Clays Ferry Bridge Incident Report Released

Clays Ferry Incident

Clays Ferry Bridge Incident

The Known Unknowns

On March 21, 2016 , the Kentucky Fatality Assessment and Control Evaluation (FACE) Program released their report on a fatality involving a 52 year old truck driver.

FACE is a research arm of The National Institute for Occupational Safety and Health (NIOSH), which in turn part of the Centers for Disease Control (CDC).

Most of this FACE report on what actually happened is based on speculation.  Whether the driver nodded off (cited as Rec. No. 3) or was distracted (Rec. No. 2) is anyone’s guess.

Nobody (perhaps, thankfully), saw exactly how the fatality occurred. For reasons still unknown, the driver braked hard and his truck jumped the wall, resulting in a fuel fire. All that is really known about the incident is the driver’s body was found several hundred feet below the bridge.

The Facts

The company was about a year old and had two trucks.

The report determined, “The employer did not have any written employee safety programs or provide any training . . .

Many startups and small companies do not, in my experience. By definition, they lack a mature safety culture.

What is Safety Culture?

Safety Culture is a value within organizational culture such that safety is never compromised.

The “maturity model” concept that says an organization’s safety culture is not developed (or remains negative) in a new company or organization until it passes a certain stage of maturity, generally with the passage of time.

The opposite of a mature safety culture or negative safety culture is based on makeshift or improvised (ad hoc) safety policies, procedures, and practices, if any.

Some safety researchers have suggested that an organization doesn’t really have a safety culture until it has met and overcome a difficult safety challenge (or sometimes a series of challenges).

There is plenty of anecdotal evidence to back this up. Organizations are never the same after loss of someone’s limb or life. By then, however, its too late . . .

Risk Maturity

Eight dimensions of “risk maturity” have been identified by Martin Loosemore, who has researched Risk Management for over 20 years and has published over 200 books and articles in risk management, crisis management, OHS, etc.. . .

  • Risk management awareness;
  • Risk management culture;
  • Risk management processes;
  • Risk management skills;
  • Risk management image;
  • Application of risk management;
  • Risk management confidence; and,
  • Resources invested in risk management

These eight dimensions have been fit by Loosemore into four “maturity levels:”

Level One Risk Management

  • Efforts are largely on an ad-hoc basis, unstructured and reactive.

Level Two Risk Management

  • There is still no structured approach except for a small number of people on selected projects with little consistency.

Level Three Risk Management

  • Risk management is integrated into business processes on most projects, through a formalized and generic risk management process, including specific processes and tools also integrated into quality management processes.

Level Four Risk Management

  • While difficult to achieve, level four requires a significant investment of time and resources. It is characterized by a proactive culture of risk management which is inextricably integrated into every project, organizational function and supply chain. Risks are analyzed by state-of-the-art techniques; there is top-down commitment to risk management.

The key benefit of having achieved proactive risk management (and a positive safety culture) is that proper resources are assigned to areas where the greatest risks are, not in “damage control.” As one risk expert said, “Firefighting is exciting, but not very efficient.”

Thank you for reading this.

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