FORT RUCKER, Ala. (July 12, 2018) - It was 0800 when I heard the sirens. An aircraft mechanic had fallen off a stand while conducting maintenance on the flight line. The ambulance was on its way. As I headed to the scene, I thought, "My God, this is the one."

I arrived on the flight line just as the ambulance departed with the victim. The mishap scene was still fresh and eyewitnesses remained in the area. They told me an aircraft mechanic had fallen backward off a stand and hit his head on the concrete tarmac. The impact had made a loud sound. The victim had been unconscious for a while, but witnesses said they saw no blood or other outward signs of trauma. We estimated the height from which he fell to be 2 to 3 feet above the ground.

The weather conditions that day would later be determined to be a causal factor. The temperature was in the low 40s with a stiff breeze, bringing the wind chill down into the upper 30s. The mechanic had not been wearing gloves even though he was working with fuel, which required the use of rubber gloves. We also noticed the B-4 stand he was using was coated in fuel, making the bars somewhat slippery. So, no gloves, a slippery stand and potentially cold hands were all determined to be contributing factors.

Recently, an enterprise modification was made to the B-4 stands to improve safety. A swinging gate was added at the entrance to the stand's platform, which is raised manually with a hydraulic pump handle. The mechanics complained about the upgrade, saying the swinging gates caused a dangerous situation and a pinch hazard if their hands happened to be in the wrong place when the gate shut. The investigation report into the mishap could not conclusively rule out the swinging gate as a factor, and the mechanic could not remember what caused him to fall from the stand.

The subsequent all-hands safety pause centered on:

1. Knowing and wearing the correct personal protective equipment for the job

2. Proper ingress and egress on the B-4 stand with use of the swinging gate

Further discussions with the work unit leadership revealed there was a tendency to place the primary blame for this incident on the swinging gates. The question on everyone's mind was could we prevent this same accident from happing again. Plans were made to modify the swinging gate to prevent pinching, but would that fix be enough to satisfy the mechanics? Proper use of PPE would further help reduce mishaps; that's for sure. The challenge would be to get specific PPE requirements to the worker and keep the message current, relevant and vital.

So was this mishap a one-off event or did the holes in the Swiss cheese line up? Did our mishap investigation capture all of the human factors (organizational, unsafe supervision, preconditions and the unsafe act itself)? Was our safety pause adequate to plug the holes? These are the questions I continue to ask myself as I fall asleep at night. About three months after the mishap, the mechanic continued to experience dizziness and other effects associated with the fall that kept him out of work.

With approximately 3,000 civilian workers, there isn't a day that goes by that I don't ask myself a series of questions: Are we doing enough? Is our training good enough? Is the training targeted and focused? How are our supervisors? Are they part of the problem or the solution? Are our supervisors given the time and training to play their role that is expected? Is our senior leadership engaged enough? Do our safety professionals have the time to perform the mishap investigations at the level they need to be conducted to identify all the causes and necessary corrections? Are we properly manned to fulfill our safety mission of providing a safe place to work? Is it enough? Will it ever be enough?" These are questions that must be answered.

As I sit at my desk pondering these questions, I hear the sirens go off …

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