The error cascade: Small mistakes add up to worker’s serious injury

by on September 27, 2012 · 0 Comment POSTED IN: Workplace Safety Network

Do you (and your crew) know how to prevent an error cascade? That’s when a series of errors – often by several individuals acting innocently – snowballs into an accident.

Here’s a real-life case: A subcontractor on a building-renovation project received approval from a GC supervisor to store tools and supplies in a locked bathroom cabinet, rather than haul them to and from the worksite. Only the subcontractor had the key. He went home, not realizing that a second GC supervisor needed the cabinet moved.

Two of the GC’s laborers started moving the cabinet and it seemed too heavy. They couldn’t unlock the cabinet. They asked the second GC supervisor why the cabinet was so heavy; he told them it was empty and to move it.

When the two laborers start to carry it down a flight of stairs, the weight of the tools and supplies shifted in the cabinet. They lost their grip, and the cabinet ran over one of the two laborers as it tumbled down the stairs.

Result: The worker suffered broken bones, permanent ligament and nerve damage – and the company earned a lawsuit. The litigation was dismissed: The injured laborer assumed the risk of moving the cabinet, and was limited to the GC’s workers compensation.

The case ended up with a needlessly and permanently injured worker, and a long, distracting and expensive legal battle. How could the accident have been prevented? In this case, a cascade of errors took place:

  • The first GC supervisor, who gave approval to store materials, didn’t inform the second GC supervisor that there were tools/supplies in the cabinet. Better: Whenever someone does something outside what others would expect, communicate that to other supervisors. For example, if equipment is damaged during a shift, the next supervisor (and operator) needs to know.
  • The contractor locked up the materials and took the key – limiting what others could do when he wasn’t there. Better: Whenever workers limit someone else’s options, communicate. In this case, the first GC supervisor and subcontractor should have had the foresight to realize someone may need to move the cabinet, and kept a key on site.
  • The second GC supervisor, who hadn’t been given the info he needed to make a decision, didn’t listen to the workers telling him that conditions weren’t as expected (i.e., that the cabinet seemed too heavy). Better: Separate run-of-the-mill complaints from real ones. Laborers wouldn’t make up that a cabinet was much heavier than expected.
  • The laborers just bulldozed ahead and moved a cabinet containing unknown materials inside. That made them vulnerable to a sudden weight shift when the cabinet was no longer level. Better: They probably should have cut the lock off and found out what was inside. At the very least, they should approach unknown dangers with extreme caution (in this case, make sure the object remained level).

Cite: Giovanelli v. D. Simmons General Contracting, No. 09-1082, D. N.J.

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