- Location
- NW Washington
Why mishaps and accidents happen. (long read)
I work in the aviation maintenance field and for safety and financial reasons it’s important to reduce maintenance related mishaps. One of my jobs is to analyze mishaps and give training to help prevent or at least reduce them.
As an amateur and recreational tree climber I thought some of the information and training would be useful in preventing and reducing tree working mishaps. So here goes my attempt to parallel aviation safety with tree working safety.
In every mishap there are at least one of the following factors, often two or three. These are known as ‘The Dirty Dozen’ these twelve factors are divided in to groups, ‘The Abundance of’ group and ‘The Lack of’ group.
Abundance of:
-Pressure
-Stress
-Fatigue
-Distraction
-Complacency
-Norms
Lack of:
-Knowledge
-Communication
-Resources
-Assertiveness
-Awareness
-Teamwork
-Working under pressure and stress can actually increase you awareness and ability but there comes a point where the stress and pressures increase and the performance curve starts heading downward fast. Your mental reasoning and function slows, this is where mistakes happen. Know when you are over stressed or under to much pressure.
-Fatigue is pretty obvious the more tired a person is the more careless they are and are more likely to take short cuts. I see this in my self, the longer I’m in the tree and getting tired I have to make a mental note to be careful.
-Distractions (I-Pod in the tree) customers talking to you while working, chipper, kids, problems at home, cell phone, rain, cold, heat… these all take attention away from what you are doing, increasing the risk of making a mistake. About 70% of the aviation maintenance related mishaps are caused by distractions. Be aware of distractions and take active steps to eliminate or at lest reduce them.
-Complacency come from doing the same task over and over again, your comfort level is high you stress and pressure level is low and you are simply going about business as usual, your guard is down. Like going on the second hour of feeding the chipper. Mixing things up can counteract complacence. Some examples; chipping for a long time, stand on one side of the inlet then the other, wear gloves for a while then take them off do things that won’t let you get to comfortable. If you are on the 5th fir tree of a row of 20 you are trimming change up you access SRT to DRT them back to SRT you get the idea, be creative.
-Norms, there can be good Norms and bad Norms, I here people say all the time “that’s the way we did it at…” just because it was done a certain way years ago or over on the east coast doesn’t make it right if it is an incorrect procedure or practice.
-Lack of Communication is pretty obvious but we need to be reminded that when we are convening something we need to be accurate and complete and insure our message was received. How many times has the wrong tree been cut down?
-Lack of Resources, you simply don’t have the tools or knowledge to do the job. Using a too low of rating rope for a task because you don’t have a bigger one at the job site. If you don’t have the right stuff get it or don’t do the job.
-Assertiveness, a lack of assertiveness shows up when you know what you are about to do is a bad idea but the boss told you to do it or you saw the old experience guy do it and you fell that you want to speak up but are afraid to do so. Also you see someone making a mistake and are not willing to speak up because of being junior on the crew or the person committing the error has such a dominating personality you don’t dare speak up. The lack of assertiveness factor had allowed lots of aircraft to be flown into things they were designed to fly into. The young co-pilot didn’t say anything about the mountain in front of them because he thought the senior pilot knew what he was doing.
-Awareness or the lack of is simply not paying attention usually one of the other factors has a role in this. How many climber has fallen do to them cutting their rope or lanyard. Keep you head on a swivel and adopt an attitude of heightened awareness.
-Lack of Teamwork, the odd one out of the crew is less likely to ask for help our guidance. Everyone in the work area should have a good idea of what the work plan for the day is. In my younger days logging in Eastern Washington I had a faller drop a tree on me and my skidder I was save by a good roll cage, I had no idea he was falling trees in this area and he didn’t know I was going to use this particular road to get back to the top of the hill. Poor teamwork we didn’t know each other’s work plan for the day. Good communication breeds good teamwork.
-Lack of Knowledge is pretty obvious, if you don’t know how find out how before you are up 40 feet.
These factors are counteracted by seven factors know as ‘The Magnificent Seven’
There are:
-Decision making
-Assertiveness
-Mission analysis
-Communication
-Leadership
-Adaptability and flexibility
-Situation Awareness
-Decision making using as many factors as you can to make your decision, taking into account pressures, stress, fatigue and so on. Is the limb strong enough? Is this dead tree sound, do I know for sure? Is there a safer way?
-Assertiveness, if something needs to be said say it, foster and attitude among your crew that ever opinion is valued, people should feel free to speak up and not shot down when they do.
-Mission analysis and communication go hand in hand, you should look at the task, come up with a workflow and work plan. Everyone involved should know what’s going on and how this should play out. We are going to remove this tree first, tie off on this tree lower the top over there and so on.
With mission analysis this should also include identifying hazards and how they will be safely mitigated.
-Leadership, someone has to be in charge, he is responsible for insuring the required resources are available, a good work plan is in place, hazards are identified and reduced or eliminated and distractions are reduced.
-Adaptability and flexibility a person has to be flexible to changing conditions, situation and environments. When the situation changes you have to be able to reevaluate it and change as needed. Don’t be committed to doing something a particular way, it may be safer to change you whole plan when pressure, stress, fatigue and other factors come into play.
Well that’s the short of it and of course this is not all-inclusive or covers every situation. Hopefully this helps someone, if you are aware of these factors and look for them during work you can do something about it before an accident happens.
The good news is that accidents always happen to the other guy, the bad news is that to someone else you are the other guy. Lets be safe out there.
Pat
I work in the aviation maintenance field and for safety and financial reasons it’s important to reduce maintenance related mishaps. One of my jobs is to analyze mishaps and give training to help prevent or at least reduce them.
As an amateur and recreational tree climber I thought some of the information and training would be useful in preventing and reducing tree working mishaps. So here goes my attempt to parallel aviation safety with tree working safety.
In every mishap there are at least one of the following factors, often two or three. These are known as ‘The Dirty Dozen’ these twelve factors are divided in to groups, ‘The Abundance of’ group and ‘The Lack of’ group.
Abundance of:
-Pressure
-Stress
-Fatigue
-Distraction
-Complacency
-Norms
Lack of:
-Knowledge
-Communication
-Resources
-Assertiveness
-Awareness
-Teamwork
-Working under pressure and stress can actually increase you awareness and ability but there comes a point where the stress and pressures increase and the performance curve starts heading downward fast. Your mental reasoning and function slows, this is where mistakes happen. Know when you are over stressed or under to much pressure.
-Fatigue is pretty obvious the more tired a person is the more careless they are and are more likely to take short cuts. I see this in my self, the longer I’m in the tree and getting tired I have to make a mental note to be careful.
-Distractions (I-Pod in the tree) customers talking to you while working, chipper, kids, problems at home, cell phone, rain, cold, heat… these all take attention away from what you are doing, increasing the risk of making a mistake. About 70% of the aviation maintenance related mishaps are caused by distractions. Be aware of distractions and take active steps to eliminate or at lest reduce them.
-Complacency come from doing the same task over and over again, your comfort level is high you stress and pressure level is low and you are simply going about business as usual, your guard is down. Like going on the second hour of feeding the chipper. Mixing things up can counteract complacence. Some examples; chipping for a long time, stand on one side of the inlet then the other, wear gloves for a while then take them off do things that won’t let you get to comfortable. If you are on the 5th fir tree of a row of 20 you are trimming change up you access SRT to DRT them back to SRT you get the idea, be creative.
-Norms, there can be good Norms and bad Norms, I here people say all the time “that’s the way we did it at…” just because it was done a certain way years ago or over on the east coast doesn’t make it right if it is an incorrect procedure or practice.
-Lack of Communication is pretty obvious but we need to be reminded that when we are convening something we need to be accurate and complete and insure our message was received. How many times has the wrong tree been cut down?
-Lack of Resources, you simply don’t have the tools or knowledge to do the job. Using a too low of rating rope for a task because you don’t have a bigger one at the job site. If you don’t have the right stuff get it or don’t do the job.
-Assertiveness, a lack of assertiveness shows up when you know what you are about to do is a bad idea but the boss told you to do it or you saw the old experience guy do it and you fell that you want to speak up but are afraid to do so. Also you see someone making a mistake and are not willing to speak up because of being junior on the crew or the person committing the error has such a dominating personality you don’t dare speak up. The lack of assertiveness factor had allowed lots of aircraft to be flown into things they were designed to fly into. The young co-pilot didn’t say anything about the mountain in front of them because he thought the senior pilot knew what he was doing.
-Awareness or the lack of is simply not paying attention usually one of the other factors has a role in this. How many climber has fallen do to them cutting their rope or lanyard. Keep you head on a swivel and adopt an attitude of heightened awareness.
-Lack of Teamwork, the odd one out of the crew is less likely to ask for help our guidance. Everyone in the work area should have a good idea of what the work plan for the day is. In my younger days logging in Eastern Washington I had a faller drop a tree on me and my skidder I was save by a good roll cage, I had no idea he was falling trees in this area and he didn’t know I was going to use this particular road to get back to the top of the hill. Poor teamwork we didn’t know each other’s work plan for the day. Good communication breeds good teamwork.
-Lack of Knowledge is pretty obvious, if you don’t know how find out how before you are up 40 feet.
These factors are counteracted by seven factors know as ‘The Magnificent Seven’
There are:
-Decision making
-Assertiveness
-Mission analysis
-Communication
-Leadership
-Adaptability and flexibility
-Situation Awareness
-Decision making using as many factors as you can to make your decision, taking into account pressures, stress, fatigue and so on. Is the limb strong enough? Is this dead tree sound, do I know for sure? Is there a safer way?
-Assertiveness, if something needs to be said say it, foster and attitude among your crew that ever opinion is valued, people should feel free to speak up and not shot down when they do.
-Mission analysis and communication go hand in hand, you should look at the task, come up with a workflow and work plan. Everyone involved should know what’s going on and how this should play out. We are going to remove this tree first, tie off on this tree lower the top over there and so on.
With mission analysis this should also include identifying hazards and how they will be safely mitigated.
-Leadership, someone has to be in charge, he is responsible for insuring the required resources are available, a good work plan is in place, hazards are identified and reduced or eliminated and distractions are reduced.
-Adaptability and flexibility a person has to be flexible to changing conditions, situation and environments. When the situation changes you have to be able to reevaluate it and change as needed. Don’t be committed to doing something a particular way, it may be safer to change you whole plan when pressure, stress, fatigue and other factors come into play.
Well that’s the short of it and of course this is not all-inclusive or covers every situation. Hopefully this helps someone, if you are aware of these factors and look for them during work you can do something about it before an accident happens.
The good news is that accidents always happen to the other guy, the bad news is that to someone else you are the other guy. Lets be safe out there.
Pat
