It’s a Safety Life: Decisions, Risk, and Blame
Overview
To illustrate a tragic event to a favorable outcome.
Connect with others to prevent a recurrence.
How to move on.
A day in the life
On May 10, 2007, my life changed forever. Who’s to blame? It was a risky decision. Was it the company? Was it the system? Was it behavior? Indeed, all questions typical and expected as a result of a tragic event. And because of this experience, I was given a chance to reimagine my career and take action. This is not another shock-and-awe story. What’s been great about this experience is the opportunity to learn. While it has been difficult, it has been very rewarding. The intent of sharing with you this story is to help illustrate a real-world example where decisions and risk co-exist in everyday life. We all have risks in our lives. Whether driving to the grocery store or working on a construction project. I want to share with you my story, not to cast blame and build up myself, rather, share an experience that caused me to reflect on choices and make an adjustment. To be able to take the experience and move on to do new things.
What happened?
At the time of the incident, there was nobody in the immediate vicinity. One of my best co-workers, Fred Buah, was working in a nearby room. I had recently acquired my Journeyman Wireman (JW) license through the Colorado State Electrical Board and was excited to demonstrate proficiency and profitability to my employer. I took a risk. Because of my enthusiasm to get stuff done and show my boss that I was contributing to the job, I accepted the opportunity to take over a part of the project. This was the high school auditorium at a new construction project east of Colorado Springs. It was a good job with a well-known and reputable general contractor. I had a good rapport and with everyone on the jobsite with mutual respect for my peers and my bosses. We had an onsite project manager and a superintendent. Both were experienced and knowledgeable. The president of the company was even involved as a project manager. We had been on site for several months and were still in the rough-in phase which means there was still open “dirt work” to do as we installed underground conduits. Some areas of the project had concrete masonry block units going up as well. The more finished areas had completed walls and we were doing our overhead work. Commercial construction can be fast-paced, complex and require intense coordination between many trades and management. The rough-in project phase is intellectually and physically demanding because it requires keen knowledge in how to read architectural plans, compare those design elements with the National Electric Code, and correctly order materials from vendors. Indeed, commercial construction is a very dynamic process. It’s exhilarating to watch a project come up out of the ground. We were building a new high school. That’s why I was excited when the bosses asked me to take over the auditorium project portion because as a newly licensed JW electrician at the age of 23, it seemed honorable to be asked and given an important part of the project that would be enjoyed by generations of families and the surrounding community. Plus, all the technical aspects of the auditorium seemed neat because of the unique challenges to install the power and lighting systems indicative of stage performance. I was all over it.
As the project progressed, I was asked to participate in the OSHA 10 Hour for Construction safety training provided to employees by the company. We held a 5 hour class on the evening of Wednesday, May 9, 2007. During the class, we talked about fall protection and the feasibility of properly donning fall protection equipment while working up at the grid-iron level near the ceiling. You see, the commercial auditorium had bar joists that made it difficult to access the ceiling and there were other mechanical system obstructions. So, during the OSHA 10 Hour class, we talked about the possibility of using a personal fall arrest harness and tying off the lanyard to the gridiron or the scissor lift as a means to prevent a fall. This discussion was important in the decision to utilize fall protection equipment. The risk was analyzed and reviewed and an effort was made to minimize the risk with management’s input. We adjourned our OSHA 10 Hour training for the evening.
On May 10, 2007, the work continued in the auditorium. I used a commonly used scissor lift you would see out on construction sites. An important piece of equipment on a construction site to access work at heights. This particular lift had been selected because it was nearby. It happened to be that the painting contractor had used this lift and left it in the vicinity, so I hopped onto the equipment and used it. Earlier in the auditorium project, we used 40-foot extensible boomlifts that would articulate up and down and extend out. These boomlifts were more convenient, but also a more expensive choice, so we called the rental company and got rid of the boom lifts as we had finished up the auditorium seating area and were now focused on the auditorium stage area. The auditorium stage had an inconsistent walking/working surface. It was because the concrete floor had been poured to allow for a wooden floor to be installed on the main stage area. A typical maple, tongue and groove style that would require a subfloor and the finished surface. But none of that had yet been installed. That meant that around the perimeter of the stage there was a walkway that then dropped down two inches to accommodate the new wooden floor. It wasn’t much of a drop, just about 2 inches.
Materials were organized into an efficient layout on the floor. I assembled light fixtures on the floor to have them ready for the install while up high on the lift. The job at this point was simply to install 8-foot fluorescent strip lights. These would be as near the ceiling as possible and would provide general lighting on the stage when there was no performance. It was a routine task. What was risky about this was the height of the work. To reach the work up in the space between the bar joists, the scissor lift would serve as an elevated platform. But it only ascended to about 20 vertical feet. That meant that to access the final 8 feet, or so, I would have to step onto the platform guardrails.
Now keep in mind that at this point, I had decided that it was permissible to utilize a personal fall arrest harness tied off to the lift as a method to protect myself from a fall. We had conversed about this control method during our last safety training course. Plus, using the equipment available to me onsite at that moment would enable me to get work done. After all, I had to prove myself to my bosses that I was worthy of the challenge set before me. It was a risky choice. So, I donned the equipment and snapped the pelican hook onto the guardrail of the lift. It was not the appropriate anchor point, but I needed the extra 18 inches, or so, to give me more movement to access the overhead work. The other anchor point was on the actual platform of the lift bolted down as a type of D-ring attachment point. Getting up onto the lift platform was easy, all you had to do was climb up the back steps while grasping the guardrails and enter the platform and then hook the safety chain behind you. The lift was completely lowered, so I drove the lift up over the concrete to position the lift parallel to the overhead barjoists. This would be convenient for installing the 8-foot lights because then I could walk the length of the platform to lift the light onto the hangers. But first I had to place specific barjoist metal hangers that were beat on with a hammer and then would securely clamp down onto the barjoist flanges. An effective method. This was so the jack chain could be dangled down from these special metal clips and placed onto the 8 foot light fixture hangers. The idea was to place the scissor lift directly below where the fasteners needed to go and raise up the lift one time. Efficiency in construction is essential. In my haste to get the scissor lift positioned I decided to drive the lift up onto the higher concrete perimeter that went around the stage. While working up high I realized that the scissor lift needed an adjustment. So with the lift fully extended 20 feet up, I chose to move the scissor lift. The operation of these machines is fairly simple. At least for the end-user. There is a control box with a joystick that allows you to drive the lift forward and backward. Then, to raise the platform requires you to flip a switch so the equipment can move up and down using the same joystick. There are different models and versions throughout the years, but this is how this machine worked.
Once the scissor lift was in motion, I realized that the it was too close to the painted wall. It was on my right side. So, in an effort to move away from the wall, and also miss the LED light fixtures that had just been installed, I maneuvered the scissor lift by adjusting the wheels to a sharp turn. These lifts have an autobraking mechanism that simply stops the lift’s movement once the joystick returns back to a neutral position. However, the lift will still move several inches before coming to a full stop.
The lift continued to move.
It was the front left wheel that slowly rolled over a 2 inch drop on the floor below.
What happened next was a simultaneous cascade of events.
Like a tree slowly felled by an expert woodcutter, the scissor lift leaned to the left, attempted to correct as it found center of gravity, and then leaned back to the left gaining in tipping momentum. There was a stage catwalk up high in the ceiling with a tubular metal handrail. I grabbed a hold. Quickly grasping for my life onto the handrail. Clanking metal reverberated in my ears.
It was then I realized my harness was attached to the lift.
The weight pulled on my harness, forcing me to release my grip and I lost my hold.
As I lifted my face from the ground I realized that my jaw was in particular pain and oddly misaligned. There was a lot of blood gushing out of my chin. What was worse was the right leg. The pain was so great. Unspeakable pain. The right femur hurt beyond words. The left leg was also in pain. But not as bad as the right. I yelled to someone that they needed to move my right leg. As if moving my right leg would somehow alleviate some pent up tension that had accumulated during the entire course of my 23-year lifespan and was now accumulated into that one moment. They moved my leg; it didn’t help.
One of my co-workers, Jeff Gloege, grabbed some blankets and helpt to cover up my body as it was going into shock. My co-worker, Steve Young, held my hand and said, “stay awake, stay with us Johnny, you’re going to make it”. He had worked in Kansas as an emergency responder and knew the importance of making sure that I was coherent when EMS arrived.
I yelled to someone that they should find a yellow card in my wallet which had phone numbers on it and call a trusted friend to start letting family and friends know what happened. Another worker held an IV bag to start fluids and pain management.
After the EMS professionals worked quickly to assess my injuries they realized that the situation would require air transport. A helicopter ride was in order. It was a beautiful day and the professionals on call took great care to provide the right skills for medical treatment. I was wheeled out of the construction site and lifted into the waiting aircraft. When we arrived at the hospital, I remember the beautiful spring day, although a bit foggy from pain killers and immobilized in traction on a stiff board, it was a nice afternoon.
After the helicopter landed atop the roof, a short gurney ride into the elevator happened quickly and then I was in the care of the emergency department. I laid there for several hours under hot lights unable to drink fluids in anticipation of surgery. Even the eggplant parmesan eaten for lunch didn’t want to stay down, and it came up in a profuse way. My friend, Patrick Greer, adeptly cleared my mouth and face from this unpleasantry. Uncomfortably, I now laid there waiting for medical attention due to the fact that there were other victims in more serious conditions.
Mike Wenner, our HR and Safety Manager arrived at the hospital after conducting an incident investigation at the scene and offered his comfort, as did Dan Wallace, our Director of Operations. During our conversation, I pleaded and offered to give back the leather gloves that had been recently given to all employees as recognition for going 90 days without a safety accident. An amusing thought now, but at the time I felt ashamed for making a mistake. It was my fault for tipping over the scissor lift and I had caused a major situation to now deal with, for everyone. The company. My family. My Friends. People gathered at the hospital to console one another and evaluate the situation. It was somber.
What were the damages?
The doctors evaluated the injuries and decided to proceed with an intramedullary rod to secure my bones. A maxillofacial oral surgeon put the left temporal-mandibular joint back together and the fractured mandible got a titanium plate. In addition to facial injuries, there were other problems. The left tibia had multiple fractures, the left fibula had a small fracture, the right pubic-rami “sit bones” were fractured and the big right femur bone had a fully displaced fracture. This all accumulated in the insurance claim for workers’ compensation. Which was handled efficiently and with care.
And those were just the human damages.
The company also had to purchase the scissor lift which I had chosen to use for my work.
I felt terrible about all of this and when I was able to get back home, I wrote a check to every coworker that I knew on the jobsite to reimburse them for their safety bonus. (At that time the company used a safety bonus incentive program). My co-workers thought I was nuts, but I wanted to try, even if just in some small way, to make up for my mistake.
Blame
Some people argue that the utilization of a personal fall arrest harness was an inappropriate choice and that tying off to the lift was a poor decision. Some people think that it was an OSHA requirement to tie off to the lift. Others know that the manufacturer requires fall restraint when the platform is extended out to lengthen the working area. Whatever. The fact of the matter is that I chose to operate the machine in a way that caused it to tip over. The risk existed as a culmination of contributing factors.
Others blame the company. They might say, well, a safety and health management system would have provided the worker with adequate training on how to correctly utilize the equipment. Some on-the-job training had been provided to me. I had been using a scissor lift for over 4 years at the time of the incident and was familiar with these machines.
There is another perspective that could be made is that a different piece of equipment should have been used. Indeed, the scissor lift did not fully extend or reach up to the appropriate height. Either a taller scissor lift or an extensible boomlift would have been helpful. The reason that the painter’s scissor lift was chosen to use is that it was close by and I thought it would help reduce hours of use on the scissor lift that our company had rented. Our scissor lift didn’t go up any higher.
The company was open to safety suggestions. The onsite leadership from both the superintendent and the project manager would have been open to the suggestion of getting a different lift to adequately access the work at a height. Why would a worker not choose to request the correct lift? Did the company’s culture enable employees to make risky decisions? While nobody at the company would have willingly encouraged a risky choice, construction is inherently driving to produce results. With a results-oriented mind, decisions making can yield one to take risks to get the job done. There was not immoral or unethical encouragement to take a risk, rather, the choice to operate a piece of equipment near a risk, or unsafely, resulted in the catastrophic event of a worker breaking both his legs, pelvis, and mandible. The choice was not an intentional decision to disregard safety, rather, it was evaluative of the risks involved and deciding how to balance the loss of productivity and efficiency. With an individual who was amped up and ready to prove himself in the interest of pleasing the bosses, could a riskier decision have been made?
While these questions are thoughtful, it is evident that the event still occurred.
The Results
As the experience unfolded into recovery from injuries. I spent time in a wheelchair for about 6 weeks. Then transitioned into crutches for another 6 weeks. It was not permissible to bear weight on the left tibia for 12 weeks due to the nature of the fracture and the limited blood flow around that front shin bone area. The femur healed more quickly as a result of being surrounded by massive amounts of the muscle. But recovery took time. There were physical therapy sessions that were probably more easily accomplished because of doing yoga sessions at the fitness center where my father attended. We enjoyed that activity together as an unusual weekend activity in addition to fishing in the great rocky mountains. He even took me fishing while I was recovering and still in a wheelchair. We went to Taryall reservoir and had a good time.
Also had time to recover with friends and family who took really good care to assure everything was attended to in the interest of expeditiousness and medical compliance. I worked judiciously in following the exercises to strengthen and recover effectively.
In the course of my recovery, I was on modified duty working at the office when the HR & Safety Manager stopped by my desk. I was taking measurements for the estimating preconstruction department and studying prints for an upcoming project. He asked me if I’d be interested in the safety specialist role that had been posted as a job opportunity with the company a few months earlier. Ironically, this job posting opportunity was made prior to my incident. Well, I explained to the manager that I had just passed my State exam to obtain my license and was working towards a different career path, but that I was open to the idea of becoming a worthwhile contributor towards the company’s safety program. He said that he would speak with the ownership and management team and get back with me. After filling out an application and going through the interview process, I was offered the safety specialist role. My first day on the job working in a new role was October 15, 2007 and I read a copy of NFPA 70E for 8 hours. It was similar to the National Electric Code, just with more emphasis on worker’s safety. Indeed, I had started a new career path and it’s been fantastic to be part of ever since. I’m deeply honored to have fallen into the occupational health and safety role. And it’s been a challenge to overcome the stigma of just being an injured construction worker who got into safety. But the reality is, I’ve taken it seriously. This was not just another job, this was a career path opportunity that enabled me to touch the lives of others with a positive safety message.
To hear this abridged story as a podcast please visit the IEC Current Podcast.
