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Mouse Trap


88 Health 400As we proceed through a normal day we expect to encounter a certain amount of hazards. Most of these present low level risks and most are subject to control systems that are already in place and active. Just the same, we should pay attention to these as they occur (and whenever possible in advance). One of the tools that I have championed is the risk assessment. The risk assessment may be applied at the field level (FLRA – Field Level Risk Assessment), at the institutional level (ERA – Enterprise Risk Assessment) and at various levels in between. A risk rating at any application level is a function of the likelihood that an event might occur, and the impact of the consequence of that event.

At the field level, a risk assessment (if performed thoughtfully and systematically) can have a positive impact on injury prevention. Some recent events have given me cause to consider how the risk assessment process may be improved.

In 1963 the Ideal Toy Co. began to market a new board game called “Mouse Trap.” In the course of the game, a Rube Goldberg-like contraption is constructed on the game board. Once the mousetrap is built, the object of the game is to spot the opponent’s game piece in jeopardy and to activate the machine. The machine uses rolling balls, levers, ramps, replicated household plumbing fixtures and springboards in a chain reaction of sorts that eventually traps the mouse-shaped game piece at that remote point on the board.

For me, the game represents an inadequacy in the risk assessment process. At the field level, the risk assessment is performed at the beginning of a shift or a particular job and may be repeated during the shift as changes occur or new tasks are assigned. So the process focuses on 1) what hazardous harmful energies are present or expected and 2) if released, how seriously can they hurt me. After analysis, actions are taken to either eliminate or mitigate the identified risks.

The process focuses on the risk to me (and perhaps to my immediate coworkers) during a relatively short period of time. The inadequacy as demonstrated by “Mouse Trap” is that a release of energy may trigger a chain reaction that could effect personnel a distance away or at a subsequent time. Even the controls we may employ to mitigate the risk may have an impact on other work groups.

Example: A small crane is being used to position a bundle of angle iron on a screening tower. The bundle bumps a handrail causing the load to shift and a piece of the load drops from the bundle. Two employees monitoring the pick turn and run to avoid the falling angle iron and one stumbles over an oxygen-acetylene hose stretched out toward another maintenance job in progress. The torch is jerked out of the gloved hand of the mechanic and catches his jacket on fire. The result is severe second and third degree burns to someone who was nowhere near, involved in nor aware of the initial release of energy.

A more thorough risk assessment may have identified the security issue with the angle iron bundling and rigging, the proximity of the handrail to the pick, a safer observation point, the presence and the possible relocation of the gas hoses. Any one of which may have prevented the burn injury.

There are several guides that have been developed and marketed (many others developed in-house) that help further the FLRA analysis and response process components. One in particular uses the acronym TAKE as a four-step process. Users are directed to Talk with coworkers and others that may be involved; consider how your Actions might affect you and others; make sure that you have the right Knowledge base to perform the job safely; and ensure that your Equipment (including PPE) is right for the job and in good working order.

The Actions step is targeted directly at both the proximal effects and extended effects of the actions you are about to take. Whatever process you may employ to assess risk, that extended component should be considered in each application. It really is a matter of whether you’ve got the other guy’s back or whether you risk blindsiding him.