The New York Times reported that a crane tipped and hit a building in New York City.
According to the story. Christopher Cosban, the top level crane operator at the site, left the site for the day without lowering the 250 ft boom as far as it could go.
The investigators said that his mistake – not lowering the boom – contributed to the accident. (But might not have been the “sole” cause.)
What action did they take? City officials suspended his license.
Now for the question …
Should we discipline people before we complete an investigation?
In this case the article seemed pretty clear that lowering the boom when not at the worksite was a requirement. But I’ve seen many cranes left for the weekend with the booms still up. Actually, I can’t think of too many places in NYC where you could lover a 250 ft boom and leave it down for the weekend (think of streets and businesses blocked for two days).
So maybe they should have completed their investigation before they blamed the operator.
Is this a lesson we can learn? Let me know what you think.
I agree, all the facts of the incident should be investigated and what the root cause is before “lowering the boom” on the employee.
There is a big difference between suspending a licence and suspending employment. In this case I agree with suspending the licence pending the investigation findings. As there is no suggestion of delibrate act, suspension of employment pending the investigation would not be warranted.
Did the crane driver know this procedure. Did the City officials inform the contractor’s supervisor of this procedure.If there was no room to lower the boom, then some other mechanical support system should have been put in place. A lifting/rigging plan should have been in place.
I agree with a full investigation before any diciplinary action.
The questions for me are? Did the crane driver always do it that way? or only on that particular day? were management aware that he left his boom in that position?
What do the risk assessments say? what SSOW are in place?
and was the driver asked why?
a lot to put in place befoe we discipline anyone , to many unanswered questions for me?
Remember ,that this may have been due to a lack of a management control ! who do we discipline then?
All the questions above are relevant. As we are in a world of labor unions and similar bodies, it is imperative that all instances of high potential incidents are handled with the aggression that the potential deserves. Suspension of his license is the first step. As the saga unravels there would be, in my mind a few other actions that would have to be addressed up to and including, if found negligent, the supervision, Management discipline. This could go all the way up the line as the buck stops with the CEO of the company.
This man was designated as the “top level crane operator at the site”. I am assuming, since I know nothing of the crane operating business, that this means he was experienced. So, What was different about this particular day (also noted by Robert Warden)? Is it a requirement to lower the boom(also referred to by Keith Ramdin)? – was this verified? I also liked Keiths comment about contingency plans if the boom can’t be dropped. And I certainly can’t disagree with Robert Green with evaluating the management’s part in this incident.
But I failed to answer the question. And since, as I stated before, I have no knowledge of the crane operating business, I am not knowledgeable if there are any defined rules or regulations that apply to this situation. Example, like a policeman that shoots someone…don’t they get a suspension until the investigation is completed? If there aren’t any rules governing this situation, then No, in most cases, the investigation should be complete before disciplining the employee. Until the investigation is over, how do you know what really happened?
This appears on the surface to be a knee-jerk reaction by the city to “demonstrate” that they are taking it seriously and acting swiftly. Very public incidents such as this can take the rational and methodical best practices and throw them out the window to expedite the process, “satisfy” those in the public (and press) who want instant answers, and (most importantly to public officials) get the issue out of the papers as soon as possible (and hopefully look like a hero). This may be showing my cynical side, but we’ve all seen it countless times.
A complete investigation should take place prior to any remedial actions unless there is a safety issue that needs to be immediately addressed. Employees tend to deviate from the procedure and over time it becomes an accepted practice. It is very important for companies to set up periodic reviews. This gives supervisors the opportunity to review the procedure with their employees to ensure the that it is understood and being followed.
I also think that applying discipline before investigation is a little bit pre mature. Also putting discipline at the end of investigation is also detrimental to the investigation process. People will not talk or tell the truth if they know that their jobs are at stake, or if they have already been disciplined, what’s the use of them cooperating.
So how should we deal with it? I believe companies should have clear policies that spell out when to discipline, so that if an is act clearly against those policies we can then apply discipline. Even a violation of a procedure in most cases has reasons why, and firing or suspending people’s licenses before knowing why, is actually killing our industry. For example if the policies of the company for crane operation states “leaving a crane extended will lead to disciplinary” then it is obvious even to the employee why discipline is applied. If it something that was not done according to procedure let’s find out why, and leave discipline out.
Ideally a “no-fault” policy should be in place with the only exception for disciplinary action being a proven malicious act. The no fault policy should have a companion, “compliance” pollcy, which in turn requires that detailed up-to-date procedures and/or checklists be in place and be required to be followed, with provision for exceptions that is effective in handling them. If all or part of a procedure or checklist can’t be executed, there should be provision for safe alternative action with all cognizant parties (including regulators in some extreme cases) involved in the decision to deviate. This requires close management attention and support at all times, but especially at those times when exceptions to best, safest practice must be made. If the procedure doesn’t exist or if management hasn’t required that operators be trained and tested on it then management becomes at least a co-cause of any accident and must be part of the corrective action (retraining, allocation of resources to prevent recurrence or other positive steps to mitigate in future situations).
I think a suspension is warranted, for two constructive reasons:
1) I think it shows a decisive action on the part of management/leadership to deal with the situation.
2) It also takes the person/people at the center out of a stressful situation. Emotions rise (guilt, anger, grief, etc.) from significant incidents. I don’t know that I would want this crane driver back working just yet until he has had a chance to understand as well what happened and learn from it, regardless of responsibility.
A suspension does not have to be considered disciplinary, although it does impact pay typically. I think it is all about how it is communicated. How about simply making the policy to suspend (in significant events) in order to depressurize the situation a bit for those involved until more information is known? As the investigation unfolds, a determination of root cause, people involved, etc. can lead to more appropriate disciplinary actions.
I was involved with an incident investigation that if I insisted that no discipline be administered before the investigation was complete, the employee would have been fired for not following a procedure.
As it turned out, there were many other issues at hand that lead the employee deviate from the procedure, for example:
1. Poor design of newly installed equipment.
2. Lack of attention to a faulty piece of equipment that was reported for over 15 years that the equipment didn’t work right.
3. Lack of understanding of the newly installed equipment.
4. Bypassing of emergency alarm because the emergency stops were used operationally (which was done by all operators in that area, and most likely know to supervision as the alarm was muffled).
5. Pressure to get the product out.
This resulted in the employee being disciplined, but not fired and it pointed out that there are many other factors that go on that can lead a person to deviate from what’s expected.
Remove imediately from assigned task. May not be able to get the incident sufficiently out of mind and may endanger other workers.
Must be available and feel secure for participation during investigation.
If accoutable for incident disciplinary action taken – up to termination or suspension of license if appropiate.
If not responsible full reinstatement to assignment with back pay.
Should we discipline people before we complete an investigation? Depends on the situation. The crane tipping example is set up to look like a knee-jerk reaction and the responses above pretty much have it covered. But it also depends on the definition of discipline. For many employees mandatory drug testing following an incident or being sent home with pay pending a thorough investigation would be considered discipline. The investigation and discipline models should be set up and clearly communicated before an incident occurs. Then they need to be followed. We may want to jump to conclusions and fire “Joe Worthless” or we may want to give “Johnny Bestever” a pass on the discipline but we shouldn’t. Not following management policies suggests its ok not to follow shop floor procedures. After the initial “what happened?” investigation and “discipline” if warranted, the thorough root cause investigation should take place as quickly and efficiently as possible.
If many cranes in the area are observed to have not lowered their booms when work is not in progress and these operators have not had their licences revoked, then there is no reason for this crane operator to be disciplined. Any behaviours that are ignored, these are by default, are being approved. It is not acceptable to only enforce rules when things go wrong.
I believe discipline is necessary. When policies are violated, when procedures are not followed and the investigation does not shows any gap within the management system, when the person takes shortcuts endangering the well been of others, the environment or the asset, when is nothing wrong with the equipment, procedures and training and the person took the decision of not to follow the procedure. Then as a result of the investigation, this is the hardest part, keeping the discipline apart/separate from the investigation in order to protect the investigation process, the disciplinary action might be taken. This can be accomplished through working together with the HHRR department and establishing good and fear company policies.
I don’t want to sound like I am totally in favor with discipline employees but experience tells me that is another tool to keep the people safe and it shall be administered consciously and respectfully. This is a very tough subject and is going to depend on a case to case basis.
I want to finally say how amazing it is the different opinions after checking all your comments but lets always keep in mind that whatever action is taken, it must be taken because the sake of safety of the workers and because we really care about people.
If I understand the situation, his company did not discipline him the city suspended his crane operators license. His action was a clear violation of the rules and as such having a “suspension” is about the same as placing an employee on administrative leave until the investigation is completed. I think the action was correct in that many contributing factors could have resulted in the larger failure.
This….is exactly the reason I took it upon myself to get trained with the TapRooT system.
I was involved in an investigation where the first knee-jerk reaction was: “Well, we know what happened here, so we will suspend the folks involved because they obviously did not follow the procedures.” “This will also look good because we are taking an immediate corrective action. You can bet your bottom dollar this will never happen again.” – - Words of wisdom from management ignorant of a proper investigation. Do you wish to instill fear in the minds of your employees? This is a sure-fire method to accomplish just that.
I told myslef I would never let those words cloud any investigation of mine “Well, we know what happened here….”
My answer became “No, you don’t…and you will not know until a proper root cause investigation has been completed and we can understand all of the causal factors that contributed to this incident.”
After that point and during the following 11 years of accident/incident investigation, there was not one situation that required the suspension or termination of any employee involved as a principal in one of those accidents. And not once during that time, did management ever suggest that I take that action. They were much more interested in seeing my Snapchart and understanding what really happened.
Planning, was the crane positioned in the correct area to allow booms to be lowered ???
I believe suspension of work til after the investigation to find the root cause
Was the operator drug tested immeadiately ?
What is the objective of suspension or no suspension and an investigation. It should be to reduce accidents in the future. There is little chance that the operator involved will do the same action again, so there is no safety concern for his remaining on the job. There is, however, a real value in the information that this operator can provide to find the root cause/s and reduce the probability of a similar accident. If I am his lawyer, I would tell him to say nothing as long as his livelihood is being threatened by politicians or management all trying to cover their rears. Enlightened management would enlist the operator in the investigation to help obtain all of the facts in the incident and perhaps reward him for this effort.
I would have expected the city authority to follow Jim Reason’s model for a just culture by asking the following questions:
Were the actions as intended?
Was the outcome as intended? If yes then its sabotage!
Did the operator knowingly violate procedures?
Are the procedures clear and workable? If yes then its a reckless violation; if no then its a system induced violation.
Does the operator have a history or violating procedures? If yes then train him, if no its a no blame error.
Finally there’s the substitution test. Given the same set of circumstances what would another operator have done?
But the authorities will need to conduct an investigation to find an answer to these questions!
Suspending the operator’s license will has no direct link to preventing the accident in future. An investigation is the only tool that will reveal the accident causes. It will only add fear to prevent others giving their statements about the accident to conceal some information that will be vital towards preventing future occurrences. The operator in question will now be seeking ways and giving testimonies that will exonerate him and revoke the suspension instead of testimonies that will lead to root causes of the accident. Of course, there was a supervisor on that site and there are also other management procedures which had failed. The investigation must be concluded first before implementing any consequence management.
Disciplining someone before the investigation, if feel, is a form of over-reaction. Look at the awkward situation the government is in over the Shirley Sherrod situation, where they fired her before having all the information. Regarding Debbie Meeks’s comment about policemen being disciplined for shooting someone, I have to disagree. They are not disciplined, but put on Administrative Leave pending the investigation. They are still getting their full paychecks and know this is “standard procedure”.
No. Discipline should not be handed out until investigating the accident. This may send the message that the investigation is not an important part of the Safety Process. At the conclusion of the investigation it may or maynot have been the operators responsibility.