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Kate W. Pile
executive director of the Pulp & Paper Safety Association.

Fatalities in the pulp & paper industry

by Kate W. Pile

Despite improvements in the safety process, employees continue to die every year across America. The paper industry, sadly, is no exception. Records maintained by the Bureau of Labor Statistics, as well as by industry groups like the Pulp & Paper Safety Association, show annual decreases in the Total Case Incident Rate but fairly static Fatality Rates.

Companies are, understandably, hesitant to release many details about these tragic accidents. Some of them result in legal action, either involving the employer or the original manufacturer of the equipment involved. And all of them require extensive investigation. Interested parties clamor for details as soon as news gets out about the incident, but typically there is no data available for several months.

TARGETING ROOT CAUSES. This lack of information makes it difficult for non-government organizations to compile data on fatalities. However, two elements show up over and over. They are breakdowns in communication and employees working alone.

The first should be easy to eliminate. Good communication depends on adequate written policies, training, and accountability; these should be sufficient to control this element. For example: two employees are working on setting up a line; for part of the setup process, they are not visible to each other. (We'll assume that the equipment is properly locked and tagged during maintenance and during the portions of setup when it's possible to have it locked out.) Sound levels are high, so the employees are wearing hearing protection. One shouts, "Are you clear?"; the other responds—but did he say "No!" or "Go!"? A mistake can be deadly. Obviously, verbal signals are inadequate and too easily confused. While this seems obvious, poor communication is often found to be an element in serious injuries and fatalities. Too many of the investigation reports include statements such as "I thought she was clear of the machine," or "I thought maintenance was finished," or "I didn't know he was there."

The other element is more difficult to deal with and more controversial as well. As the economy has tightened, the workplace has become more sparsely populated. Extra hands are difficult to find because almost everyone is operating with fewer employees. During normal operations this is not a problem, but it can become an issue in special circumstances. There are too many different situations to list here, but I urge you to take a close look at the operations within your facility. How often do supervisors check on employees who work in areas not readily visible to others? Are maintenance workers sent to remote areas alone or in pairs? If someone is injured, how quickly will another employee realize it so they can call for help? Do you give individual attention to special project groups, like clean-up crews, who perform out-of-the-ordinary work in unfamiliar areas and may be using tools or chemicals they don't normally use?

CASCADE EFFECT. Catastrophic accidents are usually the result of a series of problems. Imagine the following fictional account: start with a well-run mill, where the safety manager is experienced and knowledgeable, the facility manger and engineer both support safety, and these factors are reflected in their excellent record. Everyone feels good about his safety performance, but a late shift supervisor has become a bit too complacent (element #1). It's been months since the last accident in his department, and all of his employees have at least six months experience. His inspections and safety meetings aren't as enthusiastic as they once were (element #2). His group is short-handed tonight with two employees out (element #3), but he has production goals that must be met (element #4: we say "safety first" but sometimes the priorities get murky). An operator is injured and no one notices right away; he dies before help can arrive.

If policies are in place, if employees follow them, if supervisors manage their work area, if training is adequate, if equipment is maintained, if top management promotes the expectation for a safe workplace, etc., etc., etc., then the breakdown of a single element will rarely result in a serious injury. However, if one or more of the elements is weak, then the stage is set for tragedy. Does that sound too dramatic? If you have experienced a fatality in your facility, then you know there is no way to over-dramatize the effect. Lives and families are changed forever. Everyone feels a terrible sense of responsibility and guilt. The investigation, no matter how tactfully conducted, can create apprehension among employees and anxiety in the local community. We must control as many elements as possible to prevent catastrophic incidents. Each control may be the one that stops the cascade of events leading to a fatality.

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