CEO killed at industrial site by worker operating forklift (opens in new tab)

>The company was ultimately fined just under $10,000 for his death.

1. An operator made a mistake and opened the wrong valve during a routine operation. 15000 liters of hydrochloric acid flooded the factory. As the flood started from the side with the emergency exits, it trapped the workers, 20 people died horribly.

2. At a chemical factory, the automated system that handles tank transfers was out of order. A worker was operating a manual override and attempted to open the wrong valve. A safety interlock prevented this. Violating procedure, the worker opened the safety interlock, causing 15000 liters of hydrochloric acid to flood the facility. As the main exit was blocked, workers scrambled towards an additional emergency exit hatch that had been installed, but couldn't open the door because a pallet of cement had been improperly stored next to it, blocking it. 20 people died horribly.

If you look at them in isolation, the first looks like just one mistake was made, while the second looks like one grossly negligent fuckup after another, making the second report look much worse. What you don't notice at first glance is that the first facility didn't have an automated system that reduced risk for most operations in the first place, didn't have the safety interlock on the valve, and didn't have the extra exit.

So, when you read an incident report, pay attention to this: If it doesn't look like multiple controls failed, often in embarrassing/bad/negligent/criminal ways, that's potentially worse, because the controls that should have existed didn't. "Human error took down production" is worse than "A human making a wrong decision overrode a safety system because they thought they knew better, and the presubmit that was supposed to catch the mistake had a typo". The latter is holes in the several layers of Swiss Cheese lining up, the former is only having one layer in the first place.

Why?

Someone decided to walk across the road, was wearing dark clothing, had an eyepatch on so he couldn't see one side of the road well, and was struck by a forklift while the operator was on the phone.

What combination of coincidences is striking? People are careless all the time.

It would only really be a striking coincidence if each of these elements is a rare occurence - although if the site has a poor safety culture and this sort of stuff is happening all the time, it becomes less of a coincidence and more of an inevitability.

In the UK for example sites generally mandate hi-vis vests, establish pedestrian walk routes, ensure visitors can't walk straight into the warehouse without supervision or training, and ban using mobile phones when using any form of MHE - so if sites had good safety standards and enforced all this, then the chance of it happening would be much smaller than a site that didn't enforce all this (Just saying this is how it is in the UK as my experience all this is less common in the USA - although no doubt many sites operate the same).

If a site lets people wear what they want and does not stop MHE operators from using phones and lets a visitor freely walk around the warehouse... I don't know if a person getting hit at that stage is a coincidence IMO (regardless of the eye patch).

Knowing about the swiss cheese model is great, but you also need to have some heuristic about when those holes might line up and bite you. Typically it's when people are rushed, stressed and tired and you have to be able to spot that even when you're rushed, stressed and tired.

That said, forgetting to put on your hi-vis might be a careless error, but walking outside of marked pedestrian zones and operating a forklift while using a phone absolutely aren't! The forklift driver fleeing the scene makes me think safety culture had to be abysmal.

https://www.youtube.com/watch?v=e_SMTc-sOHQ

It also detects humans of course.

When CEO dies for the same reason it's "the universe randomly hands out some justice" story, which is always a good story.

eg: Tesla Doors: 15 People Have Died in Crashes Where it Wouldn't Open (18 hours ago https://news.ycombinator.com/item?id=46365597)

and a host of similar stories about worker / third party accidents and fatalities related to tech.

the real irony would be if the forklift opperators phone call, was getting the gears from his supervisor for not bieng fast, enough.

I worked night shift at steel processing plant once. Lots of my coworkers were walking around zombiefied. Forklift and crane operators were moving around 10-20 tons coils of steel and loading them into machines and people were paying no attention to them. Yes, the guy with 10 tons of product on his forks is responsible for paying attention, but the same rules apply as in traffic - right of way doesn't matter when you're dead. Pay attention and be aware of what's going on around you. Do not wear headphones!

Also CEO types on job sites, in my experience, often get to skip the mandatory safety course, because nobody dares tell them no and they feel big and important because they're wearing a tie and have shiny shoes. And these types need it the most, because they have zero experience working and moving around these types of places.