For safety managers, accident investigation is part of the job. Here, Helen Ibbotson gives an account of her time at a food factory, when a little extra digging around revealed that the circumstances surrounding an amputation incident were not as straightforward as they first seemed.
When a factory employing 1700 staff is in full swing,
accidents will occur, and some of them, unfortunately, will be serious. Investigating those accidents thoroughly is of enormous value, often highlighting risks as nothing else can.
In a food factory, machinery using huge and sharp blades is commonplace. The risks associated with these blades are considerable, and well recognised; thus effective guards have been developed and, as a result, accidents during operation of the blades are thankfully rare. However, the blades have to be changed, transported, disposed of, and, above all, thoroughly cleaned — all tasks that involve contact with the blades for various members of staff. Here, too, the risks are well recognised and have been thoroughly assessed. They are managed by a combination of physical safeguards, such as specially designed blade carriers, and procedures that are properly documented and in which each person handling the blades has been carefully trained. So that’s alright, then.
Night-shift nightmare
The first shift at the factory starts at 6am, so I’m in early as usual. Even so, most of the management team is there before me, so something is up. The factory operates a twilight-shift hygiene team, whose remit is to come in after production has finished, at about 9pm, and carry out a thorough clean of production areas and equipment. Their duties include cleaning the processing machinery and the blades. A young man — let’s call him Kevin — in the job for only eight weeks, has had a very serious accident with one of the blades. Three fingers have been amputated, he has lost a lot of blood, and he is currently in hospital.
By lunchtime, I have established the following facts:
Kevin was washing the blade in a sink of soapy water, not using the carrier or any other precaution. As he lifted the wet and slippery blade out of the sink, he lost his grip on it and attempted to catch it as it fell. He was working completely outside the procedures given for the task.
The line managers and Kevin’s supervisor are satisfied that they are in the clear. Kevin chose to act in an unsafe manner, and to disregard the training he had been given. The case is straightforward. It is worth noting, however, that line management often responds to an accident by being overly ready to blame the victim. This is a very natural response, and alleviates any guilt they may feel, but should be taken into consideration by the investigator.
I decided that a little more investigation would be worthwhile. Talking to the accident victim was not possible, as is often the case with the most serious accidents. There are other avenues to explore, of course. The mystery to me was why Kevin should have so disregarded the training he had received and the procedures he had been taught.
I spent the evening and the early part of the night with the hygiene team, watching them work, and taking the chance to get to know a team that is rather detached from the main employee body, and very self-sufficient. I talked to the team supervisor, a somewhat intimidating man. He was well regarded by his management for the high standards of cleanliness achieved by his team, and for the rarity of problems with the team and its performance.
I also chatted to the union representatives, and reviewed attendance and accident records for the team. Interestingly, it had an excellent accident record, with virtually no accidents reported, and had twice won accolades for the best accident and incident performance in the factory.
Communication with the team members was somewhat difficult, partly because some of them had little English. Also, they were intent upon their work and reluctant to break off and talk to me. They were working strictly in accordance with the procedures. The supervisor assured me that this was always the case, and that he could not understand Kevin’s actions.
The fog begins to clear
The following evening I was there again, much to the supervisor’s annoyance. This time, I removed two of the team who had seemed most willing to talk to me, and took them to the empty canteen to talk in private, at which point a different picture began to emerge.
Getting the trust of the operatives was not easy. Promises had to be given regarding anonymity and protection for them in the event of a comeback. At that time, in this area, jobs were hard to come by. But the workers were compelled to talk to me because of their own sense of unease.
The twilight-shift hygiene team worked alone in the factory, and management visits were rare. New workers, once their company induction and training were complete, were passed to the supervisor. “Forget all that crap, you do it my way” was the message they were given.
The supervisor had one interest, and that was to get the factory cleanliness to the highest standard he could in the minimum time, so they could go home. Where safety procedures slowed the job, or made it more difficult, they were dismissed with scorn. He brooked no opposition, and no questioning. He had the power to dismiss workers instantly, and frequently did. He wielded power, backed with his fists on occasion. Only when under observation by management would the procedures be followed.
Accidents happened, but no worker who reported one would keep his job. Only an accident so serious that it could not be covered up had shed any light on the situation.
Looking at this from the perspective of the ‘villain’ of the piece — the supervisor — he was judged on results, and the results he provided were an immaculately clean factory and no problems. For these achievements, he gathered approval and praise. He dismissed the safety precautions as devised by ‘management types’, who didn’t understand the job and were simply trying to protect themselves against claims. Claims were not going to happen on his watch; his team wouldn’t dare. He therefore saw himself as doing his job well, and meeting the requirements made of him — and having the courage to disregard inessentials when they got in the way.
The root of the problem
The basics of this tale underlie many accidents. How do we motivate our staff? We give them a job to do, we make clear the importance of that job and, sometimes, we impose safety requirements that make the job harder and the outcome less certain.
In this case, the liability of my employer emerged clearly enough. Kevin had worked as he was instructed by his supervisor, and as those around him worked. We had done nearly everything right, and then failed Kevin in these most important respects.
The fact that the team worked alone was highly relevant, as it could never have shrugged off the safety procedures if managers and other teams had been around. Unfortunately, though, in the nature of the modern labour market, many teams and individuals work alone for much of their time.
There is also an element of masculine bravado to the events. The supervisor and the entire team were young men. “Wear gloves? What are you, a big girl’s blouse? Scared you’ll cut your little pinkies off?”
Sometimes, accidents arise from a failure to follow safety procedures that are hopelessly impractical, and/or would make the job impossible. Washing those machine blades in a protective carrier is slower and much more difficult than washing a blade alone. The results may not be as good, and getting perfect cleanliness is certainly impeded.
Safety procedures written by managers (including safety managers) in offices, remote from the job, usually fail. How different might it have been had our supervisor and his team been brought together to thrash out the risks in their work, and suggest sensible ways of reducing the major risks? Their procedures would not have looked as good, but would probably have been followed. It’s called buy-in.
Above all, we had not monitored safety in the work of this team in any meaningful way. Yes, we kept an eye on accident figures, but monitoring accidents often simply motivates people not to report them. We hoped we knew what they were doing, but we didn’t know. That is a very real management failure.
We also failed to consult and communicate with the team, with all communication filtered through the supervisor. Although there was an active union at the factory, none of the team belonged to it. Now why could that be? We had not provided any alternative route for the team members to raise concerns.
We had worked hard on our safety culture, and put some effort into training. In pockets, though, a very different culture had thrived, and much of our training had missed a team that worked outside our normal hours. Our supervisor had been rewarded for a job well done, and he saw no interest from management in whether it was done safely. We had inadvertently motivated him to disregard safety instructions.
This accident resulted from a culture in which the outcome — in this case, high standards of cleanliness — was the most important measure of success for the workers. Elsewhere in the factory, the great god Production would have been the measured outcome of the highest importance. Although time and money were expended on safety, the workers read between the lines and took the message that meeting production, quality and hygiene targets was of much greater importance.
Conclusion
My recommendations were:
As is ever the case, my report and recommendations went to the senior team for review. The managing director, who had felt sure that there was no fault to be found in this case — that it was simply a matter of an errant worker disobeying clear instructions — was very unhappy with the findings. Not with me, incidentally, but with the uphill battle they represented, and which he knew was going to be difficult to progress.
This is where temperament intervened. Successful food-factory and production managers don’t tend to be very reflective. Problem? Bang — solved! Next? The managing director gave the hygiene manager a telling off, the hygiene manager sacked the supervisor, Kevin got compensation, and we all settled down again. . .until the next accident.
Helen Ibbotson is a safety consultant.
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