Pit & Quarry, April 2012

SPONSORED BY As we look at other peoples misbehaving children we shake our heads and pontificate that the behavior is the result of heredity environment or some combination As management looks at an injury victim it shakes its head and reflects that this flawed human has done himself in the behavior is the result of heredity environment or some combination As management looks at an injury victim it shakes its collective head and reflects that this flawed human has done himself in completely forgetting that the working environment is the prerogative and responsibility of management When there are flaws in the first two premises of an argument the conclusion is sure to be suspect Next in the third domino is the tried failed and abused unsafe act unsafe condition cause The working conditions are the physical surroundings procedures and practices created and maintained by management Time management and financial resources have to be provided to create and maintain the systems in which miners are guided into success and not diverted into failure A mere human can gather diverse information and generalize and do it regularly and well However repeating the same action for extended periods ultimately leads to failure which can be an injury PQ Carl R Metzgar CSP has more than 30 years of safety and health experience in the aggregates industry He provides consulting services with a specialization in program evaluation training compliance and loss control and can be reached at 336 766 1218 cmetz46840@ aol com BY CARL METZGAR Five factor failure T he second edition of Heinrichs book Industrial Accident Prevention A Scientific Approach was published in 1941 Not far removed from that time H L Mencken suggested something like For every complex problem there is a solution that is simple neat and wrong Injury causation is a complex loss control problem Heinrich offered his fallingdomino explanation to this complex issue in 1941 and it was and remains simple neat and wrong Heinrich reduced his explanation to five factors that he illustrated with dominoes set on end so that if the first one falls the succeeding dominoes fall in turn First domino The social environment which includes the very essence of being human reflecting inheritance and environment Second domino A fault of the person reflecting possible acquired faults in judgment inconsiderateness recklessness and ignorance of safe practices Third domino Unsafe act and mechanical physical hazard Fourth domino The accident Fifth domino Injury Heinrichs explanation calls for the dominoes falling in order Despite being wrong it has been repeated unnumbered times since 1941 The social environment domino falls into the faults of the person which in turn falls into the unsafe act and or unsafe condition to cause the accident that results in injury Influenced by psychology The Heinrich injury prevention solution is to somehow remove or lift the unsafe act and or condition out of the sequence With the unsafe act and or unsafe condition out of the sequence the falling action cannot move to the injury Heinrich built his thinking under the fashionable predominating influence of psychology That of course turns out to have been unsound see my February column That point of view has continued to be the dominant theory for years and unfortunately is still being taught Eliminating unsafe acts and unsafe conditions is presumed to be simple and neat which of course turns out to be wrong The causes of unsafe acts in and of themselves are complicated On top of that extensive complexities can result in unsafe conditions and equipment Reducing these complexities is beyond pseudo psychological knee jerk reactions Concentrating on the miner and unsafe conditions masks the real issue which is the management system Heinrichs book was written before systems safety and the recognized but not generally accepted notion that management is responsible for its systems Loss control is only one vital system for which management is responsible In current cliché speak Its the system stupid Blaming the victim for his or her injuries is shortsighted nonproductive pointless destructive and misdirected Finding flaws The characteristics included in the first and second dominoes overlap The first domino concentrating on heredity and environment includes everything named in the second domino The second domino only serves to detail the first domino As we look at other peoples misbehaving children we shake our heads and pontificate that 48 PIT QUARRY April 2012 www pitandquarry com