Confluence - the point where two rivers meet
The death of a young father, just 33 years old, a wife and children with a hole that will never heal.
When first I heard the report I struggled to assimilate how it happened – until the later reports came across the desk, countermeasures being proposed to avoid recurrence. He was placing the trailer jack-stand (a safety precaution against failing landing gear while being loaded). He didn’t apply the parking brake. I can see it now, dropping the trailer, making the check call, pulling away and getting ready to make the next hook, looking out the back door, and seeing the jack-stand next to the trailer. Quickly hitting the brakes, jumping out, thinking it will only take a second. He runs; it creeps, the incline that makes sure water doesn't pool overcoming the inertia of the stopped truck. It likely did not have much speed, and had but a few feet to travel. Just enough to build momentum - backwards it drifts, slowly heavily, to its disastrous outcome as the moving truck met the static trailer.
I need to see things in detail to understand how they happened. To help me identify how I can get to a solution that will prevent this from happening on my watch. Imagining this in all its gruesomeness was unsettling.
Conversations were had with co-workers and peers – It's not like he was trained to not apply the parking brakes when leaving his truck – so why this time? Fast pace of the job, perhaps? Was this the first time they weren't applied? Or a shortcut that had developed over time - each individual occurence a reinforcing positive outcome, a result of its singular absence of negatives. The possible scenarios ---- Waiting for the next call in the flat staging area – brakes not applied; stepping onto the catwalk to attach the lines before lifting the trailer for a pull – brakes not applied; dropping the trailer, brakes not applied. In each instance no negative outcome. It is but one short step from these to leaping out at the last minute, for a task that will take “no-time” – but took all the time in the world.
In one of my previous articles I mentioned how some entities can function for years in the absence of safety, just as some smokers will never get cancer or emphysema. They are the statistical anomalies. This young man, working hard to earn a living for himself and his family, did not set out on this day to take a tragic shortcut in the pursuit of high productivity demands. But the confluence of circumstance and complacency delivered that outcome regardless. Processes, policies and procedures are created for our protection. As leaders we must be aware of human nature and its tendency to take shortcuts. We must be vigilant against it, and use opportunities to educate its potential for unanticipated outcomes. We must keep it constantly in the field of view.
My deepest sympathies to the family for their loss. I know that is not enough.