THE HUMAN ERROR


Total Award: $2.9 million plus a lot of lawyer fees and some VERY bad publicity.


Over 700 “small stuffs” (hazards) tried to tell them.Why


serve coffee so hot that the skin would come off at the burn area? You would severely burn your mouth if you tried to drink it that hot. The response was that it was believed at that time that it would taste better once it cooled at that temperature. Today coffee is served at a much more reasonable 140° to 145°F (60°C to 63°C) temperature that if spilt will redden the skin but certainly not require skin grafts. A small, seemingly insignificant hazard that may have been


there for a long time caused a lot of grief for my wife. We were returning to Canada from South America on a very reputable airline in “steerage” class. My wife who had the aisle seat, turned to sit when she suddenly collapsed into the seat grabbing her left knee in pain. The small piece of track cover under her left foot had shifted aft just enough to cause her knee to pop out of the socket for a split second before she fell into the seat. While it was back in its socket, she was in severe pain and the knee began to swell. The flight attendant was very professional and arranged an ice pack as well as some pain relievers. A wheelchair was arranged for the ongoing flight connection and as much as possible was done to make her comfortable for the long flight home. As an ex-investigator I recognized the hazard and documented the scene. I recall I sometimes had the job of installing seats like these that I hated. The crew chief had always insisted that there be no movement of the track covers. Why he was so picky escaped me at the time. Long story short — I sent the photos and my report to the airline’s Safety committee, some of whom I knew, who immediately responded by saying that all their aircraft were going to be inspected for this now known hazard and the incident would be used as a training example of the importance of ensuring there was no movement of the track covers. Had my wife’s knee not


popped back into its socket, that little hazard would have resulted in an expensive delay, medical bills and a ruined planned family Christmas get together. Part of the problem is that we live with hazards and often


fail to see the danger should the hazard be released. Besides, we have learned to work around the hazard and nothing will happen to us. Sound familiar? This is what a properly functioning Safety Management System (SMS) should catch — assess worse case scenarios for risk and resolve. All too many SMS are simply “books on the shelf” and nothing changes. I say that SMS is nothing more than putting a system in place to sweat the small stuff, so you never have to sweat the big stuff. So let’s start with McDonald’s. Their hazard was very hot coffee that could cause serious injuries if spilled. One would guess that they were depending on “common sense” to prevent the hazard from being released. With a proper SMS each of the accidents would be recorded as a hazard and as the numbers began to build up, a trend analysis carried out by “someone” (SMS Safety Manager) would see a pattern emerging and raise an alarm. A child being burned or a court payout of one half million dollars should have been sufficient warning that there was a high potential of the small stuff becoming a big stuff. However, like Ford and the Pinto hazard, (D.O.M. August 2019) they continued to ignore the hazard. You can be sure that there were many unreported incidents where the casualty was too embarrassed to admit he/she had burnt their mouth with the hot liquid or the injury was minor enough to be ignored. It took a $2.9 million “kick in the pocketbook” for them to finally realize that they needed to mitigate the hazard. Today, thanks in large part to Stella’s burns, your coffee may burn you but not scald you. I believe that an SMS would have saved Stella from years of misery. With powerful lawyers on their side, I suspect that settlement was likely appealed until she died or at least ended up being a lot less than the original award.


30 DOMmagazine.com | mar 2020


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