Our ubiquitous Stilsons appears to have claimed another life on a rig. Despite a whole lot of history, an organisation chose to do a job they knew was a roll of the dice.

Hand tools aren’t designed for applying mechanical force beyond what can be done by hand. Their handle lengths are used to calculate how strong they need to be so extending them or applying hydraulic forces are absolutely outside of their intended and designed use. Virtually every tool manufacturer clearly and explicitly communicates this if not on the tool, at least in the manual / user guide. Stepping outside of this is stepping into the liability zone should something slip up.

While there may be thoughts focussed on the individual’s decisions in the moment, in the scheme of things more often than not – largely irrelevant. It misses awareness of how these events could have easily been avoided. This would be via systems, not via behaviour. Behaviour doesn’t occur in a vacuum, but in the context of the work environment.

We worry about protecting our team members when they have a brain-fart or lapse of judgement, so we put comprehensive systems in place that reduce decision making. While in principle this is great, in practice it’s rarely applied effectively. Systems often aren’t quite done well enough and end up turning the brain off. OR they aren’t done right and the human ends up throwing the whole system out doing it their own way.

So in any tragic event, we should all look inside and investigate how it could have happened to us. Don’t look for why it can’t, but dig into why it might. Where could our systems allow someone to override them or ignore them? Where is the difference between life and death left to a single decision to step forward or to not step forward? Where are we left with a single control on our risk register of “Don’t have a brain-fart”?

Worksafe – Worker fatally injured working on drill rig