Surprise: Employer Finds "Worker Error" To Blame For Fatality

Why is this not surprising? Employer investigates employee's death. And the cause is? Worker error, of course.

Public employees, as we regularly complain, are not covered by OSHA in 26 states. This is bad for a number of reasons, the first being that they get injured and killed in easily preventable accidents because the employer is not incompliance with the same OSHA standards that apply to private sector workers doing the same job.

Another reason why it's bad not to cover public employees is that when one is killed, there's likely to an inadequate investigation or no investigation at all.

Take the case of Shawn Patilla. I wrote about Patilla's death already last October, after a valve ruptured in the high-pressure water main he was working on. He died from head and neck injuries as a result of being hit by the water at a pressure of 90 pounds per square inch Patilla had two daughters and a son.

So what was the problem? Human error, according to the investigation, conducted by Denver Water, the utility that employed Patilla. The problem with employers investigating their own accidents (which happens with workplace fatalities in workplaces not covered by OSHA) is that they often come up with "human error."

Denver Water officials wouldn't name the foreman or say how he was disciplined. He is a 25-year employee with a good safety record who cooperated fully with the investigation, said Trina McGuire-Collier, Denver Water spokeswoman.

The three-week probe by the water utility revealed that Patilla's foreman failed to pass on information to the crew that a 24- inch conduit had not been drained and was fully pressurized.

The crew's routine job that night was to remove an 8-inch line and reconnect it to a newer pipe that had been installed earlier in the summer.

Initially, the 24-inch conduit was expected to be drained. But it was decided the job could be accomplished without draining the conduit, which would avoid temporarily disrupting water service to dozens of homes.

The foreman reportedly told investigators he thought the crew had overheard a discussion about the conduit not being drained, but he didn't directly tell them it would be pressurized.

He also assumed a valve was bolted to the conduit, the investigation determined. Instead, it was a few feet from the conduit attached by pipe and steel restraining rods.

When the rods were cut and a small section of the pipe was removed, the valve and remaining length of pipe "separated violently from the conduit, flooding the excavation with water and causing the fatal injuries to Patilla," according to a Denver Water statement Friday.

Sure, blame some worker for screwing up. Discipline him, problem solved. Right?

Wrong.

Now, believe it or not, a worker being injured or killed because he cut into a pressurized pipe is not a freak accident; it happens all too often. In fact, it happens so often that OSHA has a standard designed to protect workers from being killed or injured in such incidents. It's called the "Lockout-Tagout" standard, technically known as the "Control of Hazardous Energy" standard, and is used to protect workers who may be repairing equipment that could turn on while they're working on it, or for pipelines that may be pressurized, as the one that killed Shawn Patilla was.

The utility blamed a supervisor for failing to communicate properly. He probably did fail to communicate properly. But that's only the direct cause of the incident, not the root cause. Lack of communication and miscommunication in these situations is so common that the OSHA standard requires a lockout-tagout program. In fact, the most likely root cause of Patilla's death was not worker error, but the employer's failure to have a lockout tagout program.

The OSHA standard for The Control of Hazardous Energy (Lockout/Tagout), Title 29 Code of Federal Regulations (CFR) Part 1910.147, addresses the practices and procedures necessary to disable machinery or equipment, thereby preventing the release of hazardous energy while employees perform servicing and maintenance activities. The standard outlines measures for controlling hazardous energies — electrical, mechanical, hydraulic, pneumatic, chemical, thermal, and other energy sources.

The lockout-tagout standard standard also requires workers to be trained about the employers program.

Pressurized pipes need to be depressurized, or the pressurized part needs to be isolated from the section the workers will be working on. A number of safeguards -- work permits or tags, for example -- must be used to ensure that workers don't work on the piping until it's safe, and that the pipes are not re-pressurized until the work has finished.

Bottom Line: Blaming workers (even foremen) for accidents is generally a way of shifting blame from poor management safety systems. And the fact that OSHA doesn't cover public employees just allows them to get away with it.

Tragic, Yes. Bizarre, No

Webster's Dictionary defines "bizarre" as: "strikingly out of the ordinary."

Now, read this.

Worker killed in Webster Parish plant accident

SAREPTA, La. A bizarre accident at a plastic car parts plant in Webster Parish has claimed the life of a woman. It happened at Continental Structural Plastics in Sarepta.

Authorities say Colotha Gates was loading her machine and someone apparently tripped the machine accidentally, causing the press to come down and crush her skull. Gates later died from her injury.

The company molds plastic parts for all types of vehicles.

The Webster Parish Sheriff's Office is investigating.

This is, unfortunately not strikingly out of the ordinary. Getting crushed in a machine that is accidentally turned on is, unfortunately, striking common enough that there's an OSHA standard designed to prevent such tragedies. It's technical name is "Control of Hazardous Energy," (29 CFR 1910.147), but it's commonly known as the "Lockout Tagout Standard."

What that means is that before a worker puts any part of his or her body inside a machine, it has to either be locked out (so that only that worker can turn it back on) or tagged out (warning other workers not to turn on the machine.)

According to OSHA:

"Lockout/Tagout (LOTO)" refers to specific practices and procedures to safeguard employees from the unexpected energization or startup of machinery and equipment, or the release of hazardous energy during service or maintenance activities.

Approximately 3 million workers service equipment and face the greatest risk of injury if lockout/tagout is not properly implemented.

Three million workers facing the same hazard is not "bizarre." What would be bizarre is if Colotha Gates' employer is found to be out of compliance with the lockout-tagout standard and gets away with only a relatively small fine.

On the other hand, that would not be "out of the ordinary" for OSHA. Tragic, yes. But unfortunately not bizarre.

Miners Killed In "Dogholes:" Freak Accidents, Worker Error and Drugs?

Kris Maher of the Wall St. Journal took a close look earlier this week at what miners call "dogholes," small, undercapitalized mines that have become economical -- and deadly -- since coal prices have surged. Eleven out of 33 coal mining deaths this year, and 14 out of 22 deaths last year occurred in mines employing fewer than 50 people. Maher also reveals the mining industry's rather shocking analysis of the reasons for the rising death rate in American mines.

A report by the National Institute for Occupational Safety and Health, which examined data from 1988 to 1997, found the fatality rate at coal mines with fewer than 50 employees was 4.24 times the rate at mines with 250 or more workers. According to data from the Labor Department's Mine Safety and Health Administration, in each of the past three years, the fatality rate at underground coal mines with fewer than 50 workers was higher than the rate for all underground coal mines.

Demand for coal is rising due to utilities switching from expensive natural gas, using US steelmakers using more metallurgical coal, and the rising demand for coal to make steel in China, and the price of coal has risen from $29 in 2002 to $58 per ton last year.

Many of the these mines are owned by small companies that contract for the large coal companies. And although coal prices are high, the Journal points out that many of the smaller companies still operate close to the edge.

It often costs more per ton to extract coal from lower-quality seams. Many small operators don't own the land they mine; instead they mine on a contract basis, selling the coal at below-market prices to larger operators who own the mineral rights to the property.

So what's the problem? Nothing much to worry about, according to coal company executives.

Most fatalities that occur in mines of any size are the result of "freak accidents," and some are due to human error, says [president of the Kentucky Coal AssociationBill] Caylor. The term "dogholes" is a sensational one, used by mine-safety "zealots," he adds. "But there is some legitimacy to this," he says. "There are some operators that are ruthless that have been the bad apple in the entire barrel."

***

Mr. Caylor, of the Kentucky Coal Association, believes the best way to improve safety is for state and federal inspectors to observe the working habits of a miner "and teach him how to work safer, rather than sitting there as a policeman, writing a ticket."

"Freak accidents?" "Human error?"

Wrong, wrong, wrong say most mine safety experts:

"As long as prices stay high, you're going to get the marginal producers coming in to capture a share of the market," says R. Larry Grayson, chairman of the department of mining and nuclear engineering at the University of Missouri-Rolla. He says the danger of accidents increases when smaller mines proliferate because they tend to have less-experienced workers, use older equipment and mine harder-to-reach coal seams that are passed over by big companies.

And this:

Workers at small mines tend to be less experienced and more economically desperate than those at big mines, says [former MSHA official, Tony] Oppegard. "You've got this permanent base of unemployed people in eastern Kentucky," he says. "You'll always have people who are willing to work under whatever conditions that you impose."

And do these incidents, described in the Journal article sound like "freak accidents" or "human error that could have been prevented by "teaching miners to work more safely?"

"The 13th coal miner killed this year, Cornelius Yates, died Jan. 10 in a Pikeville, Ky., mine that employed nine. The 44-year-old was operating a machine used to drive six-foot-long bolts into the mine roof to secure it when the roof collapsed and killed him.

In that case, federal investigators determined the roof was unstable. "The condition was widespread and obvious and should have been detected by a reasonable prudent mine examiner," investigators wrote. The company was cited for safety violations related to the accident, but fines haven't been set yet, says MSHA.

And how would more training have saved the lives of the 11 of the 12 dead Sago miners who suffocated, or the two Aracoma miners who died in a belt fire or three of the five miners killed at the Kentucky Darby who suffocated to death after the explosion?

Then there are those who say that the problem with small mines is that they don't do enough drug testing and Congressman Charlie Norwood (R-GA) wants to drug test every miner, and indeed, when David Sherman Morris was killed last December at H&D Mining Inc., of Cumberland, Ky after being struck by a loaded coal hauler used to transport coal inside the mine, his urine showed that he had been smoking marijuana in recent days or weeks. Morris's left leg was severed and his right leg was crushed. So drugs were to blame, right?

Not according to the MSHA investigation.

Instead, they pointed to errors and negligence of mine management. Investigators said a major contributing cause was that side boards -- which allow more coal to be carried -- had been attached to the coal hauler, and coal was loaded 60 inches high, obstructing the view of the person operating it. The height of the mine where the accident occurred was 67 inches.

The company's procedures for operating equipment underground placed Mr. Morris in a dangerous position when he was struck from behind, investigators said. They also determined "this injury became a fatality because basic first-aid was not properly performed" by mine personnel. No fine has been issued for the accident yet, according to MSHA.

The other problem is that smaller mines are not generally unionized. The Journal reports "miners say raising safety concerns at small mines can mean risking one's job, as well as future employment at other mines" and points out that 30 of the 33 miners killed so far this year worked in non-union mines.

More mine safety stories here.

Why I Hate Most News Articles About Workplace Deaths

All too often I rant and I rave over newspaper and television stories of workplace fatalities because the give the impress that it was just a "freak accident," or theh dumb worker's fault, or just kinda one of those tragic things.

44-year-old Donald Wilson of Grass Valley, Calif died in a Nevada wastewater treatment plant last weekend when his head was caught in a piece of machinery.

I can't get the details of the incident from the newspaper, but it seems like this was your well known, every-day lockout accident. There's an OSHA standard -- commonly referred to as the Lockout-Tagout standard -- that requires machinery to be de-energized (or at least tagged to warn others not to turn it on) to prevent unexpected energization or startup of machinery and equipment.

Here's the 'dumb worker got his head stuck' story:

Randall Gray, who manages the plant at 8500 Clean Water Way in Sparks, said Wilson apparently got his head stuck in a piece of machinery.

The Oregon-based company has been contracted to clean the tanks for several years, and there's never been a serious safety issue, Gray said.

Yeah, there's never a "serious safety issue" until someone gets killed.

Then there's the "freak accident" story:

Donald Anthony Wilson, known throughout the local firefighting community as "Tony," a dedicated and passionate public servant, died Sunday in a freak accident at a Sparks, Nev., water treatment plant.

As I've said before, a "freak accident" is when you're sitting at your desk, minding your own business and a runaway satellite crashes through the roof over your head. It is not a "freak accident" when the "accident" could have been prevented by complying with the relevant OSHA standard.

Then there's the article I might write:

A wastewater treatment plant worker was killed yesterday when his head was crushed in a piece of machinery due to the apparent failure of plant management to implement an OSHA-mandated lockout-tagout system. Lockout-tagout is intended to safeguard employees from the unexpected energization or startup of machinery and equipment.

When questioned, the plant's supervisors refused to confirm or deny whether they had a lockout-tagout program, or whether contract workers were trained in its implementation.

You get the idea.

Related Articles

• Freak Accident: New Comic Genius Is Born, August 12, 2005
• Bad Trench, Worse Article, July 12, 2005
  
• What's 'Freak' Got To Do With It? May 5, 2004
• What's So Freak About It? July 12, 2003

Another Deadly "Accident." Who Would Have Thought That Pesticides Are Bad For You?

What do these words have in common: homicide, suicide, genocide, pesticide?

Yes, they all end in "cide," the latin word for "killing."

Which is why University of Washington Professor (and former Washington State OSHA Director) Michael Silverstein is a bit perplexed about the pesticide "accident" that killed a woman in Florence, Oregon.

Florence Kolbeck, 76, of Florence died "most likely from a cardiac arrhythmia associated with non-lethal levels of the pyrethroid insecticide," according to the autopsy.

The death was ruled accidental, which closes the criminal investigation, a Florence police spokeswoman said Thursday.

The Department of Agriculture and Department of Human Services may complete its investigation by early December, said Agriculture spokesman Bruce Pokarney.

Kolbeck, who had heart disease, died a few hours after her home was sprayed June 29 by a technician with Swanson's Pest Management of Eugene.

"The level of insecticide in the home was not a toxic level," deputy medical examiner Lynn Walter said. "But it was a level sufficient enough to cause respiratory distress and irritation. That led to an arrhythmia, which led to the cause of death."(emphasis added)

Mike notes that this is the same type of logic used to label a trench collapse a "freak accident" despite the fact that numerous safety standards were violated.

The part I love is the medical examiner’s statement that “the level of insecticide in the home was not a toxic level…But it was a level sufficient enough to cause respiratory distress and irritation. That led to an arrhythmia, which led to the cause of death.” I guess that means something like sufficiently non-toxic to accidentally send your lungs and heart to the cleaners. No wonder the employer “couldn’t draw any conclusion.” At least he does “feel terrible the lady died.”

Moral of the story: Pesticides are bad. Some are less bad than others, but they are designed to kill undesirable critters, and most also have ill effects on humans. Given the well-recognized fact that humans have variable susceptibilities to toxic materials depending on their age, health situation, allergic sensitivities, etc, the effects can be worse on some than on others -- even deadly.

These facts shouldn't be a surprise to pesticide applicators or their employers. And this was an "accident" only in the same sense that most workplace deaths and injuries are the result of accidents. They may not be "intentional," but they're also not unforeseeable.

Freak Accident: New Comic Genius Is Born

Susie Madrak found this great site where you can make your own comics. Here's my first try (it's clearer if you click on it):

And another one here.

.

What's 'Freak' Got To Do With It?

Those of you who read this Blog know that there are a few things that really irritate me. (Actually, there a more than a few, but...): trench collapses and stupid articles or headlines about how a "freak" accident killed a worker.

As far as I'm concerned, a "freak accident" is when you're sitting at your desk, minding your own business and a runaway satellite crashes through the roof over your head.

This, on the other hand, is not a "freak accident:"

Freak accident kills local steel worker

TRYMAINE D. LEE, Staff Writer 05/05/2004

A 47-year-old Trenton man was killed yesterday morning in a freak industrial accident at the Certified Steel processing facility in Hamilton.

According to police, Wayne Austin, a six-year employee of the company, received a fatal blow to the head when he was struck by a load of hanging steel.

"He was struck in the head by material being suspended by a crane," Certified Steel spokesman Bob Kramer confirmed yesterday.

The accident occurred at 10:42 a.m. in the "angle iron storage area."

Police said the steel, which was suspended by a crane operating through mobile tracks along the ceiling, killed Austin almost immediately.

***

The L-shaped pieces of steel that struck the laborer likely weighed "hundreds of pounds, possibly thousands," Kramer said.

Officials from Certified Steel said Austin was wearing the proper head gear at the time of the accident. But the sheer impact of the blow was tremendous, Kramer said.

"It was certainly enough to ... kill," he added.

The Merriam-Webster Dictionary defines "freak" as "a seemingly capricious (unpredictable) action or event."

So how capricious or unpredictable was this incident? I'm not too sure about the exact details, but it couldn't be too unpredictable if OSHA has two standards dealing with overhead cranes (Overhead and gantry cranes, 1910.179 and Crawler locomotive and truck cranes, 1910.180), both of which state "The employer shall require that the operator avoid carrying loads over people."

And generally, one thinks of "freak," as more or less unique -- as in, you've never heard of such a thing, and never will again.

In this case, however, according to the article,

The United States Bureau of Labor Statistics Web site indicates that in all of 2002 only four fabricated structural metal industry workers died as a result of being struck by objects at the workplace. Since 1996, 25 such workers have been killed, the site reports.

Certified Steel management may have been "freaked out," but that doesn't make this a "freak accident."

Accidents like this one are extremely rare," Kramer said, within a few hours of the fatal accident. "It has never happened before. Not to us."

In fact, most workplace fatalities have "never happened before" in any given workplace ... until they do. That's why we have OSHA standards -- to prevent the incidents that "never happened before" from ever happening the first time. This fatality may have been Certified's first, but the company was not exactly a virgin. Certified Steel has received a dozen OSHA citations over the past five years.

So what's the problem with labeling something like this a "freak accident?" Well, as I wrote in my incredibly inciteful article, "Acts of God, Acts of Man,"

Unfortunately, blaming a workplace fatality on God, freak occurrences, or a careless worker is a way of thinking that the media often falls into and that some employers encourage. After all, if a workplace fatality is unpredictable and unpreventable, then no great public outcry is warranted. If someone's inattentiveness or stupidity or laziness (or drug problem) or God's will led to the death, then it's a tragedy for the family and friends, but no real investigation is needed, no lessons are to be learned, no changes in the workplace are demanded, no new OSHA regulations are needed, no enforcement is appropriate and no wider social problems need to be addressed.

And employers often get away with blaming deaths and injuries on "freak" accidents and other "excuses" -- at least in the public eye. They are typically quoted about the "freak" accident in a short one-day story in the local newspaper and by the time experts are found (if anyone bothers) or the OSHA report comes out explaining the employer's failure to provide a safe workplace, the local media has often lost interest.

So what is to be done? As I suggested in a previous rant about this same subject,

Don't let the media or employers ever get away with dismissing a preventable workplace tragedy as "freak." Don't let them leave the impression that there was nothing that could have been done, or the worker's luck had just run out. What to do? Reporters need to be educated about how such tragedies can be prevented. And employers need to be challenged when they assert that no one cforeseenve forseen what happened. That's almost never the case and it certainly wasn't the case in the incident mentioned above. Don't let them get away with it.

What's So Freak About It?

One of the many things that piss me off is workplace accidents being labeled "freak" when, like the one in this article, they're actually well-known, preventable and often well-regulated hazards.

1 killed, 5 injured in freak electrical accident

REHOBOTH -- An accident on Baker Street yesterday afternoon involving electrical workers left one man dead and five others injured, one critically, police said.

Subcontractors for Massachusetts Electric were doing routine pole work at about 3:30 p.m. when the boom from a bucket truck came in contact with a high tension wire, sending 115,000 volts of electricity through the boom, Acting Chief Lt. James Trombetta said.

And it only gets worse:

Lineman from Connecticut second to die in Rehoboth accident

By Associated Press, 7/2/2003 14:03
REHOBOTH, Mass. (AP) A second electrical lineman injured after his crew's equipment contacted live power lines Monday has died.

Walter Shaw, 44, died Tuesday afternoon at Rhode Island Hospital in Providence where he had been taken when critically injured, hospital spokeswoman Polly Stiness said Wednesday. A woman answering the phone at the home of Walter Shaw, in Columbia, Conn., confirmed he was the man involved in the accident.

On Monday, Joshua Ladd of Belfast, Maine, died at Morton Hospital and Medical Center in Taunton.

Labeling something like this a "freak accident" implies that there was no way anyone could possibly have predicted it. And if you couldn't have predicted it, there's no way anyone could have done anything to prevent it. Instead of public anger that might have been stimulated by a more accurate headline like "Lack of Precautions Kills Two Workers," the public is left with the impression that "shit happens." Some people just don't have very good luck.

Six months down the line there will probably be an OSHA citation, but it probably won't make big headlines.

There was nothing at all "freak" about this electrocution. There are a number of OSHA publications about how to prevent electrocutions from overhead power lines: the lines can be de-energized or they can be shielded. If neither of these alternatives is possible, a designated spotter can monitor the job to make sure that nothing comes within ten feet of the energized line.

Try doing a Google search for "freak accident." Some of them will actually be freak e.g. A guy is walking down the street, minding his own business when a tree falls on him. But I'd wager that almost every single "freak accident" that occurs in a workplace was predictable and preventable.

I did such a search recently while doing research for an article I was writing. One of the many articles I came up with was about a "freak" confined space asphyxiation in a winery. Late in the article the writer noted that a similar incident had occurred a few years before. Two identical "freak" accidents? Pretty freaky.

Don't let the media or employers ever get away with dismissing a preventable workplace tragedy as "freak." Don't let them leave the impression that there was nothing that could have been done, or the worker's luck had just run out. What to do? Reporters need to be educated about how such tragedies can be prevented. And employers need to be challenged when they assert that no one could have forseen what happened. That's almost never the case and it certainly wasn't the case in the incident mentioned above. Don't let them get away with it.

An Act of God?

Employers often blame "acts of God" or the "whims of Mother Nature" for workers' deaths in trench collapses or by asphyxiation in manholes or other confined spaces. In other words, despite OSHA regulations and general industry recognition, "nothing could have been done to prevent this tragedy." This article about the death of a tomato field worker, Immokalee farm worker killed by lightning strike, might actually come close to an act of God. Or?

When lightning and thunder threaten, my kids are rushed off their soccer and baseball fields and out of the public pool. I wonder if field workers are also given the opportunity to seek shelter from the storm as experts and federal government agencies recommend? It's not smart to try to fool Mother Nature.