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Russian roulette in the American workplace

August 30, 2001
Every day millions of workers routinely perform thousands of different tasks safely, following established and proven safety procedures. But some, for whatever reason, decide to play "Russian Roulette" by cutting corners, ignoring written safety rules.

Each day more than 4,600 workers get nicked by the bullet, suffering an injury severe enough that they lose work time, according to the Bureau of Labor Statistics. Unfortunately, every day the "last chance" bullet causes 16 workers to lose at the game, never returning home to their families.

Let's look at some cases?

Lockout/tagout

...the dog apparently bumped the lever, closing the gate on the farmer, killing him.

An experienced farmer was operating a tractor and stacker machine, compacting old corn stalks. Every few loads he would check the cables inside the stacker. To do this he activated the hydraulic levers to open the rear upper and lower gates of the stacker. He left the tractor running, exited the cab and shut the door, leaving his dog inside. While he leaned inside the stacker, the dog apparently bumped the lever, closing the gate on the farmer, killing him.

Note: Instructions for machinery are very specific when talking about lockout/tagout while working on the equipment.

Personnel platforms

...the other (worker) fell directly under the platform and was crushed by lumber and supplies that fell.

Two carpenters were installing siding on a new apartment complex, working from a "homemade" wooden platform which was lifted by a hydraulic lift. The platform was 14 feet long by 4 feet wide, made of plywood, 2x4s and 2x6s. It was normally lifted from the center, allowing the four-foot long forks to extend through the entire width.

Unable to access a narrow area between buildings, they inserted the forks into the end, leaving 10 feet without fork support. They reached a height of 25 feet and had worked for 45 minutes when the platform snapped at the end of the forks, causing them to fall to the ground. One worker was thrown clear and survived, the other fell directly under the platform and was crushed by lumber and supplies that fell.

Note: OSHA has very specific rules concerning personnel platforms and how they are constructed. These were not followed.

Fall protection

...For unknown reasons, he slipped and fell to his death.

A laborer was sandblasting the outside of a water tower, approximately 150 feet above ground. He had performed this type of work for more than five years. For unknown reasons, he slipped and fell to his death.

There was fall protection equipment available, but he ignored established safety guidelines. The company's disciplinary policy stated that non-use of fall protection gear would result in a verbal warning for the first offense, written warning for the second, and termination for the third. This was his third offense in a year.

Flight maneuvers

...They were unable to recover in time and both were killed upon impact.

A flight instructor and student were practicing stall maneuvers at a high altitude, a routine that involves flying level, shutting off power to the engine, then re-powering. This causes the plane to go into a nose down position, often spiraling towards the ground. The instructor had performed this many times before.

Witnesses on the ground observed the aircraft perform several stalls. For reasons unknown, the last attempt was initiated only 500 feet above ground level, well below the accepted minimum altitude. They were unable to recover in time and both were killed upon impact. Complacency may have been an issue in this mishap.

Machining operation

...the carriage had traveled "full cycle" and crushed the mechanic between it and the stamper.

A maintenance mechanic had been employed by a manufacturing company for 24 years. He was called to work on a piece of equipment called an angle processor, which he had worked on for 15 years. A 40-foot piece of angle iron is laid on a "carriage," which moves it to be stamped, have holes punched and cut to specific lengths, according to what information the operator had placed into the computer.

The mechanic and a helper worked on the machine for most of the day. They believed it was not level, causing it to cut the metal wrong. They used a portable hoist to lift it off the concrete floor to see if anything was underneath to cause the imbalance. After lowering it back in place, they had the operator run a single 40-foot piece through. Several more adjustments were made until the machine was properly adjusted.

The mechanic had the operator run one more piece of metal through. The operator inputted the request to the computer, which started the five-minute cycle. Once started, the machine does not need an operator to complete the cycle. The mechanic and helper were on the operator's platform, while the operator went to the "finish" area where the sheared piece of angle iron is collected. The helper remained on the platform to install some covers, and the mechanic walked behind the machine to tighten the bolts holding the equipment to the floor.

The helper saw the mechanic lying on his side with his back to the approaching carriage. He heard a yell and immediately hit the emergency stop button. He rushed around to see that the carriage had traveled "full cycle" and crushed the mechanic between it and the stamper. The victim was able to push the carriage enough to free himself. He was airlifted to a local hospital where he died several hours later.

The company had lockout/tagout procedures, personnel were trained, and procedures were reviewed at monthly safety meetings. The mechanic had a good record of always following established procedures, as evidenced by the company's lockout/tagout logs. No one knows why this time he decided not to follow procedures.

Stack the odds

The safety history books are filled with stories such as these. The workplace doesn't have to be a game of Russian Roulette. Stack the odds in your favor by following all the safety policies and always wear your personnel protective equipment. Keep the bullets out of the gun!

These cases come from the Nebraska Fatality Assessment and Control Evaluation, an occupational fatality surveillance project to determine the epidemiology of all fatal work-related injuries and identify and recommend prevention strategies. FACE is a research program of the National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research.

These fatality investigations serve to prevent fatal work-related injuries in the future by studying the work environment, the worker, the task the worker was performing, the tools the worker was using, the energy exchange resulting in injury, and the role of management in controlling how these factors interact.

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