A former client had an amputation accident, and an OSHA inspection followed, with several citations following that. We were hired to help the company digest all that OSHA found wrong, and there was plenty that OSHA found, but there was even more that OSHA did not see or address with its inspection or citations. The client wanted help with the "abatement plans" to close out the OSHA citations and "put this behind us." Still, they had no interest in understanding what needed to be done outside the "abatement plan" to help reduce the likelihood this same accident would happen again.
This happens quite often, and it's a serious problem when we play the "compliance game." OSHA assesses the business's "compliance," usually around particular circumstances. This assessment is based solely on compliance with OSHA's MINIMUM standards. They issue citations, and the company has to "abate" those issues. However, those citations usually do not address the "ROOT CAUSE(S)" of those issues.
The facility was cited for:
- Not having a "specific procedure" for the machine involved in the accident,
- Guarding issues associated with the machine involved in the accident and
- Failure to perform "periodic inspections" of authorized employees associated with the maintenance and servicing of the machine involved in the accident.
Sound familiar? And OSHA had them dead-to-rights and ordered each citation to be accompanied by an abatement plan. We abated the citations for the client before the informal conference, and OSHA was pleased. They reduced the citation $ by 50% but left the citations as "Serious." We were NOT part of the informal conference; their legal representation was present instead.
While working with this client, we assessed how these failures came to be and found the same issues with other machines and authorized employees. However, OSHA did not see these issues, so the facility did not want to address these plant-wide serious LOTO and guarding issues, so I refer to them as a "former client."
Fast forward three (3) years, and that same facility is in the news with another amputation accident, and I am sure there will be another OSHA inspection. If I were a betting man, I would bet that OSHA would find the same issues as before, and if OSHA is serious, it would issue REPEAT citations this time. And I will give odds: the company will abate these specific OSHA citations as they did before, "put it all behind us, " and wait for the next injury.
So, OSHA abatement plans are about making OSHA happy but do little to improve overall safety.
The safety failures that led to both accidents (and prior citations) are what we call SAFETY MANAGEMENT SYSTEM failures; one may even call them LATENT ORGANIZATIONAL FAILURES (e.g., James Reason). And much like we see across the board, this facility had plenty of discipline cases around LOTO, as this was the route the lawyer wanted to go. But OSHA did not issue citations blaming the worker who lost two (2) fingertips; OSHA only cited the employer for "management system" issues:
- There was no energy control procedure for the machine
- Lack of proper guarding on the machine
- Failure to perform "periodic inspections" on the workers associated with servicing and maintaining that specific machine
The lawyer still wanted to lay these failures at the feet of the employee who had been an employee of this business and operating the machine for less than a year. They claimed "employee misconduct," which is insulting, and even OSHA was confused about this defense. Nonetheless, that was their plan. They wanted no part in accepting these MANAGEMENT SYSTEM FAILURES as such and thus had no desire to address these failures so that we could reduce the likelihood of a similar accident. Fix the OSHA citations, and that will be all; thank you.
We did leave them with a "New Equipment Assessment Checklist" so they could assess their other machinery/equipment and any new equipment to ensure that they develop a specific LO procedure for their machines, evaluate the adequacy of the machine guarding, and perform periodic inspections on their authorized personnel annually. My guess is they failed to do any of that, and now they are staring at another amputation injury and potentially REPEAT citations. And I will bet they will challenge the citations as repeats, as it is probably a different machine, so in their eyes, this is not a repeat.
OSHA does not issue "Management System" failure citations, as OSHA does not require a Safety Management System. So many businesses treat OSHA citations like the "Whack a Mole" game; address ONLY the citations, not the management system failures that allowed the unsafe conditions to exist and the citations to be issued after the amputation accident.
Why did this facility not have a LOTO procedure for this machine?
Why was this machine in service without adequate guarding?
Why were authorized employees not getting an annual LOTO inspection?
A simple 5-Why exercise on these management system failures would identify needed actions to address them with long-term MANAGEMENT SYSTEM fixes. However, this approach to managing safety properly requires the organization to have the desire to LEARN from these failures rather than making OSHA happy and "putting this behind us."
That is how OSHA abatement plans are about making OSHA happy but do little to improve overall safety.
