A near-miss, a lack of management of change, an unnecessary initiative, ignorence, and life at risk…

Today, the subject for me is about how important it is to be in the moment, to dive into deep, and go till you hit the bone and find the root cause. I was in a visit a couple of months back, when I came across the scene that you will see in the picture below. A man was working on top of a wall, wearing no protection to avoid him from falling and seeming as if it didn`t matter at all. As we came close, he stopped what he was doing and with the help of his friend, get down using a crappy platform that was standing close to the wall.


We, in a very polite manner, went nearby and greeted them. They were anxious and furstrated at being disturbed but greeted us back. To start the converstaion, I usually start by asking how they have been doing, how life is or similar small talk questions but this time, I was also not in the mood and very dissapointed. The place I was in, had known to be a place of high H&S discipline with a good level of awareness and motivation. Seeing a work being done in such an unsafe and reckless mode shocked me.

I asked the both gentelmen what were they doing and why actually they were doing it for. They replied me, stating that they were actually installing barriers of cardboards to stop the wind. Those guys were in the refurbishment business and actually helping the entitiy to maintain their equipment. They had been given the place by the entity.

I asked, if it was possible for them to show me the permit to work. They looked at each other in a questioning way which led me to believe that they had neither knew the permit to work concept nor had they ever been included in an orientation program or a safety training. It was also obvious that they had no idea of what might have happen to them if one of them would fall. The area responsible was also speechless at that moment.

After covering the esentials, I asked for the reason behind the need of installing a wind barrier. It was cleared when we enter to the building that, the building was recieving a lot of wind which was whirling up the dust and making it pretty uncomfortable to work. They told me that they used to work in another building wihch was completely closed, so they had been doing their job without being effected by the weather conditions. When a necessity came up, forcing a decision to move the guys, a proper management of change protocol which could have easly spot the need had not been executed. They were simply carried from a place to another.

After changing the place, the guys became aware of the negative impacts of the weather conditions due to the openings around the walls, they started to complain to the area responsibles. The quickness showed when moving the operating could not be repeated when it comes to closing the openings which led the workers to take a risky initiative. With no proper preparation, no protection, no training and no emergency plan, they decided to do the thing on their own as to show everyone that actually they did not need any help and they could do their work on their own.

Without the knowledge, comes a great courage, a fools courage out of ignorance. Not even knowing that falling from a height of approximately 3,5 meters could be fatal, the worker climbed up and started to install. To his luck or unluck, we were there to have a site visit, and we spotted him at the early stages.

The place is dealt with and everything is normal now, but this experience has left a huge what if in my mind as I am thinking from time to time what if, anyone was a little too late to spot?…

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