[Updated 12/28/2014: see below]
Those were the first words out of the mouth of the Southwest Airlines' official when describing the incident on January 27, 2012 at Dulles International Airport that claimed the life of 25 year-old employee Jared Patrick Dodson. The five-year employee was driving a luggage cart when he was fatally struck by a three-story people mover used to transfer passengers across the airport tarmac.
Scott Halfmann vice president for safety and security said young Mr. Dodson was following all procedures correctly. He was in the proper travel lane. He stopped at all designated intersections. He followed the correct traffic pattern and at an appropriate speed. The trouble was, an airplane was parked in a non-standard area. This led the air traffic-controlled people mover to use a non-standard travelway. The result: an individual fatally injured at work.
Southwest Airlines' Halfmann, along with Caroline Llewellyn and John Andrus, shared this story with a small group of individuals who know first-hand the pain and anguish of workplace fatalities. Families representing United Support & Memorial for Workplace Fatalities (USMWF) met with the Southwest officials earlier this week during a trip to Dallas, and told of their own experiences loving someone who went to work one day but never came home. The shocking difference for these families was hearing those first words from Mr. Halfmann's mouth: "Jared did everything right."
In their cases and in many others, employers react by blaming the dead worker for his or her own fatal injury. Workers are blamed for falling from heights, being crushed by equipment, suffocating in toxic environments, and being pulled into equipment. Many employers fail to look beyond the surface to ask "WHY?" the incident occurred. Was the worker expected to do a task without the proper equipment? Was the worker pressured to perform a new assignment without sufficient training because managers failed to schedule the proper crew? Was the worker placed in a situation to rush through a task because the company was falling behind schedule at the next jobsite?
I watched the faces of the family members, who traveled to the Southwest Airlines' headquarters in Dallas from California, Florida, Ohio, and elsewhere in Texas, as Mr. Scott Halfmann spoke. Their eyes welled up when he talked about Jared Dodson, hearing in his voice the respect and humanity for the former employee. I knew what was going through their minds: such a contrast to what they witnessed, read in documents or learned through the grapevine about their loved ones' employers.
Far too many firms insist that the "unsafe acts" of workers themselves are the root cause of work-related fatalities and injuries. In fact, a whole industry has evolved around behavior-based safety, with major corporations and other businesses in the U.S. embracing the flawed notion that 80, even 90% of workplace injuries are caused by "unsafe acts." These programs go by different names---at the former Massey Energy's coal mines it was the Raymond Safety program, while DuPont's program is called STOP----but all have one thing in common: a laser focus on personal behavior and observations of and by workers and management. It's a far too superficial way to identify hazards and work environment factors that are the true cause of occupational injuries, illnesses and deaths.
My cynical streak tells me not to drink the entire cup of Southwest Airlines' kool-aid. I'm sure they have their share of workplace safety problems. But with a corporate vice president insisting that "Jared did everthing right," this is one U.S. firm that may actually live up to its claims that its employees are its greatest strength, and they all work together to ensure they all make it home safe and sound after their shifts.
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Updated 12/29/2014: The Washington Post reports in "Parents of ramp agent killed at Dulles International says airport has serious flaws," (Dec 28, 2014) on the findings and outcome of the Dodson family's wrongful death suit against the Washington Metropolitan Airport Authority (WMAA). Their investigation found, among other things,
"confusion over the rules about the Dulles runways and the lack of a risk management system at the airport."
WashPost's Tom Jackman quotes Jared Dodson's father, a retired Air Force pilot:
“There’s a reason they don’t use mobile lounges anywhere else. At the end of the day, the factors that drove the causation of this accident have not changed, and there doesn’t seem to be any willingness by the airport’s management to look into it and see what should be changed.”
Virginia-OSHA issued one citation, classified as serious, to Southwest Airlines. It related to the company's failure to follow the manufacturer's specifications for the "operation, training, use, installation, inspection, testing, repair and maintenance" of machinery and vehicles. No violations were issued to WMAA. The agency's decision not to cite WMAA may relate to the workplace safety law's grounding in the traditional employer-employee relationship. Dodson was employed by Southwest Airlines, not WMAA. It's clear to me, however, that WMAA created the hazard that killed 25 year-old Jared Dodson.
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Safety is, from one point of view, another kind of quality. And in that light, Deming made a very persuasive case that you don't solve quality (or safety) problems by demanding more of people or by blaming them -- you solve quality and safety problems by instituting processes that accept the limitations of people and produce the desired result.
The USA is still in collective denial regarding quality, so it's not shocking (shameful, but not shocking) to find that we're no better regarding safety.
Nancy Leveson has a nice book on these kinds of systemic safety issues - there's a short review & link at http://blog.irvingwb.com/blog/2012/05/systems-thinking-safety-and-risk-…