Incident Prevention Magazine

Kelly Sparrow, CUSP, J.D.

Production, Quality, Safety and the Bermuda Triangle

We’ve all heard or read about the Bermuda Triangle, a loose geographic area with Miami, Bermuda and San Juan, Puerto Rico, serving as the triangle’s three points. Legend has it that lots of strange things have happened in the Bermuda Triangle, mostly the unexplained disappearances of ships and airplanes that sailed or flew through the area. You may remember the story of Flight 19, a group of five torpedo bombers that disappeared on December 5, 1945, over the Bermuda Triangle while on a training mission. Fourteen airmen were lost in the incident.

There is a part of the story that a lot of people don’t know about. Those in command responded to the missing Flight 19 by sending a flying boat – a plane that can land on water – to search for the lost planes. It is believed that the rescue plane had a small, undetected fuel leak that caused a vapor buildup in the fuselage. The plane exploded in midair, and all 13 crew members were lost while they were looking for Flight 19.

Experts think the five planes of Flight 19 may have been uniformly underfueled due to a faulty gauge on the tanker that fueled them before they took off. Because systems for checking the gauge failed to discover that problem, 14 men died and 13 more died searching for them. If a quality equipment inspection had found the faulty gauge on the truck, or the operator of the truck had questioned why the filling operation had been completed so quickly, or the flight crew had asked for a recheck, the Flight 19 mission might have gone off without any problems. If that had happened, the rescuers would not have died because their flight would have been unnecessary.

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Kelly Sparrow, CUSP, J.D.

The Power of a Tool and Equipment Inspection System

It’s a hot, muggy day in Missouri. A crew is preparing forms for a foundation that will be poured later, when it cools down a bit. Two employees are pounding in steel support stakes for the forms. They’ve used theses stakes forever, and the heads of the stakes have always looked like mushrooms due to their frequent contact with a 10-pound sledge. Santiago is on the sledgehammer, using all the force he can muster to drive the stakes deep into the earth. Jeff, waiting to hold the next support stake, momentarily removes his safety glasses to wipe the sweat from his brow. Santiago takes one last swing with the sledge and the unthinkable happens. A piece of the rusted mushroom on the head of the stake he is pounding breaks off, ricochets off a rock on the ground and enters Jeff’s left eye, causing permanent loss of vision.

In Georgia, a logging foreman gets his truck stuck in mud. The crew prepares to pull the truck out, using their truck to pull and a 20-foot logging chain as the connection between the two vehicles. The chain has been in their truck for some time and is rated for the intended purpose. They attach the chain to the frames of the two vehicles and start the pull.

It all happens so fast. About 4 feet out from the bumper of the stuck vehicle, a link gives way. Sixteen feet of heavy chain recoils, striking an employee standing by the chain in both knees. After extensive surgery, the employee retrains for work that is less demanding than the logging work he loves. Investigation reveals that the broken link in the chain was severely compromised by abrasive wear and neglect.

What could have prevented these two incidents? In the first incident, it would be easy to blame the injured employee for taking off his PPE, but we all know that PPE is the last line of defense. Good safety systems prevent unwanted occurrences before PPE is needed.

Both of these incidents could have been prevented by an aggressive inspection and removal-from-service program. Below are a few things to think about when reviewing or revamping your inspection program.

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Kelly Sparrow, CUSP, J.D.

The Importance of Situational Awareness in the Utility Industry

Years ago I read an account of an injury that took place on a U.S. Army base in California. I’m not sure if this account is truth or fiction, but it serves to illustrate a point about the importance of thinking a plan all the way through prior to implementing it.

A private was assigned the job of removing broken Spanish tiles from a rooftop after a large tree fell on the building. He was ordered not to throw the tiles off the roof. The private drove a jeep to the site and assessed his work.

There were lots of broken tiles, and it would take many trips up and down a ladder using the canvas he had to wrap them in. The building had an empty rain barrel, the private had a rope and a block and tackle, and a brilliant plan formed in the private’s head. He climbed a ladder to the edge of the roof and tied the block and tackle to a beam left exposed by the damage. He threaded the rope and lowered it to the ground. He went back down the ladder, attached the rope to the barrel and raised it to roof level, and tied the rope off to the bumper of the jeep.

The private went back up the ladder and quickly filled the barrel with broken tiles. This was going to be a piece of cake. He went back down the ladder thinking he would be done in three barrels’ worth. He untied the rope from the bumper and held onto it.

Can you guess what happened next?

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Kelly Sparrow, CUSP, J.D.

A Mother on the Job

We’ve all watched young mothers care for a newborn child. As the child learns to crawl, mom is meticulous in placing household cleaners out of reach. She ensures that dad installs locks on all drawers that have knives or sharp objects, and together they remove all objects that could fall on their little explorer if he should jiggle a table. The vigilance is endless.

As the child grows older, mom and dad teach him to ride a bike, but always with a helmet, and always with the proper high-visibility clothing. They are constantly teaching the child to obey rules that will keep him safe.

Soon the child is off to school, and with school come more dangers. Mom teaches her child about the perils of traffic, riding a school bus and a myriad of other activities the child engages in, now without mom’s close supervision.

Mom continually insists that her child form good safety habits too numerous to mention. Is he wearing his helmet when he rides a bike or skateboard? Does he look both ways before crossing the street? Is coming home when the streetlights go on a routine part of his life?

Then the day comes when mom and dad hand their son the car keys. They teach the child about speed, alcohol, drugs and other drivers who may make poor choices. By example, they have taught their child about proper use of seat belts and other safety precautions. He knows how to change a flat tire and perform other emergency techniques.

Finally, after all those years of worry and vigilance, their 20-year-old son gets a job as an apprentice with your company. If the mother of your new employee were observing her child during his first few days of work, would it change how you introduce him to the workplace? What if all the mothers of your employees were continually watching how their sons and daughters are treated at your worksite?

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Kelly Sparrow, CUSP, J.D.

The 911 Dilemma

It’s happened to most of us. We’re at a job site and someone gets hurt. We’re not sure how badly the employee is hurt or if we should call 911. Sometimes when an incident occurs, we think it might be better to take the injured employee to a care facility rather than call 911 for emergency assistance. If you ever find yourself in this predicament, there are two simple guidelines to help you decide what to do. First and foremost, remember to do no further harm. If there is any chance that you could cause the employee additional injury by taking him or her to get medical care, call 911 for professional help at the job site. Second, there are three types of injuries that always necessitate medical personnel capable of advanced care. Always call 911 when any of the following are involved.

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Kelly Sparrow, CUSP, J.D.

Safe By a Nose

Years ago I went to a horse-racing track with my co-worker Larry. Horse racing is his passion, so he spent hours choosing which horses he would wager on in the races that were on the slate that day. Larry taught me a lot about how the races work.

In a nutshell, the track establishes the line on each horse in a race by reviewing lineage and the relationship the horse has with its assigned jockey. They calculate how well each horse runs on a particular type of track, such as turf or dirt. They also consider track conditions. Does the horse run best in wet or dry conditions? Is the horse better at long distances or shorter ones? Additionally, they check the form of each horse in the race, including win-loss records, how the horse has interacted with other horses in the race and its record on different types of tracks.

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