Sunday, January 07, 2007

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?


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.