THE HUMAN ERROR
FINDING HAZARDS BY GORDON DUPONT
Finding hazards in order to carry out a risk assessment is not as easy as one would think. Looking at the cartoon used in the SMS Safety poster series you’ll see what I call the iceberg of ignorance. The data used in this study was presented at a Quality symposium and was a real eye opener (at least for me).
At the bottom of the iceberg you
have the workers. You see and work around hazards in your daily routine. The study shows this group as having 100% knowledge of the hazards. Hazards, as you may remember, are simply “anything that can cause you or the company grief.” A hazard can be anything from a simple small clamp forgotten, resulting in four deaths. (D.O.M. October 2019) to one tire low on pressure resulting in 261 fatalities (Video – Death of an Airline). Moving up the management chain, the study found that supervisors were less aware of the hazards. Middle management knew even less about what hazards there might be. However, the man at the top with the money and the ability to “fi x” the hazards knew very little of what was happening below the waterline of the iceberg of ignorance. Give the percentages a WAG (Wild Ass Guess) and if you continue reading, you’ll see what may be surprising results near the end. I believe I became interested in “small stuff ” (hazards) when, as an accident investigator, I would dig down to fi nd the root causes and would run across hazards that were trying to tell them that one day something bad was going to happen. The now infamous 1992 McDonald’s $2.9 million award for spilled coff ee in a woman’s lap fl oored me. How could
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anyone get an award like that for their own carelessness in spilling coff ee? To be honest the thought did cross my mind to spill some McCafe in my lap and retire for life. I decided to dig deeper into what could possibly justify an award like that. Stella was the woman’s name and she was 79 years old at the time of the accident. She was a passenger in her nephew’s car, was served a 180°F to 190°F coff ee (82°C to 89°C) in a thin cup in a drive-thru. She put the cup between her legs to stabilize it - trying to be careful and removed the lid to add cream and sugar. A small amount of coff ee sloshed out onto her hand upon removing the lid, causing her to spill the balance, as it quickly gave her third-degree burns across her groin, inner thighs, and buttocks. She spent eight days in a hospital, had to go through numerous skin grafts, and was disabled for more than two years. She almost died, all for a 49-cent cup of coff ee in a fl imsy cup that McDonald’s served way, way, too hot for a drive-in window or anywhere else.
I have seen the other pictures of her injuries and decided I wouldn’t trade places even for $2.9 million.
And the company knew, too. The company had received “at least 700” scalding coff ee reports in the previous ten years, with some involving children (“Go get Daddy a refi ll” shouldn’t be a dangerous statement.) It settled some of those claims for up to $500,000. In this case, the woman’s medical bills alone totaled over $11,000 in 1992 dollars. McDonald’s off ered her $800 to go away. A court-appointed mediator recommended that McDonald’s settle for $225,000, but the company refused, went to trial and was hit with $200,000 in compensatory damages (reduced to $160,000 as the jury attributed 20% of the fault to the woman for having the coff ee in her lap), and $2.7 million in punitive damages, based on the fact that at that time, McDonald’s earned $1.35 million per day in coff ee revenues alone. The damage award was two days’ worth of McDonald’s corporate coff ee income.
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