Magazine article Occupational Hazards

Injuries While on Autopilot: What Are We Missing? A Systems Approach to Safety Helps Ensure Solutions That Are Natural and Effective. (Core Practices)

Magazine article Occupational Hazards

Injuries While on Autopilot: What Are We Missing? A Systems Approach to Safety Helps Ensure Solutions That Are Natural and Effective. (Core Practices)

Article excerpt

An employee was walking into work from the company parking lot one cold, winter morninng. A very careful worker, she had gone the last 15 yeras without anything more than a paper cut. As she got out of her car, she was careful to chek for ice. Walking through the parking lot, she took smaller-than-usual steps and placed her weight directly over her bearing fooft. Opening the entry door to the office complex, she even stopped to straighten out the large rug just beyond the door to eliminate a triping hazard for others.

Turning toward the elevator, she stepped on a splattering of water left just seconds earlier on the polished marble floor. Suddenly, she was airborne. She landed hard on her hip and the outstretched arm she used to try to brace her fall. Her injuries resulted in many months off work, hundreds of thousands of dollars in workers' compensation costs and a permanent partial disability.

The company she worked for was in its third year of implementing a behavior-based safety program. In general, the behavior-based approach had been very successful in reducing the amount of injuries and the costs associated with them. Underlying these indicators, the three-year approach had been extremely valuable in clarifying safe behaviors, standardizing and entrenching known consequences for behaviors, and getting employees actively participating in the safety program. Using behavior-based analysis, company officials concluded that this was an anomaly, a quirk, an isolated event. But was it?

In fact, this injury represents a large percentage of accidents, both work-related and nonwork-related. A brick is dropped, a finger is caught, a slip occurs, someone stumbles, fingers are pinched in a closing garage door, a load is set down in the wrong place - things like this happen everywhere, everyday.

"If only people kept their mind in gear," we conclude in our analysis. "You've got to think all the time!" In our Monday morning quarterbacking, however, we miss the real problem because we think in terms of "parts" and not "systems." In using our learned cause-finding approaches rather than "system thinking," we fail to understand common accidents that happen while people are going about their daily activities on autopilot.

Autopilot Exposure

Using walking as an excellent example of this type of autopilot exposure, let's look at some of the analytical differences.

Scenario: A person walking on a sidewalk toward an office door strides up three steps, walks down a 100-foot sidewalk pathway, approaches the office door, trips against a 1/2-inch rise from one sidewalk plate to the next and falls.

Traditional analysis 1: The person is clumsy and inattentive. They are sternly counseled to be more careful and to keep alert. They even may be disciplined for being stupid or breaking a safety record.

Traditional analysis 2: The cause of the injury is the rise in surfaces. The correction is a quick coat of yellow paint and a work order to have the edge ground down or a new concrete patch installed to remove the difference in walking surfaces. The employee is still coached to be more careful and attentive when walking.

What's wrong with this thinking? In a nutshell, both traditional analyses missed the true cause, damaged the morale of a person and, by ripple, his/her working team, sent the wrong message into the "safety culture" and probably wasted money and effort in the solution.

Looking at this same scenario from a systems perspective brings about a very different result. From a systems perspective, you must look at all the parts that make up the system. You simply cannot ignore the mechanics of walking or the walking control process and patterns that are natural to each of us.

Body mechanics of walking: Walking is a simple process of weight transfer and pendulum motion of the legs. As one takes a step, the leg's pendulum motion causes the body weight to move from the plant foot to what will become the step foot. …

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