In this article, safety expert R K Poddar shares his personal views, experiences, and insights on safety management in large corporations and industries.
Let me start this piece with an unfortunate incident: a gentleman would start from his home at 08.00 hours every morning to board a train for his office. He would reach platform no. 2 by crossing the foot over-bridge (FOB) that ran across all the platforms. On the fateful Monday morning, on reaching the entry gate a bit late, he saw that his train was about to leave. So, he got down onto the railway tracks, having decided to board the train from the wrong side even as it started inching forward. Thus preoccupied, he was about to cross the rail tracks when a train coming from the opposite direction ran over him.
Is this incident an accident and is the resultant fatality indicative of ‘accidents don’t happen, they are caused’? (a safety slogan displayed all over industrial set-ups). Did the victim bring on his death of his own volition? Was he a victim of his own indiscretion? Was his death brought on by his choice?
If this incident is translocated to a workplace, the above questions will touch upon the spirit of our contemporary safety management system. We ‘safety’ people (I feel shy of using the word ‘professional’ as many of us hardly qualify for that term) keep on teaching Hazard Identification, Risk Assessment & Control etc. But did the victim know the risk? Was he in a position to eliminate or control the risk? Many safety people will say: yes, he knew the risk and did calculate the outcome of the risk. But his compulsion to board the train threw caution away. Many others would call the unfortunate incident an ‘accident’ or an ‘accidental death’.
Distinction between ‘accident’ and the ‘outcome’ of the accident
This incident raises two fundamental questions in my mind: is our understanding of ‘accident’ right and do we draw a distinction between ‘accident’ and the ‘outcome’ of the accident? In my experience, most of such incidents and their outcomes are treated as an integral entity – rather such deaths are invariably classified as ‘accidental’, ignoring the process that triggered the death (well, what’s ‘accidental’ about them?). If we agree to such postulates, then all suicidal deaths are supposed to be accidental deaths only, keeping aside the psychological aspects.
Let me take an extreme case of cause-and-effect analysis: One Sunday morning you’re cleaning your pistol; you then load it and place it on your tea table. You plan to later take the bullet out and put on the safety latch and keep the pistol back in its safe place. A friend drops in and when you enter the room, you find him holding the pistol, unmindful of it being loaded. In jest, he fires at you, believing it to be unloaded. Now, either of the two outcomes can be expected: the bullet may fly past you by a few millimeters, or it may hit you.
In an industrial situation, how do we categorize a near-miss or a fatal accident? Are we sure our categorization is right? Let me explain my reservation: leaving the loaded pistol on the tea table, the friend toying with the idea of firing the pistol and then firing at you in fun – all these elements of the event comprising ‘various elements of the one integral process’ which in popular parlance is categorized as ‘accident’ and the resultant ‘near-miss or grievous/fatal head injury’ as ‘outcome’.
The very concept of ‘accident’ is misplaced in popular imagination. If an accident denotes the ‘unexpected’ then any ‘unexpected outcome’ should not be treated as culpable. In which case, all industrial incidents that cause bodily injury, damage to material, a near miss, or environmental degradation, should be exempt from all culpabilities since they are legally categorized as an ‘accident’.
I see an accident as a process and the consequence as an outcome of the process. Every accident does not result in a personal injury or material damage etc. Hence, it is important that we should comprehend the relevance of installing a safety management system to deliver the expected result.
Section 88 & 88A of the Factories Act
Before I proceed further, I would like to elaborate ‘accident’ as a process and its ‘outcome’ as a potential personal injury and/or material damage or near-miss or environmental degradation. I quote Section 88 & 88A of the Factories Act and the related Sections of the Building & Other Construction Workers (Regulation of conditions of service) Act to substantiate my understanding of the ‘Process & the Outcome of the Process’, though I see certain contradictions in the way the accident as a process and injury/damage as its outcome has been corelated in the Sections of FA and BOCWA.
Section 88 Notice of certain accidents: Where in any factory an accident occurs which causes death, or which causes any bodily injury by reason of which the person injured is prevented from working for a period of forty-eight hours or more immediately following the accident, or which is of such nature as may be prescribed in this behalf, the manager of the factory shall send notice thereof to such authorities, and in such form and within such time, as may be prescribed.
Section 88A Notice of certain dangerous occurrences: Where in a factory any dangerous occurrence of such nature as may be prescribed occurs, whether causing any bodily injury or disability or not, the manager of the factory shall send notice thereof to such authorities, and in such form and within such time, as may be prescribed.
It may be noted that unless an accident (process) results in at least a personal injury causing the injured person’s disability for at least 48 hours or more, the process concerned is not deemed to be an accident requiring the enforcement agency to be notified for further scrutiny/investigation that may facilitate corrective action.
The Factory Inspectorate is the only enforcement agency authorized by the Act to take cognizance and start the legal punitive action in the court of a First-Class Magistrate. An accident not qualifying for reporting to the enforcement agency amounts to giving the employer the option to bury the event under the carpet, even though that event might have the potential to cause colossal damage/environmental degradation/personal injury, barring those few specified dangerous occurrences under Section 88A, which the employers would be required to report, but may often be tempted to suppress or ignore. Not taking up such occurrences seriously is bound to manifest in a catastrophe later.
An accident by choice or by chance?
I had the opportunity of heading a safety engineering and training department at one of the largest construction organizations in the country for several years during which tenure I dealt first-hand with numerous unsafe conditions, unsafe acts, and accidents as a process/fatality/bodily injury and such other outcomes.
Here I use the words “my subjective conclusion” since I am expressing my observation in my individual capacity as a safety professional. I reproduce hereunder certain pictures snapped at the accident scene which can be easily spotted in any workplace, and which have the potential to help you choose between the two options: by choice or by chance.
The illustration shows a muck dumper which seems to have broken down. P&M is under pressure to get it repaired and made functional fast. A mechanic (skilled) and a helper (unskilled) are assigned to attend to the breakdown. Mechanical excavation for a deep foundation is under way and the excavated earth accumulating overload at the edge must be whisked away, lest it results in accumulation overloading the edge of the excavation and making it collapse at the excavated edge.
They are made to understand the urgency of the situation and mandated to get the dumper running in the shortest possible time. No supervisory personnel accompany them as the job is deemed to be routine. The two maintenance guys reach the spot with their toolkit, hoist the body of the dumper to inspect and determine the nature of the defect, and they squeeze into the limited space between the raised dumper body and the chassis. They spot a leak in the hydraulic system from a gland and try to tighten the bolts, when the gland gives way and a profuse leakage erupts. Suddenly, the hydraulic system holding the dumber body up loses pressure and the raised body comes down, without allowing time for the maintenance crew to move to safety. Both were crushed to death.
Now, let’s examine this fatality vis-à-vis the fatality of the person trying to run across the rail tracks instead of opting to use the FOB. The latter case is a typical incident of a calculated risk gone awry. The resultant fatality amounts to ‘an outcome of the accident (process) by choice.’ By taking a conscious decision to cross the tracks, the fatality was of his own making.
But the same logic does not hold good in respect of the dumper guys who were under compulsion to rush through the job. Also, the maintenance job was not planned from the safety point of view by the maintenance management that had no clue about the nature of the breakdown. It was left to the judgement of the two maintenance personnel to diagnose and rectify the problem.
Simply placing a wedge between the lifted body and the chassis would have held up the dumper body and prevented it from crashing down. But the maintenance crew did not carry any wedge with them as they did not know what the problem was in the muck dumper, which was standing immobile at an isolated place.
The fatalities and the preceding accident (start of the process) was, in my judgement, a consequence of an unplanned activity – showing utmost disregard to the need for proactive planning on the part of the management. In this case, the senior members of the maintenance department ought to be held accountable.
If you read the OHS code, the intent of the law makers is clear: the P&M boss who instructed the maintenance crew to rush to the stranded dumper was representing the employer and was, in fact, the process owner in the workplace, though the two maintenance guys could be perceived as the secondary process owner who either did not know the risk involved or were unmindful of the hidden risk. Muck dumpers work on a hydraulic/pneumatic system for dumping operations and people associated with the operation or maintenance must be fully trained in hazard identification, risk assessment, and in risk control measures.
Root cause analysis and relevance of OHS Code 2020
I have had the opportunity to investigate and go to the root causes of various industrial accidents and their outcomes. I daresay that most of the serious accidents involving bodily injury/material damage/environmental degradation are not objectively investigated.
The Code which talks about the process owner and his accountability, may perhaps do away with the concept of occupier. Replacing it with employer/process owner is a step in the right direction. The onus for exercising due diligence must rest with the process owner who is operating at the operational level.
About the author:
R K Poddar has held various senior posts as:
Ex-Head Safety Engineering of L&T-Construction
Ex-Head Safety Engineering of Simplex Infrastructures
Ex-HSE Consultant of Bureau Veritas India
Ex-Associate Director of Indian Institute of Production Management
Ex-Member, Board of Governors of National Safety Council of India
Visiting Faculty, CIDC, NICMAR, CII & others