This statement is clearly pointing to a human failure—the worker himself is responsible. A few examples in the tool category help illustrate the need to dig deeper than blaming the worker. A worker in a cleaning room
received burns on his fingers from contact with a hot casting. The worker had defeated the protec- tion of his right hand by cutting off the fingers of his glove. Upon investigation, it was discovered the actuator switch for a tool he was required to use had a guard that had inadequate clearance for a gloved finger. The worker had compensated for the poorly designed tool by cutting the glove’s fingers off, permitting him to use the tool as intended. A worker in the melt shop fell and was injured during fluxing and dross-off of an aluminum holding furnace. Investigation revealed he had been issued a drossing tool that had a relatively short handle, creating substantial heat burden on the worker. The melt shop employ- ees had welded an extension to the handle to allow the worker to be farther away from the melt. This had broken suddenly during opera- tion resulting in a fall and fracture. A worker in a rework area was
struck by an overhead fixture and required stitches to his head. The worker, to reduce the trip hazard from the excessively long hose/ cable connections to his tool, had wrapped them around a fixture on his work station to get them out of the way. Fatigue on the fixture from the cabling and hoses finally overcame the fixture attachment and it struck the worker while falling. In each of these cases, a poorly
reviewed tool was provided to the worker. The worker, faced with the dilemma of his desire to do the job well while still using the deficient tool, made the situation work until the safety risk and probability caught up. Only with the most superficial of analyses can these cases be designated as worker- caused injuries.
26 | MODERN CASTING June 2017
the simple observation that proper PPE was not worn. Workers must be able to do the task (repetitively) with the PPE in place; it must work as required and not entail other problems that drive workers to compensate. For example, poorly designed or ill-fitting eye wear leading to fogging or unstable fit with head gear will only be period- ically worn (or perhaps completely ignored) by workers.
Harm in the Belief of Human Error Causality of Injury
Failure to identify and address the
Figure 3. Heinrich’s “Domino theory of ac- cident causation” expressed in a why-why analysis.
Personal Protective Equipment Management is responsible
to provide appropriate personal protective equipment to workers. Workers are required to wear this equipment and failure to do so is normally attributed as a worker responsibility. Yet management also has an obligation to make the PPE fit properly and be wearable for the duration required, instruct on proper fitment and sizing, and provide accommodation in the job routine for the limitations and constraints associated with PPE use. Injuries where PPE was not worn must be investigated beyond
root cause of any problem means the problem will recur. Just as clipping the top off a dandelion growing in a garden will only have a short- term effect, so too problems that are addressed only at a symptomatic level will happen again. Tragically, recur- rence of the problems in a foundry is tallied in a human cost, not just time wasted weeding again. Recurrence of safety problems wastes valuable people resources by implementing programs that are ineffective, misguided and sedative in their effect, meaning short term improvements often result from a focus on safety performance and operator attention and vigilance will increase temporarily. This leads the organization into the false belief that this improvement is sustainable and early results will continue long term. Often this experience leads organizations to try another program with similar emphasis thinking it was a flaw in the implementation or the par- ticular character of the individual program that caused initial results to fade rather than rethinking the premise behind such programs. Beyond recurrence, belief that
the workers themselves are the primary focus in preventing injury shifts responsibility for correction from management to the worker. This permits management to evade its true responsibility, namely to provide that which their work- ers need to be safe and success- ful. Executive management has a stewardship responsibility for the
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