In the one that took someone's leg off, I personally assessed the blame as mine: I was working on the shutdown of a site and a friend of mine who was also working the shutdown, but in a supervisory role, pulled up in a van and asked if I could help take down a sign that had been left on a different part of the site. I hopped in the van with a cutting torch and we drove down there and I was surprised when we got there that the sign had an enormous ladder frame made of 3x3x1/4" angle iron that the welders had clearly put together in a fit of structural overkill.
"Well," I said, "I can cut it down but we'll have to get a truck to drag the pieces out of here. It's small enough that we can drop it this way and not hit anything but once it goes, it'll go, so stay back and I'll take it down."
But that was all I said, because I'd been working with steel and cranes for a long time at that point. So had my friend, but not as closely - she worked on our crew but didn't personally handle cranes or steel. But I didn't think about the fact that she didn't have the same instincts as me, and when the other ironworkers and pile drivers said to you "if it starts to go, let it go" you know that's really f'ing serious. But it requires you to suppress this instinct that you have to prop something up that starts to tilt.
I started cutting and the frame started to sag, and my friend, instead of just staying back, stepped in and tried to prop up about 800 pounds of angle iron at the same moment that we caught a gust of wind and the time between her stepping into the fall zone and the steel hitting the ground was only about a second and I didn't have time to shove her back and the steel scissored her leg off. I was able to lift the steel and get her out but then had to clamp a hand down on her leg and drive my thumb into her femoral to slow down the bleeding (honestly not certain whether this was working; the bleeding did slow but whether that was a result of the pressure or just her arteries retracting and her muscles locking up I don't know) and call an ambulance because there was nobody else on that section of the site and it was a huge site. The ambulance was pretty quick and they got her loaded onto the stretcher and took her away.
The investigation by an outside workplace safety body concluded that it was my friend's decision to step into the path of the collapsing structure that was ultimately the cause of the incident, although I argued at length during the investigation that in fact it was my failure to do a sufficient pre-work safety debrief that precipitated the whole thing. I should have known she didn't have the same reflexes as someone who worked with cranes and high steel directly and the fact that she was technically my supervisor at that point was meaningless. I knew there was a risk of the steel coming down a bit unpredictably and I warned her to stay back but what I didn't specifically say was "this will probably start to go and you will have in impulse to prop it up partly because I'm going to be right there and even though consciously with lots of time to think about it you would know you can't stop half a ton of steel, if you don't have time to think and it starts to lean, you'll see me there and think you should help and you might try to prop it up...DON'T." That's what I should have said and if I had, she'd never have been hurt, and I told the provincial safety agency that and criticized the outcome of the investigation after I was assessed as not a factor.
They described a chain of failure beginning with my friend's boss work duties. He was actually the head of the safety department, but during these last phases of the project, had been assigned a bunch of stuff that had nothing to do with safety, which was his area of expertise. He didn't really have a background in the work he was directing.
Possibly as a result of his inexperience, he sent her to just go grab a guy and take down the sign. He didn't know what the sign was made from and didn't look into it, and just assumed she could grab a single guy with gear and get it done.
The friend of mine they sent had ended up in the safety department herself but at this point in the project she was my boss, and as such the safety briefing was technically her responsibility not mine. The verdict said she made the decision to step in front after being warned, and despite my personal take on what a good safety briefing would include, that wouldn't be a typical briefing that anyone would get and if a different person had been selected to do the work instead of me, the exact same series of events would have occurred, because essentially I was carrying out instructions and the warnings I did give were typical of what you would get from a supervisor, and I wasn't the supervisor anyway.
I understand their position but I also realize that I could have prevented it if I had thought carefully about my friend's likely vulnerability to that specific risk and how that works for people without that specific level of experience and as such, I continue to disagree with the outcome of that investigation. It did assess a bunch of blame within the company, but exonerated me over my objections.
I got credited with saving my friend's life and leg and I also argued against that because neither would have been at risk if I had thought everything through carefully ahead of time and overridden the typical chain of command because of the disparity in our specific job task experience. But I didn't have any control over the outcome of the investigation and I didn't want to pursue it aggressively because my friend saw the whole thing the same way the investigators did and for obvious reasons I didn't want to get into a big conflict with her over it. But I continue to think that is also a misinterpretation of events. It's true that I was a cog in the machine, but I did have the power to interrupt that chain of failures and the actions I did take weren't sufficient to do so.
That's just one of the ones I've been present for but it was the only one I probably could have stopped if I'd done things differently, but that's how I come by the knowledge that every fatality is the result of a long chain of failures.
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