As part of Burn Awareness Week, we turn our attention to workplace burn injuries. Due to their severe nature, one might think that no one would knowingly risk a catastrophic burn injury. After all, over 70% of burn injuries treated in burn centers originate in the home. So, perhaps it's more a threat of unwatched candles rather than day-to-day work operations. While many easily overlook the sparks from a living room fireplace, we would expect far fewer would be so careless around an online boiler at a utility company.
Yet, if we take a closer look, we may be underestimating a greater threat right before our eyes – and one that moves more mercilessly than a home-based incident.
Let's consider a recent example in the utility industry. On June 29, 2017, a group of contractors reached the Tampa Electric Big Bend River Station plant to perform a common maintenance procedure that would prove fatal. The contractors from Gaffin Industrial Services and Brace Integrated Services were tasked with the removal of a boulder from a slag tank obstructing the grinder that emptied the tank. Tampa Electric decided to perform this procedure while keeping the boiler running because the cost and time associated with pulling the boiler offline were significant. According to the investigation, workers believed there existed a barrier of hardened slag several feet above their heads, separating the boiler from the tank. So, they set off to make the repair and remove the boulder. In moments, the workers arrived at the doghouse door, armed with a water blaster. As they began chipping away at the boulder, they would soon realize the slag behind the boulder was not hardened. At that precise moment, the molten slag burst through releasing thousands of gallons of burning slag on top of them.
Following the tragedy, OSHA conducted an investigation concluding that Tampa Electric failed to follow energy control procedures while performing the maintenance operation, resulting in a safety citation. The contractor, Gaffin Industrial Services, was also cited for failing to develop procedures to control hazardous energy. The OSHA investigation team noted, "Tampa Electric and Gaffin were also cited for failing to provide appropriate personal protective equipment to safeguard employees from burns."
Let this sink in for a moment. Slag can reach temperatures far above 1,000 degrees. What can employers use to protect their workers when the menace ahead reaches an unthinkable temperature and the worker is buried in it?
If we take a closer look at this investigation and the tragic events that led to it, we learn that this incident wasn't caused by a lack of safety processes, but rather a lack of risk-sensitivity. The rules existed – just weren't expedient to follow. The Tampa Bay Times reports that "eleven power plant experts and operators [agreed] that working at the bottom of a slag tank with the boiler online is dangerous. But it costs hundreds of thousands of dollars to turn a boiler off." Yes, it would seem that a leading indicator to this tragedy could be related to the human decision to decrease workplace safety to increase operational efficiency.
Now, before we begin picking up self-righteous stones to pelt those responsible, let’s consider times we’ve put ourselves and others at risk for personal gain. Have you ever…
Driven a car at night with others inside, children maybe, while you were fatigued?
Driven a car after a few drinks, putting those cars with families inside at risk as they pass by with only a few feet of separation?
Moved a heavy and awkward piece of furniture up flights of steps, especially putting the person below at risk?
Key Point: Over time, we all get desensitized to our exposures when nothing negative has occurred – because this wasn't the first time that this company (like many others) performed this operation with the boiler online. Workers had benefitted from dumb luck before, resulting in complacency. Now, add the cost of taking the boiler offline with associated time pressures, and you have the perfect storm brewing.
This isn't the first time I've seen this – it happens everywhere, even far away from the utilities world. A year ago, I coached Mitch, a seasoned maintenance supervisor. He personifies what true workplace safety looks like: extremely conscientious. He follows the safety rules because he believes in them and he requires others to do the same.
Mitch dislikes getting close to boilers, especially in a confined space, knowing the inherent dangers associated with them. Yet, it isn't always avoidable. Mitch told me a story about one particular day that he was in a confined space taking readings from an online boiler. While recording the values, he stepped back and his clothes caught on to a newly-installed steam release valve. Unaware, he moved forward and the unthinkable happened: the valve opened, releasing highly pressurized steam over his right side. The immense pressure pushed him further forward, trapping him on the valve. His saving grace was a nearby co-worker who rushed to his aid and extricated him from the valve. He told me the story as if it all happened yesterday: emotionally, he pulled up his shirt to show me the ghastly scars from the third-degree burns he received that day. Not a day goes by that he is not reminded of the incident embossed on his body.
We talked about the primary factor responsible for that incident. I was surprised by his response. He did not blame others, the training, or equipment; he actually praised his PPE for saving his life. Rather, he took responsibility for the outcome. He said, when conducting the JSA, he missed that release valve as a key exposure. “Either I didn’t see it or I didn't remember it. I’ve done this task hundreds of times without incident; I was likely going through the motions during the JSA, not expecting new exposures.” Complacency and a lack of awareness is what Mitch attributed the incident to.
Thanks to prompt response times and innovative medical technology, 97% of burn victims survive. Mitch represents many burn survivors: those who've escaped the dangers of fire, but not without serious scarring, life-long physical disabilities, and adjustment difficulties. Burns have little mercy. So, if you are like me, you'd like to have a single answer on how to avoid such terrible incidents. Complacency can feel like a big answer to explore when there's so much at stake.
Join me next week as I investigate how we can explore burn prevention by focusing on internal safety blind spots.