The Consequences of Faulty Risk Mediation

Articles, Climb Safe

By Edge Mugga

Edge Ascension’s tag line is “Climb safe.”

We extol all to climb safe, and we seek to encourage companies and individuals involved in climbing related activities to be objective about what they are doing, to fully understand the consequences of their actions, and to act accordingly. It is a well known fact that most climbing accidents result from climber failure in properly mediating the risk of an ascent.

Climbing to heights is the major cause of physical fatigue leading to accidents engendering property damage, injury and death.

Root causes of fall incidents are relatively simple and fall into three categories:

• Lacking or inappropriate equipment
• Insufficient inspection or maintenance of equipment
• Ignorance of or disregard for proper safety procedures.

Incident reports of falls from heights are replete with horrific accounts of accidents in industry ranging from storage tank incidents to tower incidents to building incidents, and on and on. Any activity undertaken at height has great risk of falling associated with it. With this risk come grave personal, emotional, and economic consequences.

Note: The following stories are drawn from National Institute for Occupational Safety and Health (NIOSH) Fatality Assessment and Control Evaluation (FACE) Program incident reports.

Consider the now well known story of the husband and wife team who were conducting maintenance on a communications tower with their under aged son and a not much older inexperienced co-worker. The husband, son, and co-worker were lifted up a tower together on a single line with a 1000 pound capacity and driven by a non-man rated hoist affixed to the towers base. They carried tools, materials, and three equipment platforms. Three loops had been tied in the line at 6 foot intervals to aid the workers in their ascent on the line (each knot weakens the load capacity by 20 to 50% depending on the type of knot used). The three equipment platforms were suspended from a nylon rope attached to the bottom loop. The total weight on the line is thought to have exceeded the 1000 pound load limit of the line. While the two men and the juvenile went up the tower to perform their duties, the wife was stationed at the tower’s base to operate the hoist.

They had worked on the tower day before without problems, so why would the day of the incident be any different? What went wrong was that the rope began to slip on the capstan. The winch operator, the wife, tried to stop the rope from running away by grasping it so as to tighten it on the capstan, but couldn’t hold it from slipping, as the fall was in progress and the forces too great. All three men fell 1,200 feet to their deaths before the wife/mother/co-workers eyes.

Think of the futility, the helplessness, the loss, the guilt, the shame, the horror, and the heart ache that she must have felt in that moment. What went wrong? Was it an accident that couldn’t have been predicted? Did something break that was unforeseeable? Was it unavoidable? Was it fate or failure of reason? In our view, it seems fated for a failure to maintain reason, a failure to be objective about risk management, not just by one, but by multiple individuals on multiple levels.

Think of all the things they did wrong. Placing personnel on a line connected to a non-man rated hoist. Possibly placing weight on the line in excess of its recommended limits, and tying knots in the line as foot holds and attachment points — each knot, if not correct, potentially reducing the weight baring capacity of the line by 40%. They hauled personnel and equipment on the same line. They allowed under aged personnel to ascend to heights over 6 feet from the ground.

Practical tower ascension should be as effortless and safe as driving to work.

The under aged worker issue aside, what other options did they have? Had they employed a proper lift mechanism and followed proper safety procedures, they could have sent personnel up one or two at a time, with equipment, tools and materials going separately. They could have climbed the tower directly, but this is probably just as risky as what they did that caused the accident. They could have used a man rated certified lift mechanism, such as a powered personal ascender. Had this team been properly using certified powered personal ascenders, they wouldn’t have had a slippage failure; as such devices should have built in hold on rope safeguards. Once on station, the powered ascender could be returned remotely to lift equipment, tools, and materials. The bottom line is, they should have been following the NIOSH safety recommendations for working at heights.

In another incident, there was a man in his early 20’s employed as a tower erector who died in a tower accident when he hooked onto a supporting guy wire without first hooking onto the tower. He slid approximately 1,000 feet down the guy wire. According to the NIOSH FACE Report:

“The victim and coworkers were attaching dampeners to the tower guy wires when the incident occurred. The tower being constructed was a 1,040-foot, high-definition digital television tower. When the incident occurred, the victim was at the 1,000-foot level and was wearing a positioning safety belt with a T-bar attached to the D-rings on his belt. Attached to one end of the T-bar was an adjustable-length lanyard with a large hook as its terminal device. Attached to the other end of the lanyard was a large hook. The victim placed the large hook over the guy wire but did not attach the adjustable lanyard to the tower before sliding out on the guy wire. Although he had one foot draped over the wire, he could not keep himself from sliding. The victim slid rapidly down the wire, striking the anchor point of the guy wire. He was pronounced dead at the scene [Missouri FACE 1998].”

Can anyone imagine the sudden shock and terror that went through this young mans mind upon letting loose of the tower for the last time? Or imagine the futility of his coworkers who watched and could do nothing to help? Or imagine the heart aches of his loved ones who would learn from strangers the fate of their beloved.

How could a professional tower erector hook him self onto a guy wire and step off without his adjustable lanyard attached to the tower? Most likely, it was simple human error. But, where were the safety support personnel? Why wasn’t there another person there watching and assisting his deployment onto the support guy wire? Had he climbed to the top before the accident occurred? If so, then fatigue would surely have figured into his actions at the top. The FACE report does not address this issue. Yet, fatigue is known to be the major cause of accidents resulting in falls from height.

In yet another incident, a middle aged tower erector fell to his death while working near the top of a tower. According to the NIOSH FACE Report, he…

“…fell 240 feet from a 260-foot telecommunication tower while attempting to install a new phone service device on the tower. The victim and a coworker attached their lanyards to the cable climb positioned on one leg of the tower and climbed to the 240-foot level of the tower. The owner and a third tower erector remained on the ground. Both workers wore two 6-foot lanyards attached to the side D-rings on their body harnesses. The terminal devices on the coworker’s lanyards were two large pelican hooks. The terminal device on one of the victim’s lanyards was a large pelican hook, but the other lanyard had a smaller snaphook as a terminal device. The victim began to attach a coaxial phone cable to an antenna arm while the coworker, with his back to the victim, was attaching cable tray components to the tower. A short time later, the victim fell, unwitnessed, from the tower to the ground. The coworker stated that two pelican hooks were necessary because the smaller snaphook could not be attached to the larger tower components [NIOSH 1999].”

The report mentioned several interesting things. The tower owner and a third tower erector were at the base of the tower. A co-worker accompanied him to the work at height area, but was working on another area of at the same elevation when the accident occurred. The victim had just climbed the tower to a height of 240 feet. The victim didn’t have the correct safety gear for the job.

In still another incident, a man employed as a tower erector died in a fall that occurred while erecting a tower. According to the NIOSH FACE Report he…

“…died after falling 200 feet from a telecommunication tower while attached to an 80-foot section of cable tray. He was a member of a nine-man crew erecting a 240-foot, three-sided telecommunication tower. The crew bolted a 140-foot section of the tower together on the ground. Next this section was set in place by a crane. The workers then erected the final 100-foot section on the ground, and three tower erectors climbed the 140-foot section. The final section was set in place by the crane, and the workers bolted the two sections together. The crane then lifted an 80-foot section of cable tray to the top of each side of the tower. As each section was lifted into place, an erector began to attach it to the tower using four J bolts every 10 feet. The victim began working down the tower, attaching the cable tray and tightening all bolted connections as he descended. After approximately 1 hour, the victim was at the 200-foot level of the tower. The victim then repositioned himself and connected both of his lanyards to the partially attached cable tray. Shortly thereafter, the section of cable tray gave way, falling to the ground with the victim attached [NIOSH 1998a].”

In this case, the man was wearing the correct safety gear. He seemingly fell as a result of mistakenly affixing his lanyards to the wrong attachment points. One possible contributing factor was the fatigue of his having been climbing on the tower under construction. On the other hand, there may have been other contributing factors, such as practice issues, which can only be mediated with proper risk management.

In a final incident, two men, a supervisor and a co-worker, were employed to perform maintenance in a water tank. They descended into the tank through a hatch in its top by way of a rope ladder. While the tank was 60 feet high, the top of the tank was 125 feet from ground level. In the course of their work, the men had ascended the tank twice, once to reconnoiter access, and a second time to enter the tank. The climbs were done essentially back to back.

At the end of their shift, they attempted to exit the tank. The helper completed the exit ascent first, as the supervisor followed in his ascent. Upon exiting the tank, the helper noticed that the supervisor wasn’t following as expected. When he looked to see where the supervisor was, he discovered that the man was only half way up the ladder, and appeared to be in difficulty. The helper re-entered the tank to lend assistance when the supervisor confirmed that he needed some help. The following is from the NIOSH FACE incident report:

“The co-worker noticed that the supervisor “was climbing wrong and had a funny look on his face.” (The supervisor was facing the ladder, as opposed to the standard procedure for climbing a rope ladder from the side thereby producing less swaying motion.) The co-worker asked the supervisor if he needed help. Upon receiving a positive response, the co-worker descended the ladder to assist him. The co-worker managed to grasp the supervisor’s hand, however the supervisor was unresponsive to the co-worker’s repeated calls to grasp the ladder. The co-worker was unable to retain his grip, and the supervisor slipped from the ladder and fell approximately 50 feet to the bottom of the tank. The co-worker descended the ladder to aid the victim and moved him slightly from the facedown position near the water where he landed. He returned to the top of the tank where he cried out for help. He got the attention of several individuals located at a business establishment across the street who, in turn, summoned help.”

Clearly, physical fatigue was at the root of this accident. But risk management planning was needed as well. While on the ladder, no other safety devices were employed. Again, if a certified powered personal ascender were to have been properly employed to access this tank, this fall could have been avoided. Indeed, even if the man had been injured or had a medical problem while in the tank, such an ascender could have been sent to him by remote control means. Of course with an ascender, climbing fatigue (which can bring the onset of heart attacks and other incapacitating health issues in some people) would have been avoided.

See: NIOSH recommendations for this and other incidents.

While the circumstances were different in each case, from a safety standpoint there is one common theme. Was the team qualified to do the work?

Apparently not! For, if so, why would they have proceeded so negligently? If one is a properly trained professional, one knows:

· to perform safety checks, and to decline engaging the work if anything doesn’t checkout satisfactorily.

· not to engage unqualified individuals in the work effort.

· not to proceed without proper safety backups in place.

· not to use non-man rated equipment.

· not to have too many personnel on a single line.

· how to set rigging to carry personnel and equipment.

· not to overload a hoist system, especially one that is employed in carrying people to heights.

· to check equipment manufacturers’ use restrictions and safety/maintenance requirements before employing equipment.

· to always use the proper equipment and tools for a given job.

PowerQuick ascending to heights, reducing fatigue, while improving performance and safety. The PowerQuick ascender is best employed where access to heights would otherwise engender increased risk.

Who was responsible for seeing to it that the team was qualified?

The short answer is the tower owners, the tower equipment operators, the team’s company management, and the team members themselves all share in this responsibility. The result of the tower owners not managing their risk properly is that a team may be allowed on the property that may cause death, injury, or property damage. This then may result in exposure for related liabilities as a result of noncompliance with safety regulations by the companies they have allowed to access their towers. As in any liability case, the attorneys cite everyone in the chain from the bottom up. This, in turn, usually results in increased insurance costs. The only protection is for tower owners to require tower operators to certify that their teams and those of others allowed on the site are trained in accordance with established regulations.

The result of the tower equipment operators not managing their risk properly is that they may engage an unqualified team to perform work on a tower that their equipment is attached to – a team that may cause death, injury, or property damage. This then may result in exposure for related liabilities as a result of noncompliance with safety regulations by their contractors. As in any liability case, the attorneys cite everyone in the chain from the bottom up.

The result of the team’s company management not managing their risks properly is that they can be held legally liable for criminal neglect if it can be shown that they did not provide the required training and equipment to personnel in their employ or ensure subcontractor’s employees were properly trained. This results in compounded excessive risks being taken that combine to cause deaths, injuries, or property damage, which can in turn result in exposure for related liabilities.

Team members, in not taking responsibility for properly being trained have the highest risks of all, as they are at risk of losing their lives, of endangering the safety of others, of risking damage to property they are engaged to improve, and of losing happiness in the pursuit for their engagement. All of which will most likely result from fatigue or medical conditions that could be mediated with proper risk management. Be advised, with risk goes the consequences of faulty risk management, the least of which is the resulting liability.

Related Articles:

Deadliest job in America: Working on cell phone towers

Tower climbing: Deadliest job in U.S.

admin @ May 26, 2008