March/April 2015
Everyone
knew within seconds that any effort to save Billy was futile, but hope doesn’t
die as quickly as people do. Perhaps there was a chance—however remote it might
have been—that this one time, this one person could endure 10,000 pounds of
crushing force. As the sirens grew louder in the distance, workers scrambled to
remove the lock-out devices and restart the machine so that it would refill the
hydraulic cylinders and lift the massive piece of steel off the young man. A
crowd gathered, only to look away as the shear clamp lifted, revealing Billy’s
body. There was no blood. He lay doubled over at the waist, his forehead
touching his knees.
Billy
was dead. Nothing the rescuers did could have changed that. It made no sense to
risk further danger to emergency personnel, so Billy would have to wait a while
longer, sitting in that terrible, contorted position for as long as it took to
turn off the machine and lock out all the component parts. That included taking
the one lock-out step that would have prevented this nightmare in the first
place.
A New Record
Changing
the blade on a shear takes a long time, and for most companies, time is a
precious commodity. Because Billy’s crew was experienced—because the crew
members were so good at what they did—they decided they would break the speed
record for changing the blade in the facility’s side-compression shear.
Afterward, people would wonder why they were keeping such records in the first
place.
Billy’s company—let’s call it Smith
Recycling—takes safety very seriously. It employs a full-time safety
professional who made sure the company had procedures for every operation and
provided annual training on those high-hazard jobs that required such training.
The company’s records were impeccable. In fact, during OSHA’s investigation
into the fatality, Smith Recycling was able to show that it had trained Billy
not once, but twice in the six months before his death on the very procedures
he chose not to follow on the day he died.
Out of all of Smith’s procedures, none was
taken more seriously than the one that deals with the control of hazardous
energy—what most people call lock-out/tag-out. For an operation as complex as
changing the shear blade, Smith Recycling required every employee who would be
exposed to the hazards of potential energy to sign the lock-out form, and a
supervisor had to sign the form as well. By signing, each person verified that
he or she had visually inspected each lock-out requirement and that each
requirement had been met.
On the day Billy died, none of the people who
signed the form—including Billy—had actually looked at anything. Because they
didn’t look, they could not truthfully verify anything. But there was a record
to break, and they knew they had to sign the form before the work could
proceed. It’s easy to imagine how the second, third, or sixth person who signed
the form assumed that someone on a line above had done the job he or she was
supposed to do.
Because no one looked, no one saw that the pins
that hold the clamp in place in the event of a hydraulic failure had never been
installed. After the blade change, Billy entered the compression chamber to
clear out the tools. He saw a piece of steel trapped between the floor liner
and extension arm and pulled it loose, sending the clamp crashing down on top
of him.
A New Focus
After
Billy’s death, as the pall still hung over the Smith Recycling workplace, work
had to go on. Salaries still needed to be paid, materials processed. On the day
of Billy’s death, however, everything changed. The awful burden of
responsibility for his death pushed the Smith management team to reassess its
entire approach toward safety in the workplace.
A safety program, the team realized, is not
about procedures and forms and training rosters. A safety program is about
inspiring people to do the right thing the right way, every single time. A
safety manager is an important resource, but the safety manager is not the
safety program. Every employee is the safety program. Every employee is
responsible not just for his or her own behavior, but for the behavior of other
team members as well.
As the company hires new employees, the Smiths
themselves spend time with each one of them. They emphasize, as owners, that
there is only one correct way to do a job and that it is every individual’s
responsibility to comply. The message is reinforced multiple times every single
day. No one is exempt.
Looking back, the management team members
realized that much of the responsibility for Billy’s death rested on their own
shoulders, if only because of the many times they had looked away and made
excuses for the unsafe behavior of Billy’s supervisor. They made the excuses
because the supervisor was so good at his job. So good at production. So good at
getting things done quickly and cheaply. How unsafe could he be, after all, if
the work got done and nobody got hurt? He set records, for heaven’s sake! It
was hard for the Smiths to fire a man who had been with the company for so long
and who possessed so much institutional memory. But it wasn’t nearly as hard as
they thought it would be.
Looking Grief in the
Eye
Billy’s
father was enormously proud of his son. With the headlines at the time
highlighting so much negativity—from a bad economy to high unemployment to the
alleged slothfulness of the younger generation—Billy’s dad boasted to his
friends that his boy was a hard worker. At the funeral, he took special pride
in pointing out to other mourners that even in his casket, Billy still had dirt
under his fingernails.
The Smiths were all there at the funeral, as
were many of Billy’s co-workers. They witnessed the family’s agony firsthand.
Everybody understands in principle that to lose a child at any age leaves a
hole that will never heal, but it’s different to see the anguish up close. It
tears at you. It eats you up. Sometimes it makes it hard to live with the
decisions you made—or didn’t make—that might have contributed to someone else’s
perpetual pain. You find strength in the knowledge that while you can’t change
the past, you never have to repeat it. The Smiths owe Billy that much.
John Gilstrap is the
former director of safety for ISRI.
Editor’s Note: Give us your thoughts
about this article—or tell us about an incident you’d like to share—by contacting
Scrap editor-in-chief Rachel H. Pollack at rachelpollack@scrap.org or
202/662-8543.