ATVs, commonly called 4-wheelers, have been around for decades. Most people recognize the risks associated with these machines outside of the workplace. The accident/injury statistics can be alarming. But when management claims those accident statistics are not work-related and that somehow the risks these machines pose are less in the workplace may be a very misguided approach to managing their risks. It is true, the workplace should provide more safety structure around the use of these machines versus what is provided by personal usage outside of the workplace. However, what we typically find in the workplaces where these machines are used is a severe lack of safety controls around their use. Everything from training, operational rules, maintenance on the machines to ensure safe operation, and PPE worn by the users of these machines is often found to be non-existent or badly managed.
A client recently suffered a severe/life-altering accident involving the use of these machines. The safety group made the company aware of the risks associated with these machines at the time they were introduced to the business, as well, the business was made aware of these risks from previous S&H audit findings and, most notably, many minor accidents with less severe consequences. Yet, the safety effort/structure around these risks was virtually non-existent. Then the accident happened. The investigation determined the worker had never received the required training, the machine was 2-years past due for its annual maintenance, the daily inspection log showed the machine had not been inspected on the day of the accident, in fact, the machine had not been inspected daily for over 20 months, and the user was not wearing his/her helmet. Special note, the severity of the injury stemmed from a severe head injury.
And yet, this organization was ready to lay 100% of the blame at the feet of this 27-year employee for not wearing their helmet. Special note, the investigators (both internal and OSHA) were unable to find helmets in the workplace. The company was able to find the PO and Invoice for the original purchase of helmets six years earlier; however, at the time of the acciodent not one of those helmets was available on-site.
Our review of security footage going back 3-months showed 100% failure to wear helmets when operating one of these machines. Some of the footage included management not wearing helmets, and some of these managers were the same management who wanted to discipline this employee after the accident. The investigation also found that daily inspections were not being done for any of the seven (7) machines used on site, and this began almost two years before the accident. Less than 10% of the employees who were observed operating one of these machines had been trained; this 10% were the only employees still employed from the original training course six (6) years earlier. And yet, management wanted to discipline the employee injured in this accident.
This tragedy is a near-perfect example of what we mean by ACTIVE failures and LATENT failures. Untrained management personnel tends to have blinders on when it comes to looking at accidents. They can only see the failures at the time of the accident. This is very common, but it should not be in 2023! Whether they are doing it out of guilt, ignorance, or saving their own ass, this approach to safety management can be a death sentence to any workplace culture. The absolute lack of safety controls for nearly two (2) years which were identified by audits, inspections, and incident investigations, and yet management took no actions to correct these deviations, lays this accident at the feet of a management system failure. Sure, the operator was not following the rules at the time of their accident, but to place 100% of the “blame” at their feet is quite disgusting.
But the most amazing thing the SAFTENG team found 1-week after the accident was the fact that NOTHING had changed since the accident. The company claimed they conducted a “Safety Stand-Down” regarding ATV usage. Yet within 1-hour on site, the SAFTENG team witnessed personnel operating ATVs without helmets, no daily inspections, and no training. So they were puzzled as to what this “stand-down” involved. Why was ATV use NOT suspended pending 100% complaint with site safety rules? They never got an answer as management made it clear that they were brought in to establish a root cause and not to evaluate management’s response to the accident.
To this day, almost 1-year since the accident, nothing has changed at the facility regarding the use of these machines. Management did not agree with our FTA or our corrective actions. They continue to blame the injured worker, who was not physically able to return to work due to their life-altering injury. So having gotten rid of the “bad apple” (Dekker reference), there is nothing more needed to be done to control the risks with these machines.
Finally, no one in management was disciplined or even counseled on their specific violations of safety rules regarding these machines or their lack of enforcing the safety requirements around using these machines. These failures are LATENT organizational failures or what I call management system failures. The safety team was doing what they were supposed to be doing – bringing these failures to management. They did so in very formal ways (internal/external audits, incident investigations, safety contacts involving operators of these machines, etc.). Why OSHA did not issue Willful citations for these failures is beyond me, but OSHA is NOT the answer to these risks, and issuing a Willful for a General Duty Clause is unheard of.
The risks remain because of management’s failure to manage the safety controls around the use of these machines, so it is just a matter of time until the next life-altering injury or worse occurs.