By David Libby
Falling Limb Kills Faller - Choker Setter Struck in Head by Swinging Log - Worker Killed While Welding Wood Chip Conveyor - Log Truck Driver Dies When Struck by Logs - Chaser Crushed Between Two Logs - Operator Crushed in Processor Head
How many of us have been involved with or known someone affected by incidents like these? Likely all of us.
Despite progress over the past three decades in reducing serious injuries and fatalities (SIF) in the logging industry, logging workers still experience the highest fatality rate among all occupations. (The 10 most dangerous jobs in America; logging and forestry ranked as Canada’s most dangerous industry.) This has occurred despite increased mechanization that has reduced worker exposure. Decision making and behaviors resulting in serious injuries or fatalities continue to be repeated in the workplace. Identifying those decisions and behaviors and their causes while effectively communicating that information through training and other means should result in a measurable reduction in those incidents.
Traditionally, we have looked at the site-specific unsafe acts and conditions in the few minutes or hours before the event that led to the injury or fatality, to learn how to prevent these in the future. As important as that approach is, there are other factors far upstream of the incident that likely contributed.
A study by safety consultants the Krause Bell Group of 60 total incidents from 16 companies identified 600+ decisions that ultimately contributed to the incidents. These decisions set the tone or work culture that allowed the unsafe behaviors to exist.
To illustrate this point, we can use an example from a case that was included in the study. In 2010, a metal dust explosion inside a metal blender resulted in three fatalities and one critical injury. One of the blender blades had struck the side of the blender, causing a spark that ignited the extremely explosive metal dust. During the investigation, it was found that workers had repaired the blade multiple times. When it continued to function improperly, they decided to replace it with a used blade from an older blender. In this case, it would be completely reasonable to point to that decision as a cause of the incident. But when investigated deeper, we find that management had made a chain of decisions years before the explosion that set the stage for the final, fatal decision of using the older blade. When the site was first opened, corporate had decided not to purchase backup equipment to keep on-site in case of failure. They also decided to work on a 24/7 schedule that did not allow for equipment downtime and exerted time pressure on the operation. The site manager decided not to enforce a known rule for closing the blender lids while they were operating. When first informed of the faulty equipment months before, site management decided to defer maintenance due to cost. Although the maintenance worker had the option of making a different choice, it becomes evident in cases such as this that decisions made by management had the greatest influence and created the conditions under which such a disaster could occur.
One of the most pronounced findings of the study was that decisions made above the front line have a major role in injury prevention. Of the decisions found to have influenced the 60 SIF events, 67 percent were made by individuals above the front line (department managers through corporate executive leadership).
The implications of this are far-reaching. It seems common knowledge that managers play a role in incident prevention and causation, but to suggest that they have a larger role than those at the front line could revolutionize the way we approach safety. It is critical that this finding is not misconstrued as blaming the manager, any more than it would make sense to blame the worker. What this suggests instead is that leaders are positioned to have a greater influence over safety than previously thought, and by equipping them with the appropriate knowledge and skills in decision making, they could provide the greatest opportunity in safety improvement.
In addition, the study found that of the 67 percent of decisions made above the front line, 79 percent of those were made at the site level. This was an unanticipated yet incredibly meaningful finding. What this says to the safety world is that the shortest distance to a zero-injury rate is through a direct focus on decision making within site management. These are the leaders who make critical, operational decisions every day that have direct impact on safety. Some examples of this are scheduling, over-time allocation, purchasing of new equipment, hiring, etc.
Call to Action
Identifying trends in decision making and changing the business culture can result in a measurable reduction in SIF. Krause Bell has successfully addressed this with their clients through their participation in Industry SIF Prevention Centers of Excellence (COE).
COE member companies share SIF data and incident investigation reports and make team members available for further learning. Members fund an in-depth study of three to five actual fatal incidents. Learnings, insights, and better practices resulting from the study and Krause Bell Group research and advice are shared with member companies. Ongoing data is shared to measure fatality prevention processes and how to proactively identify and mitigate SIF Precursors.
For more information, contact: David Libby, Partner Krause Bell Group at [email protected]
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