Confined Space
News and Commentary on Workplace Health & Safety, Labor and Politics

Wednesday, July 27, 2005


MSHA Makes The "Wrong Decision" To Blame Workers For Accidents

That management likes to blame worker behavior for accidents will come as no surprise to American workers. That this "blame the worker" theory is not consistent with the facts, that it doesn't get to the root causes of workplace incidents is also not a surprise to American workers.

So this new Mine Safety and Health Administration program comes as a great surprise to all of us.

MSHA Launches New Safety and Health Initiative

ARLINGTON, Va.- The U.S. Department of Labor's Mine Safety and Health Administration (MSHA) today launched "Make the Right Decision," a safety and health initiative that helps miners and mine operators focus on human factors, such as decision-making, when at work. The campaign encourages miners and mine management to work together on safety and health issues.

"MSHA will increase its focus on safety decisions during this campaign, which is not a limited-time initiative," said David G. Dye, deputy assistant secretary of labor for mine safety and health. "We want miners and management to make the right decisions to ensure the safety and health of America's miners."

Through "Make the Right Decision," miners and mine management will receive tools to help them recognize hazards and take appropriate action to correct or avoid risks. As part of the educational initiative, MSHA officials will conduct safety talks with miners and mine operators at mine sites nationwide and distribute posters, stickers and fliers with campaign messages.

Agency representatives plan to incorporate two programs in the "Make-the-Right-Decision" campaign. The first program is SLAM, an acronym for stop, look, analyze and manage. The second is SMART, an acronym for stop, measure, act, review and train. Together, these programs address the spectrum of safety decisions made in the mining workplace, from risk assessment at the miner level to risk management at the operator level.
So what's the problem with encouraging workers to make the right decision?

First, the assumption of this program is that most accident happen because workers make the wrong decisions. In other words, all you need is a little education, training and enlightenment and all will be well. If accidents continue to happen, they're caused by worker carelessness, incompetence, stupidity, suicidal tendencies -- and just plain dumb decisions.

In other words, "Make the Right Decision" is just your same old "behavioral safety" program under a new name. Behavioral safety theories say that worker carelessness or misconduct is the cause of most accidents, and disciplining workers is the answer. But behavioral theories don't hold up to a closer look at the root causes of most workplace accidents: generally management system and organizational problems that lead to unsafe conditions. (Confined Space has covered the issue numerous times before -- Here, here, here, here, and here to name just a few)

So what about these two "unavoidable accidents" reported last year? Would they be alive today if they had just made the right decision?
Two miners killed in pair of incidents

After badly burning his hands in a coal-mining accident earlier this year in Perry County, Edwin Pennington said he was finished with mining work, but he returned for the money, his father said yesterday.

On Wednesday night, Pennington, 25, of Harlan County, was crushed to death in a rock fall at a Bell County Coal Corp. mine — one of two underground mining deaths hours apart in Eastern Kentucky.

Eric Chaney, 26, of Pike County, was crushed in a roof collapse early yesterday at a Dags Branch Coal Corp. mine in Fedscreek in Pike County, officials said.

The deaths were the second and third fatal mining accidents in Kentucky this year, and the first underground fatalities. Nationally, 14 miners have died in accidents this year.

***

Bill Caylor, president of the Kentucky Coal Association, an industry group, said the two deaths were unavoidable accidents. "We don't want things like this to happen, but they will," Caylor said. "Mining is very safe, but you have to be careful because you're working around big pieces of equipment."
Or maybe Kevin Lupardus died because he made a bad decision:
Investigation of fatal accident at Boone mine continues

CHARLESTON, W.Va.- State and federal authorities are trying to determine what caused a section of high wall to fall onto an excavator at a Boone County surface mine, killing the machine's operator. The accident occurred at about 2 a.m. Saturday November 21, at Independence Coal's Red Cedar Surface Mine near Clothier. Independence Coal, a subsidiary of Richmond, Va.-based Massey Energy, operates the mine as Endurance Mining, according to federal Mine Safety and Health Administration records. Kevin Lee Lupardus, 41, of Mabscott, was operating the excavator when a "large section" of the highwall fell onto the machine's cab, said Terry Farley, an administrator with the state Office of Miners' Health Safety and Training.
It is somewhat ironic that this program is starting now. Clearly acting Assistant Secretary Dye hasn't read the June 2005 issue of Occupational Health & Safety which contains an article by Fred Manuele entitled "Serious Injury Prevention."

Manuele cites experts who point out that what may look like "human error" are actually system errors:
R. B. Whittingham, in his book The Blame Machine: Why Human Error Causes Accidents, describes how disasters and serious accidents result from recurring, but potentially avoidable, human errors. He shows that such errors are preventable because they result from defective systems within a company.

Whittingham identifies the common causes of human error and the typical system deficiencies that lead to those errors. They are principally organizational, cultural, and management system deficiencies. Whittingham says that in some organizations, a "blame culture" exists whereby the focus in incident investigation is on individual human error, and the corrective action is limited to that level. He writes: "Organizations, and sometimes whole industries, become unwilling to look too closely at the system faults which caused the error"
He notes that although humans may be involved in the errors that lead to accidents, James Reason and Alan Hobbs, in Managing Maintenance Error: A Practical Guide point out that one needs to look deeper:
Errors are consequences not just causes. They are shaped by local circumstances: by the task, the tools and equipment and the workplace in general. If we are to understand the significance of these factors, we have to stand back from what went on in the error maker's head and consider the nature of the system as a whole . . . this book has a constant theme . . . that situations and systems are easier to change than the human condition
In other words, look at the safety systems and find the root causes. If managers (and MSHA)continue to attempt to prevent accidents by focusing on human errors and "wrong decisions," the same accidents, injuries and deaths will continue to happen.

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