Working in the Line of Fire

Line of fire injuries remain an enigma. here are some reasons why – regardless of engineering controls, guarding or bypass interlocks – workers that continue to put themselves into the line of fire will eventually die on the job.

When someone dies in the workforce through no fault of his or her own it’s undeniably a tragedy. But in many people’s minds, line of fire injuries — those injuries that result when a worker places his or her body in the direct path of a serious hazard — the injured worker must bear at least some culpability for his or her injury. It’s especially easy to dismiss a line of fire injury as the worker’s “own stinking fault,” but is it?

Before I continue I should disclose something about myself that could bias me on this topic: my grandfather died on the job from a line of fire injury. As a farmer in the 1950s, he left a lucrative career installing conveyor belts — a job that required extensive travel — so that he could spend more time at home with his family. He was driving a tractor that was struck by a speeding locomotive at a poorly marked crossing. Witnesses said the train was going upward of 80 mph. His view was at least partially obscured by overgrown bushes near the tracks and he was either legally deaf or close to it.

He left behind a widow and four daughters (one of whom was developmentally disabled) who would eke out a hardscrabble living, financially and emotionally crippled by his death; a family laid waste by a single moment. While there were many things that factored into my grandfather’s untimely demise, the fact remains that in the last moments of his life he made a decision to place himself in the line of fire. As you might expect, I spent a lot of time thinking about the circumstances of my grandfather’s death, I don’t attribute it to shaping my view of worker safety, but I suppose that’s inevitable.

My grandfather isn’t alone; the Bureau of Labor Statistics reports that 17 percent of all workplace fatalities in the U.S. are the result of line-of-fire injuries. Suffice to say that line-of-fire injuries raise a lot of questions; questions, sadly, to which we will most likely never get satisfactory answers.

WHAT WERE THEY THINKING?
I have always believed in two simple truths about worker injuries: 1) nobody wants to get hurt and 2) the process isn’t designed to hurt them. If these things were really true, then why would anybody ever knowingly put himself or herself in the line of fire? Simple:

They don’t believe they are placing themselves in real danger. No one in his or her right mind expects to be killed when they place themselves in the line of fire. Let’s face it: the primary role of our central nervous system is to keep us alive, and as long as that is functioning properly we generally aren’t looking to kill ourselves.

Too often workers who place themselves in the line of fire are making a decision based on imperfect information — they either assume that something is true when it is not, or they assume something is not true when it is. In the case of my grandfather we can only speculate, of course, but for the sake of argument let’s say that he knowingly and deliberately put himself in the line of fire and crossed those railroad tracks without looking or stopping long enough.

Since there is no evidence that he was suicidal — by all accounts he was good-natured, popular, and happy in life — we can infer that he didn’t deliberately place himself in the line of fire thinking that he would most likely be killed. This means we can speculate that he believed that the likelihood that a train would approach unseen, in fact, undetected, were immeasurably small. Had he believed that there was a strong possibility that a train would strike him, he never would have taken the chance.

They believe the time of exposure is small enough to protect them. How many line of fire injuries are the result of “I’m only going to be in there for a second” thinking? It’s a big temptation to risk it when you believe that your probability of injury is directly proportionate to the length of exposure to the hazard. Unfortunately, probability doesn’t work that way and too few workers truly comprehend the dangers that some line of fire hazards pose irrespective of the length of exposure. If a worker makes contact with a piece of energized equipment of sufficient power, he or she will be electrocuted even if he or she touches the equipment just for a second.

Familiarity breeds contempt. For most of us, the longer we work around a hazard or, in this case, the more we place ourselves in the line of fire and suffer no negative consequences, the less we respect a hazard’s ability to harm us. We innately teach ourselves that an activity is safer than it is. As we become more comfortable working around a hazard, we convince ourselves that we will not get hurt “as long as we’re careful” when, in fact, we are not.

The job is too difficult to get done without placing workers in the line of fire. Much as we would love to place the blame squarely on the shoulders of the injured worker, some jobs are so poorly designed or safety procedures are so onerous that no reasonable worker will work within process. In fact, I know of many manufacturers that continue to have standard operating procedures that place the workers in the line of fire. These cases are the most troubling because, in general, workers believe that if they follow the standard operating procedures they will not be injured, even though some processes are grossly unprotected.

They aren’t thinking. Research has shown that the average worker makes 8 mistakes an hour (this number falls to around five for workers in “high consequence industries — healthcare, aviation, oil & gas, energy, etc.). These are human errors; unintended foul-ups. Five mistakes an hour, eight hours a shift, five shifts a week amounts to mistakes in the neighborhood of 10,400 mistakes in the course of a work year. Obviously this number is much higher for workers who work longer shifts, six- or seven-day workweeks, or any number of a host of other factors that would extend the worker’s work year from the traditional 2,080 hours in a typical year.

Inevitably, some of these mistakes will place the worker in the line of fire.
The incidence of human error increases when a person is sleep deprived, under stress, using drugs or alcohol or is otherwise preoccupied. Something as simple as bright lights can dramatically increase a person’s tendency to take risks.

Line of fire injuries may always remain an enigma and, as one safety veteran once told me after learning of the death of veteran colleague caused by several line of fire violations, “I don’t know how to save worker’s from themselves.” I don’t know either and, in truth, nobody really does. We try engineering controls, but people remove guards and by-pass interlocks. We put administrative controls in place, but workers ignore them. We require PPE only to have workers grouse about wearing it.

From all of this, only one thing is certain: if workers continue to put themselves into the line of fire, they will continue dying on the job.

Phil La Duke

Phil La Duke is a partner in the Performance Assurance Practice at ERM: Environmental Resources Management, 3352 128th Avenue, Holland, MI 49424, 313-244-2525, www.erm.com. You can also follow Phil and reach him on his blogs at www.philladuke.wordpress.com.

6 Comments



  • Roger Whittaker wrote:

    Story says – “From all of this, only one thing is certain: if workers continue to put themselves into the line of fire, they will continue dying on the job.” yet the copy reads that workers are not – “putting themselves” into the line of fire – instead they are making decisions based on incorrect data that will result in an action that will find them in the line of fire –
    Mostly because the person who gets injured does not know when the point of fire occurs —

    the contradiction is that workers are putting themselves in the line of fire vs making a decision which leaves the time of fire out of the equation —
    Semantics … maybe — but not much different than asking a worker how – “he hurt himself”
    or how did you do that – or _WHAT DID YOU DO?? — all blame filled questions —
    it would be so much better to ask a an injured worker – “how did that happen?” or even more removed – what happened? or what happened to you?

    Semantics are only important when you are the person to whom the question is posed. – Phil did you write that article all by yourself? is very nearly demeaning – lets try – Phil, did you write that article?”

    otherwise excellent points brought up – and a worthy discussion to be had on the ideas raised in this poignant piece.

    • Phil La Duke wrote:

      Roger:

      Thanks for reading and commenting. I don’t think it is a semantic argument as much as an omission of a single key word, “directly” or “deliberately” the point of “that workers are not — “putting themselves” into the line of fire — instead they are making decisions based on incorrect data that…” is that no one, in my estimation, is appropriately assessing the risk and deciding to put themselves in the line of fire, rather, they are making a decision based on the erroneous conclusion that the result of their decisions will not place them in the line of fire, unfortunately, the are too often wrong.

      I agree with you about your points on semantics, though. Words, and more specifically the choice of words make a big difference; especially in print, where sarcasm, tone of voice, and nonverbal cues cannot be judged.

      Thanks again.

      Phil

  • Richey Austin wrote:

    Line of Fire incidents like you have described are mostly due to a individual’s behavioral decision to take an action based on previous outcomes experieced and expectations set by their working environment. A good way to combat this issue is to create a inherent culture where the worker cares enough about themselves and the ones around them to not be tempetd to place their body in harms way. I agree that most people do not want to get hurt but we as “Management” sometimes set conflicting expectations. Making the individual’s well being the top priority over all things, will create a culture to reduce LOF injuries. Productivity and schedule will always be improved every time that the care and quality of the individual worker is placed as the top priority of any project or worksite.

    • Phil La Duke wrote:

      Richey:
      Thanks for reading and commenting. While “A good way to combat this issue is to create a inherent culture where the worker cares enough about themselves and the ones around them to not be tempetd to place their body in harms way” a better way is to properly use the hierarchy of controls to eliminate hazards or substitute a hazard for something less likely to result in a serious injury.

      I also think we place too much blame on both “management” and on the worker. Most workers (and people for that matter) take it for granted that their jobs are safe. This assumption of safety carries over to darn near every element in our life—we eat food cooked by strangers, on plates washed by strangers, using silverware provided by strangers. We ride on buses, trains, and in cabs driven by strangers. We jet around the world on airplanes designed, built, maintained, and operated by strangers. In short, there are a boatload of areas in our lives where we have a reasonable expectation for safety that may or may not be accurate. In the workplace, managers often ask workers to do things that they erroneously believe to be completely safe (because they trust the people who designed and built it, or their own experiences with a process) and the workers perform those tasks (because they trust that their managers would never knowingly put them in harm’s way.) The result, as we all know, is injuries and sometimes fatalities. Safety professionals have to do a better job of educating both managers and workers on exactly what “safe” means. Safety is contextual, and the “reasonable” expectation of safety is sometimes our worst enemy.

      Thanks again for taking time to read and comment.

      Phil

  • Andrew King wrote:

    I can only agree with the general line of the discussion. In my experiences as a line supervisor and later as an operations manager, the fundemental problem tends to lie with an lack of judgement in evaluating the risk / rewards relationship.

    In our private lives how many people wold risk their entire family financial security to gain an extra 1% in assets?

    No amount of written operating procedures and disciplinary consequences will stop a certain proportion of the population taking disproportionate risks as they don’t understand the potential consequences along with the probability of the “bad outcome” becoming reality.

    Conversely, at the opposite end of the scale there is what one of my previous bosses called “the nodding dog”, blindly following procedure because that’s what was written and never questioning if what they’re engaged in is actually appropriate for the task in hand.

    Trying to shift both those thought processes, often within the same shift team, to a situation where people are accepting of procedures and engineering safeguards, be that interlock systems, alarms, physical barriers etc, whilst still being prepared to challenge accepted wisdom is hard work. To reach a point where there is enough “buy-in” that the development, maintenance and updating of safety systems, both procedural and physical requires an acceptance from 3 different groups that they all have something to contribute and will have to accept that others may have differing, and at least equally valid viewpoints.

    The front-line operator needs to accept that he/she has a certain responsibilty for his/her own safety and that of their colleagues. This requires both contributing with their experiences and accepting (but not blindly) the established precautions.
    The design engineer needs to accept that the cheapest/easiest construction/installation may not be the correct solution. These installations have to be operated by real people in the real world, it’s not just a CAD drawing, or my particular bug bear, render maintenance and changing out of equipement nigh on impossible due to poor layout. I don’t know of a better example of the phrase “an accident waiting to happen.”

    The manager needs to accept that he/she might not get the cheapest / easiest / quickest solution, here and now, but should remember an old addage I heard several years ago.
    1 dollar spent at concept stage can save 100 dollars under detailed design, 10,000 dollars under construction and commisioning and 1,000,000 dollars in legal fees when it all goes wrong. Short term gain – long term pain.

    I would be very interested in reading furter into the research on human error rates. I am currently involved in a project to establish a Quantitative Risk Assessment for a refinery where there is a debate as to where to set the “human reliability” factor. Is there a source you can quote / link?

    • Phil La Duke wrote:

      Andrew:

      I too am fascinated by human error and the reasons why people make poor decisions. I read voraciously and while I don’t have a simple link for you, the following books are very helpful:

      Whack A Mole (David Marx)
      The Invisible Gorilla (Christopher Chabirs and Daniel Simons)
      Risk Makes Sense (Robert Long)
      Blunder (Zachary Shore)
      Humble Inquiry (Edgar Schein)
      Human Error (James Reason)Predictably Irrational (Dan Ariely)
      Thinking Fast and Slow (Daniel Kahneman)
      Why We Make Mistakes (Joseph T. Hallinan)
      The Synaptic Self (Joseph LeDoux)
      The Field Guide to Understanding Human Error (Sydney Dekker)
      Words and Rules: the Ingredients of Language (Steven Pinker)
      Drift Into Failure (Sidney Dekker)
      The Achaeology of Mind (Jaak Pankseep and Lucy Biven)
      The Power of Habit (Charles Duhigg)
      The Human Brain Book (Rita Carter) and
      Brain: the Complete Mind (Michael Sweeny)

      Some of these are pretty dry reads, but if you want to skip the reading and contact me directly please feel free to do so.

      Thanks for reading and your comments,

      Phil