear and lurched forward; at about the same time the plaintiff in this lawsuit came running out of an adjacent cubicle to see what had happened. And that was when her foot got run over by one of the wheels on the scissor-lift.

Now the moral of the story is NOT to discourage someone from trying to make a job safer by improving upon the procedure in place. That’s what safety people are supposed to do when they find a hazard that is not being adequately addressed. Frankly, I’m impressed the safety manager implemented a comprehensive ladder safety program that consisted of proper ladder selection, set-up and use after the initial accident occurred many years ago. But in hindsight, he probably wishes that he would have stopped right there, at least when it came to applying their "best practice" of requiring 100-percent tie-off when using a ladder to change burned-out light bulbs in the office. Now I’m just hoping the company does not implement a new "best practice" that requires office workers to wear steel-toe shoes! And still lost in all of this was the irony that every time the maintenance man had to mount the scissor-lift, he actually had to climb up a short built-in ladder affixed to one end of the lift.  

No, the point of my sharing this story with you is just to remind fellow safety professionals that we should not implement a new or revised safety procedure without thoroughly considering all the potential ramifications. And while I’m at it, let me ask you to do me a favor; the next time you develop or update one of your safety policies, please try and avoid pronouncing it a “best practice”, unless you have some kind of validation to back it up. Perhaps you could instead say something like “this is the safety policy or practice that works best for us”.


If you’d like to share a story about your experiences with a safety improvement that ran amuck, or make some other comment about this blog post, please do so in the “comments” section below. And last but not least, please pass a link to this blog post along to others in your network who you think may benefit (or at least be amused) by this information.

26 comments:

  1. I'm wondering why the senior management at this company didn't take the safety "manager" firmly by the scruff of his neck and insert some common sense into him via a size 9 boot up his rear end.

    It just goes to prove - yet again - that common sense isn't so common :0( - Andy

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  2. Another great blog. Thanks Curtis.

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  3. We assess thousands of incident reports every year and see nonsense like this all the time. The law of unintended consequences is very powerful.

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  4. Great job! I love to read your posts.

    Isabel.

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  5. It troubles me that individuals call themselves ‘safety professionals’ and yet their actions prove otherwise. Having a practical safety approach that is well thought out will, in most cases, lead to a cost effective program that will be successful, rather than one that looks like it was inherited by someone who is lost.

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  6. Very enjoyable, in a perverse sense.
    Perhaps the safety profession should heed the hippocratic oath, "First, do no harm".

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  7. Curtis - thanks for the blog. It is a good chronology showing why a safety professional cannot work in a vaccum!!

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  8. WOW! That's what I'm seeing more and more of "Best Practice" good attention however not thought through. One of my previous employers established a Best Practice for dust control when sweeping out their large hangers. The "Best Practice" stated to use a Hudson sprayer or a water source to dampen effected area prior to sweeping to control dust. When they added water they introduced to issues; first the area became very slippery and second the Base EPA wanted the dust now to be treated as solid hazardous waste $$$$.
    They ended up going back to dry sweeping with a Negative ventilation system (exhaust fans) and the employees wearing N95 mask. - Ray

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  9. Awesome blog... and I have seen it happen over and over again... I'm still chuckling...

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  10. Common sense is not common! I laughed and I cried, because the right hand certainly doesn't know what the left hand is doing. Nice piece. M.J.

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  11. Excellent blog. One important thing it illustrates is that one rarely, if ever, understands all of the variables that will be impacted when a new action is implemented. One answer might have been to implement the requirement to use a fall protection harness attached to a lanyard or safety line when the worker is above a certain height (5 feet? 8 feet? 12 feet?). An alternative would be that one must use a ladder of the proper height for the job at hand, that is, you may not climb above the third or fourth rung from the top. Clearly, there are a number of other possible approaches to be considered that would have been more workable than those that were implemented. Louis

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  12. So this should end with the question. "How many Best Practices does it take to change a light bulb?" LOL

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    1. Well, that response is just too funny! I always enjoy the blogs (and the responses too). It is very disheartening to know that there are safety "professionals" out there that are doing this kind of thing.

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  13. Curtis,

    I really enjoy your newsletters and articles. Thanks for starting my day with a laugh / cry.

    Al

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  14. Mr. Chambers. I always enjoy your posts. They are informative, humorous and to the point. Thanks for keeping me informed. I’ll try not to call our new safety procedures a ‘best practice’, but rather, a policy or the best practice that works for us.

    Thank you very much!

    Donna

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  15. I have got to say that that was one of the best articles I have read lately. I love how the cure is sometimes worse then the disease. Did they ever fix that leaky pipe that started all of this? I question those who have 100% tie off. If it is good when used on the first couple of rungs on a ladder, why don't we just use it in case of a trip so we don't fall down? Mandate overhead lines to assist us whenever we walk so that we won't trip? Thanks for the blog - I enjoyed it very much. Terry

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  16. This is interesting. I attended a safety meeting for a major oil company last week where the head honcho was communicating an accident they had. When he was summarizing the cause he said "with that said we are not avocating that we make new procedures or implement a new plan, instead why don't we just use (i.e.DO )the procedures we already have and are susposed to use.......DUH! At the end of the meeting I approched him him and told him how nice it was to hear what he had to say..no MORE procedures/plans; DO the stuff we already have.

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  17. Proof again of Eric Severeid's Law: "(T)he primary cause of problems is... solutions."

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  18. Nice story! At some point as you rightly said, the best practice phrase isn't just the best thing to say when change procedures as a result of incident...Thanks for sharing!

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  19. Sadly enough, if engineering controls were truly sought out, there are devices (such as JLG's Liftpod) that would be much more appropriate for such activities. However, I always enjoyed the "Administrative control" approach which involves creating a policy that bans falling from elevations. (THAT should fix it!!!)

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  20. The ladder safety training made sense, as long as it was done by someone who knew what they were talking about. That is not always the case. It should have stopped there. The rest was just plain silly. Two of the accidents could have been prevented by a policy that says: "All employees will watch where they're going." I'm sure all employees would immediately and forever obey that policy. A comp case for a stubbed toe and broken toenail? We're sure getting delicate these days. At least it would have been an easy return to work. Another policy could rear its ugly head: "Pick up your feet."

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    1. Yeah blame the employees, that always works.

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  21. Bureaucracy at it's best. Classic case of managment making decisions about something they have no real knowledge of.

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  22. Great story of management by incident(s). Next problem is a fire/haz mat incident from the lift while charging the batteries in the confined space (Office).

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  23. A great example why thorough, research, feedback, testing, and investigations are so necessary after any injury or near miss incident. The problem could have been solved the first time.

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  24. Curtis,

    That you for the interesting story. This case is relevant to construction as more general contractors go to a "ladders last" policy. They want employees in lifts when possible. Use of a ladder is by permit only. My concern, recently confirmed on SoCal job site, is that the GC won't coodinate with the structural engineer of record to determine how many lifts can be used in particular area. Five employees, with tools, don't add up to much weight in a room. Five employees on lifts, even the JLG 1230 (which says the weight over each wheel is nearly 900 pounds), can and has damaged the floor. Fortunately, it wasn't a post-tension floor.

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