A plant manager called me with the news of a near miss. A forklift collided with a steel column.
When I asked who was operating the forklift, the answer surprised me. The person at the controls was one of their best operators. This operator had aced his forklift re-qualification. He is someone who I publicly highlight during SafeTask® training as a role model to influence safe behaviors. Not only did we have to deal with the near miss, but a good employee had fallen from the safety pedestal.
This post shares how we created an active learning experience after the near miss to engage their people to understand the risk, as well as how we engaged the good operator in the solution.
Learning the Causation
Let’s start with something positive. This company takes every near miss seriously.
This company has a proactive safety culture based upon the James Reason model described in Managing the Risk of Organizational Accidents (1997). One aspect of this safety culture is fostering a learning culture in which people within a safety management system learn from mistakes.
The operations staff was interested to learn the error(s) with the intent to influence safe behaviors related to that task. In order to learn from the near miss, the company conducted an incident analysis to understand the causation.
What we learned was interesting.
The forklift operator fully cooperated with the incident analysis in spite of being embarrassed. During our interview, the operator said something profound, “That steel pole could have been a person.” He said aloud what everyone was thinking.
Lining up the facts from the scene with the interview, the causation came to light. The employee was operating a stand-up forklift. The operator stands 90° perpendicular to the front field of vision. He had leaned his head left to see around the mast to view an employee 30 feet away. The operator then moved his head back to a centerline position. When he did, the forklift drifted right and collided into the steel column.
This sequence happened in less than three seconds.
We re-enacted the body motions several times with the operator and separately with other persons. When the operator re-positioned the head and shoulders from left leaning back to centerline, the left hand controlling the steering wheel rotated inward. That subtle motion caused the forklift to drift right in response.
The steel column was in the right front blind spot of the mast. He never saw the column in his peripheral vision when leaning left. That is when we knew the at-risk behaviors were innocent human factors errors, not an instance of intentional risk-taking.
Sharing the Takeaway
A learning culture necessitates that we share the takeaways with the people affected by the task. Following the SafeTask® System, we desired for this learning to be a high-impact safety contact that would make people stop and think about risk.
That’s when we decided to offer this good operator an opportunity to teach others about the near miss from his perspective. He jumped on the invitation. We scheduled him to share the lessons learned at the next regular monthly safety training.
It was a huge success.
Make a High-Impact Safety Contact
The forklift operator and a SafeTask® Instructor developed a lesson plan for a high-impact safety contact. The operator agreed the theme should be what he said before, “That steel pole could have been a person.”
The learning objectives supported this theme, providing clear takeaways to influence safe behaviors. We wrote down the takeaways for forklift operators and pedestrians on an easel. Then we designed a hands-on, active learning experience to engage everyone in the causation.
We re-created the near miss scene for the active learning experience. We placed the forklift where the chain of events began. Taped arrows were placed on the floor to trace the drift path into the steel column. The web of the steel column was labeled with the words Blind Spot. And we made a positional timeline of key events with cardboard placards to explain the correlation between the head and shoulders, steering wheel control, the drift, and point of collision.
Groups of employees were brought into the warehouse for the active learning experience. During a 20-minute lesson, the forklift operator walked through the chain of events. His lesson was authentic, both emotionally and sprinkled with self-deprecating humor.
We explained the human factors involved and how the collision occurred. Then each employee took a turn taking a standing position in the forklift at the controls. This experience gave them the perspective of the steel column disappearing in the blind spot. It generated a buzz.
Here is why this high-impact safety contact engaged the employees in the active learning experience. They were able to visualize how the near miss happened and understand the human factors involved. They experienced seeing and touching the scene, as well as interacting with the operator.
Forklift operators understood first hand the importance of two key safe behaviors: (1) five-point eye scanning and (2) naming the objects in their field of vision as they seem them. Pedestrians understood why stepping to the sideline when a forklift apporaches and making eye contact with the operator is a two-part safe behavior that is critical to their personal protection.
Another benefit of this active learning experience was that the forklift operator retained a positive status. By encouraging the operator to serve as a trainer, he was able to recover from embarrassment through the goodwill of teaching others. People learned the errors and how he felt in his words.
Something else happened during the active learning experience that we did not expect. First, side conversations began amongst the forklift operators. They questioned the norm of driving forks first. Why not drive with the forks to the rear, improving the front field of vision? Next, at the end of each session, frontline employees spoke up to the group and made a similar comment:
“If a small error and incident like this can happen to one of our best forklift operators, then we all need to be careful and follow these precautions.”
They got it.
A near miss is a free learning opportunity. When we experience a near miss, it is easy to broadcast a quick email with the lessons learned.
But we can also leverage the near miss to generate a high-impact safety contact with an active learning experience. This combination gets insides people’s minds and improves their good judgment about risk.