Well today it almost happened....someone almost lost their life at my workplace.  While my first post focused on my knowledge gained as a nuclear Quality Assurance professional, my job as Corrective Action Manager also takes me into realms beyond.  Today it was personnel safety.

Two men were working together changing out an anvil on a huge forge press.  One of the men had been doing the job alone since being trained by a long time employee who'd recently retired.  But this time there were two doing the job.  One of the men was in a control room looking through windows as the other man disconnected the anvil.  Someone came into the building on a forklift and dropped something off, causing the man in the control room to look away from his task.  When the control room operator returned his gaze to the task, he saw his own shadow in the windows of the control room and believed what he was seeing was the other man leaving the equipment, after which he activated the forge press toward the anvil.  He happened to look out at the equipment and was shocked to see the first man laying pinned between the press and the anvil.

HO-LEE-SHIT!!!!

The man who was pinned was OK it turned out but had injuries to his back and knee.

In the station meeting this morning attended by all management we talked about the event.  I was (but shouldn't have been) surprised some were trying to minimize the consequences of the event.  I thought our policy was clear:  personnel fatality or near miss needs a Root Cause Analysis (RCA).  Some argued a lower level investigation would be sufficient.  Finally the Engineering Manager stated the event should be classified higher and HR Manager read the policy aloud.  Most finally seemed to "get it" and the consensus was to perform the RCA.  The next topic was who should lead the RCA.  I was shocked when the managers of the next available analyst stated his department would be shut down if he did it.  HELL-O....why are we still reinforcing Production over Safety when someone was nearly killed today?

The whole thing made me cry, not because I felt responsibility but because I continue to see a management team who believes the corrective action program causes unnecessary work.  The ironic thing is the mister and I just this past weekend discussed how it was just a matter of time before something like this - or worse - happened.  Well, we've now had 4 RCAs this year - twice as many as last year, and it's only the middle of the year.  I pray the leaders of my company will wake up and get serious about determining *why* these events are happening and correcting same.