Human Error in System Approach to Hazard Inspection

When you look at a system approach to inspecting work areas, you must recognize that approximately 80% to 95% of all accidents are caused by human errors. This means that somewhere at some time a human being interacted with the system and, either by omission or commission, caused the hazard that resulted in an accident. There are human, material, and environmental factors that will be caused by one or more system inadequacies. Your inspections must look for these factors to identify the causes of hazards.

There are five system inadequacies that I use within the management approach to hazard inspections (Field Manual 100-14, 1999):

  • Support Failure – equipment, material, or supplies not provided.
  • Standard Failure – inadequate or no procedures in place.
  • Training Failure – poor or no training provided.
  • Management Failure – ineffective or no manager participation.
  • Individual Failure – an employee that does not follow procedures.

A Support Failure could be an employee assigned to work with a corrosive chemical, but was not provided gloves because none were available. The result of this failure is likely to be exposure to the chemical and damage to the skin on the employee’s hands. The immediate cause is chemical contact with the skin. The system inadequacy is a support failure because gloves were not available.

A Standards Failure could be an employee performing work in an area with respiratory hazards and failing to notice the respirator exhalation valve is missing on the respirator he wears. In this scenario, the organization had no standard operating procedure that requires training and proper respiratory maintenance. The employee was exposed to a toxic chemical, injuring his lungs and throat. The immediate cause of injury was inhalation of the chemical, but the systemic inadequacy was a standards failure because no procedure was in place.

A Training Failure could be an employee assigned to operate a forklift that received no training beforehand. The employee operates the forklift too fast while making a turn, resulting in the forklift overturning and crushing the worker. The immediate cause was the employee driving the forklift at a high rate of speed without wearing a seatbelt. The system inadequacy was a Training Failure because the employee was not trained to operate the forklift. The training would have included the requirement to wear a seatbelt.

A Management Failure could involve a supervisor of a lawn mowing crew who does not enforce standards and ignores employees who don’t follow the rules. Thus, an employee fills a lawnmower with fuel without allowing the motor to cool. The fumes from the fuel ignite, destroying the mower and burning the worker. The immediate cause was the hot engine igniting fuel; however, the systemic inadequacy was a Management Failure because the supervisor did not enforce safety standards that required the motor to be cooled before refueling.

An Individual Failure could be an employee assigned to operate a company vehicle after he received proper training. The employee partied late the evening before and got less than two hours’ sleep. This made him fall asleep while driving, allowing the vehicle to drive off the road and overturn, injuring the employee and severely damaging the vehicle. The immediate cause of the accident was that the employee fell asleep while driving. The system inadequacy is an Individual Failure because the employee came to work the next day tired because of inadequate sleep. The system should encourage employees to take the necessary steps to come to work prepared and able to work.


Field Manual (US Army) 100-14, Risk Management Program, Washington, USA, 1999.

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A Systems Approach to Hazard Inspections

A systemic approach looks at the organization as a system. A typical system has inputs a process to manipulate the inputs and outputs. All systems work the same. Figure 1 shows a simple system. In this example, materials are the input. The process manipulates those materials to make a good or service that is the output.



“The whole system can be affected by just one thing or by any one individual” (Fanning, 2003). That is a hazard corrected by the inspection program can create problems and hazards in other areas of the organization. This is often referred to as unintended consequences.

From an accident perspective, this means that a hazard may have occurred days or weeks earlier in another part of the organization away from the point that it causes an accident. It is important to identify who created the hazard or allowed it to exist. This will enable you to determine the steps necessary to prevent a reoccurrence of the hazard. This is done by looking at the management system before correcting hazards. Correcting a hazard in one part of the system can create a hazard in another part of the system. Hazard abatement may only be temporary if you have not identified the other locations that same hazard may exist.

As a safety professional, your primary duties involve management of the safety program as outlined in Figure 2. “Your job is basically to identify, assess, and recommend control measures to reduce hazards. Your duties will revolve in a circular fashion” (Fanning, 2003). You should begin with hazard recognition so that you are working to correct a problem that exists.


This book focuses on hazard recognition while conducting an inspection. This involves reviewing the following before conducting an inspection.

  • Accident reports
  • Construction drawings
  • Employee physicals and reports
  • Previous inspection report
  • Hazard surveys
  • Job hazard analysis
  • Equipment analysis
  • Purchase reviews

I have found that it is best to have a safety management information system in place. This is a single information technology solution that allows all safety information to be in a single location. There are products available that you can purchase. However, if you are like me, you do not have a management system. In this book, I can tell you how to create a rough example of one.

If you do not have one, you can put all the accidents, near misses, awards, inspection findings, reports of unsafe working conditions, and citations in a single database using building and room numbers as a reference. Then before an inspection, you can sort and print out all the information for a building to be inspected.

The safety management information system should also include a log for all the violations or hazards found during the inspection. You will also need a hazard abatement plan. This is a form that identifies those hazards that cannot be corrected on the spot and identifies a hazard control plan that will reduce the risk until the hazard can be rectified. This plan is posted next to the hazard, so workers in the area will be aware of it.

Your organization must also use Risk Assessment Codes. These codes are not a full process of risk management. Risk management is normally a five-step process that begins with identifying the hazards, assessing the hazards, identifying control measures, implementing control measures, and supervising the process. They codes are from the utilization of the first two steps of the risk management process. The result is a code that identifies the severity and probability of a hazard to result in injuries, illnesses, or damage to property or the environment (Fanning, 2015).

Your organization must also combine hazards that can be resolved by the same corrective measure whenever possible. For example, don’t fix one fire extinguisher identified as non-operational. Instead, combine all hazards concerning fire extinguishers into a contract for repair. This will get several hazards fixed at one time. Fixing one at a time is not usually a good approach because the same problem is often found later.

The last thing you need to do is identify root causes of the hazards. Let us look at the fire extinguisher example again. What caused all the fire extinguishers that were identified to get that way? Fix that cause, and you will stop the fire extinguishers from being a problem in the future.

What can you get from using a systems approach to inspections? Anyone, using a systems approach, will see a reduction in the cost of correcting hazards primarily because you should be able to fix several hazards with one solution and not fix hazards over again. You should also see an improvement in the process because correcting hazards can improve the processes. You will also look at the way management operates within the system, and by correcting the systemic defects at the management level, improve the system. In a general sense, a management systems approach to hazard inspecting can be used to enhance the system within the organization and not just correct a few hazards. Using a management systems approach leads to the use of human error to control hazards.

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Fixed Stairs and Ladders Case Study

With the information provided in the previous blog posts, I would like to present the case study.

This analysis was caused in response to a facility management professional found lying at the bottom of stairs with a pool of blood emerging from his head. He died from his head injury a few days later.

Let me tell you up front that it could not be determined that the condition of the stairs had any effect on his fall. However, this information can still be used to show how two buildings comply with the standards. The analysis was limited because the organization only owned two buildings.

Dr. Doug Parrish was the safety specialist in charge of this analysis. He compared requirements from:

“NFPA 101 (2012) Appendix A comment on the Section “grandfather” paragraph for existing stairs further expands on topic,” (HQ DOE, 2014):

“A. It is the intent of to permit the use of Table in existing buildings, even where there is a change in occupancy per 4.6.11. Safety improvements should be made that are reasonable and feasible at minimal cost,” (City, 2016).

“Improvements include removal, repair, or replacement of step coverings, as described in A., particularly Figure A., and the addition of functional handrails and guardrails in place of, or in conjunction with, other rails, as described in,” (HQ DOE, 2014)

The team assessed stairs (internal and external building public stairs; mechanical room and other maintenance area stairs) in two large buildings. I will call them Bldg. 1 and Bldg. 2.

Dr. Parrish’s team looked at approximately 2,515 steps in 56 stairs in three buildings and surrounding areas at Bldg. 1 and approximately 1,800 steps in 57 stairs in four buildings and surrounding areas at Bldg. 2. The team tasks were to:

  • Measure step rise and tread run.
  • Measure handrail and stair rail heights.
  • Note stair and railing material, attachment, covering, and any deficiencies.
  • Compared any differences in height between:
  • Adjacent steps.
  • All steps in the same stair run between landings.


Location Public Interior Stairs Public Exterior Stairs Maintenance Access Stairs
Building No. 1 15 15 26
Building No. 2 16 17 24

Table 1 – Stair Count

Table 1 shows the number of stairs in Bldg. 1 and Bldg. 2.

The exterior stairs for Bldg. 1 were made of poured-in-place concrete, 2” metal, smooth, round continuous handrails, and non-slip metal toecaps. Some handrails were found to be noncompliant for rising/run variability on the NFPA and IBC requirements.

The internal public stairs for Bldg. 1 had hand railings that were of correct height to meet NFPA and OSHA requirements.

The exterior public stairs of Bldg. 1 were found be non-compliant with NFPA 101 requirements.

Some rails on stairs were found to be loose. The balusters did not meet the NFPA 101 minimum gap requirement.

It is noted that many stairs had 3/4” difference between the highest and lowest steps’ rise and run. Per IBC and NFPA 101 (2010), the maximum allowed difference for both rising and run should be no more than 3/8” for existing steps in a flight of stairs and 3/16” for adjacent steps.

OSHA General Industry Standard requires both rises and run in a stair to be uniform.

When they looked at fixed industrial stairs, they found that some were made from metal grate while others were made from concrete with non-slip metal toecaps. Both types met the non-skid requirement.

The team found that fixed ladders in elevator pits did not comply with OSHA fixed industrial stair requirements. IBC Section 3404.1 allows existing stairs to remain due to space constraints of space or pitch.

One flight of stairs was found to be a spiral metal staircase. These stairs did not meet the IBC Section 1009.9.

Bldg. 1 exterior stairs were also analyzed. Some met requirements while others were found to be noncompliant for step rise/run variability.

The interior stairs were made from poured concrete with non-slip coating. These stairs were provided with a 2” standard stair railings and handrails. Some were made of metal while others were made of wood. All stair railings and hand railings were compliant to NFPA and OSHA requirements.

However, as in Bldg. 1 many did not meet the NFPA 101- standard for spacing of balusters on stair rails and handrails.

The Bldg. 2 interior stairs were made from poured, non-slip plastic coverings, with removable stair railings and handrail. The stair rails and handrails were compliant per OSHA requirements. However, it was noted that the stairs were noncompliant for variability in step rise and run per NFPA 101 and IBC requirements. The balusters were also noncompliant for limited spacing per NFPA 101-

Several flights of stairs in areas used by maintenance personnel were found to be non-standard stairs that did not meet OSHA or NFPA requirements. These stairs appeared to be hand made from wood.

One flight of nonstandard stairs was made from wooden and was found noncompliant with IBC Section 1009.9 because they were too narrow, too steep, and had incorrect handrails.


City of Rockland Zoning Board of Appeals, Minutes of Meeting, (accessed December 08, 2016).

HQ DOE Stair Safety Meeting Decision Brief, May 13, 2104.


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Fixed Ladders

Finally, I would like to address fixed ladders. OSHA 1910.27 is the standard that is used for fixed ladders.

The fixed ladder is made up of steps called rungs that can either be fixated into the wall or placed on two rails that are vertically upright. The purpose of the fixed ladder is to provide access to workers for areas above the ceiling or below the floor.

Fixed ladders are usually designed for a concentrated load of at least 200 pounds.

Fixed ladders used to be made of wood. In some circumstances, they still can, but the design criteria are different. The load for a wooden ladder is addressed in 1910.25.

Rungs must have a minimum diameter of three-fourths of an inch for metal ladders and a “minimum diameter of one and one-eighth inches for wood ladders” (41123, 2016).

The distance between rungs must not be more than 12 inches and must be uniform throughout the length of the ladder. The minimum length of rungs must be 16 inches.

Side rails can be used to help the person climb. Thus, they should be made with a surface that is gripping without sharp edges, splinters, or burrs.

It is important to paint metal ladders to resist corrosion and rusting.

It is also important to treat wooden ladders when they are in conditions where the wood can get wet, and decay may occur.

“On fixed ladders, the perpendicular distance from the centerline of the rungs to the nearest permanent object on the climbing side of the ladder shall be 36 inches for a pitch of 76 degrees, and 30 inches for a pitch of 90 degrees” (Fixed, 2016). This gives the person climbing the ladder room behind them to climb.

Most ladders that are used for climbing to have a hatch above that must be opened. There should be a counterweight on the hatch that allows it to be opened a minimum of 60 degrees.

Cages must be provided on ladders of more than 20 feet. Cages wrap around the ladder, protecting the sides and rear of the climber.

“Cages shall extend down the ladder to a point not less than 7 feet” from the base (Fixed, 2106).

When ladders are used to climb down, they usually come with a ladder well. This well must have a clear width of at least 30 inches from the centerline of the rungs.

When ladders are used to climb more than 20 feet, they often come with a landing platforms. Platforms shall be not less than 24 inches in width and 30 inches in length. If the ladder is a lot taller than 20 feet more than on landing may be necessary. The landing platforms must be equipped with standard railings and toe boards.

At the top of the ladder, there are often vertical grab bars that help the climber get up, and onto the surface they are hoping to reach. These grab bars should have the same diameter as the round rungs.

Fixed ladders appear to go straight up and down. However, they have a pitch to them. The preferred pitch of fixed ladders shall be considered to be in the range of 75 degrees and 90 degrees with the horizontal (Fixed, 2016). They lean towards the top of the ladder.

Owners must maintain all ladders in a safe working condition. They should inspect the ladders regularly, with the intervals between inspections being determined by use and exposure.


4123:1-5-03 Ladders and scaffolds. – Ohio Bureau of, (accessed December 08, 2016).

Fixed ladders. – 1910.27 | Occupational Safety and Health, (accessed December 08, 2016).

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Fixed Stairs

Now I would like to focus on fixed stairs. Each day we may walk up and down stairs at home and work and pay little attention to them. We take them for granted. What if the steps were not built or installed to standard? In most cases, it might cause us to trip or slip as we climbed on down.

The part you put your foot on when using stairs is called the tread. The end of the tread nearest the person is referred to as the nosing. The board between two treads is known as the riser. The height that a flight of stairs goes up is called the rise. The part that runs down the side of the stairs is referred to as the stringer. The height of the rise and width of the tread should be uniform throughout a flight of stairs.

Stairs also have railings. The part of the railing that runs up vertically is called the newel. The part of the railing that you usually place your hand on is known as the top rail. The rail in between the top rail and the stairs is termed the mid-rail. Per OSHA, if stairs have four steps then railing must be provided.

The main purpose of stairs is to move people up and down to different floors of a building. We also use stairs to move material up and down between floors using a dolly or other piece of material handling equipment.

You can find stairs with walls around them, which are called stairwells. You may also see stairs as standalone metal frames.

OSHA Code of Federal Regulation (CFR) 1910.24 is the standard for fixed industrial stairs. This section of the code has some useful information.

The stairway must carry five times the normal load but never less than a moving load of 1,000 pounds. It must also be a minimum of 22 inches wide.

The angle to the horizontal on any given stairway must be between 30 and 50 degrees, and any uniform combination of rising/tread dimensions may be used that will result in a stairway at an angle to the horizontal within the permissible range.

Table D to section (e) provides the specific length in inches of the rise and tread run based on the angle of the stairway to horizontal.

All treads shall be slip-resistant, and the nosings shall be of nonslip finish. In some cases, the builder uses welded bar grating for treads without nosings. These are acceptable if the leading edge can be readily identified.

If the stairway includes platforms, they should “be no less than the width of a stairway and a minimum of 30 inches in length” (1924, 2016).

Railings must be provided on the open sides of all exposed stairways and stair platforms. For closed stairways, a handrail must be provided on at least one side. People prefer the right. I always recommend installing handrails on both sides.

Vertical clearance above any stair tread to an overhead obstruction must be at least 7 “feet measured from the leading edge of the tread” to prevent someone from bumping their head (1924, 2016).

Several documents provide specific rules and guidance on stairs and ladders. The ones that safety professionals should be familiar with include:

  • International Building Code, dated 2009
  • 29 Code of Federal Regulation 1926.1052 OSHA Construction
  • Proposed 29 CFR 1910.24 and .25, dated 1999, 2003, and 2010
  • National Fire Protection Association Life Safety Code 101, dated 2012
  • 29 Code of Federal Regulation 1910.23 and .24 OSHA General Industry

Americans with Disabilities Act 2010/Architectural Barriers Act, dated 1968 as amended


1910.24 Walking and Working Surfaces. (accessed December 12, 2016.)

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Temporary Ladders

There are many types of ladders for many different purposes. There are portable and fixed ladders. There are portable ladders that support themselves and others that don’t support themselves. There are fixed ladders attached to buildings, towers, and antennas.

Non-self-supporting ladders are ladders that lean against a wall or other support. To get the right ladder, the weight of the worker and the weight of everything carried up and down the ladder must be determined. Furthermore, a ladder must support four times the maximum expected load. Manufacturers rate their ladders so users will know how much weight the ladder can hold. Per the Ladder Safety Institute, there are five categories of ladder Duty Ratings:

  • Type IAA (Extra Heavy Duty) 375 pounds
  • Type IA (Extra Heavy Duty) 300 pounds
  • Type I (Heavy Duty) 250 pounds
  • Type II (Medium Duty) 225 pounds
  • Type III (Light Duty) 200 pounds

Ladders are made of wood, metal, and fiberglass. When working with electricity, a non-metallic ladder must be used to reduce the risk of electric shock.

Non-self-supporting ladders are leaned against a wall or support. When using a ladder for access to the upper landing surface, the side rails must extend “at least three feet above the top landing” surface (Pre-Installation, 2016). Also, the ladder is placed at an angle with the foot away from the wall the distance ¼ of the ladder length. A quick example: when using a 20-foot ladder the bottom feet are positioned five feet out from the wall the ladder leans against. This formula is ¼ of 20 feet or five feet. The worker must add the ¼ of the ladder length and the additional three feet to the length to determine total ladder height.

On construction sites, Double Cleated Ladders are used. This ladder has double-cleats with a center rail. This type can be two or more ladders joined. There is only one situation to use this kind of ladder -when it is the only way for 25 or more employees to enter or exit the work simultaneously.

There are many things to do to prevent hazards from becoming a reality. “It begins with selecting the right ladder for the job” (Ladder, 2016). Using ladders for their intended purpose is also important, and workers should never:

  • Tie ladders together to make longer sections
  • Place ladders on top of things to gain extra height
  • Paint a covering on a wood ladder that prevents seeing damage
  • “Use the top step of a stepladder as a step” (Before, 2016)
  • Use cross bracing on the rear of a stepladder for climbing

Because portable ladders are moved and transported, it is imperative to keep them in a safe condition and good working order. The rungs, cleats, and steps must be level and uniformly spaced at 10 to 14 inches apart. Side rails must be at least 11½ inches apart. A competent person should inspect ladders before each use. Those with visible defects should be removed from service and label with “Do Not Use” installed.

“Ladders should only be used on stable and level surfaces unless secured” (Safety Meeting, 2016). To secure a ladder, attach it to a fixed object. This will prevent it from accidentally moving due to work being done on the ladder. The area around the top and bottom of the ladder must be kept clear. The area at the bottom of the ladder should also be kept free of slipping hazards.

When climbing, the ladder workers should face the ladder whether going up or down. Workers should use three points of the contract while climbing and not carry objects or loads that could cause them to lose balance. This means two hands and one foot or two feet and one hand on the ladder always.

If the fixed ladder is longer than 24 feet, it must be equipped with a ladder safety device or self-retracting lifeline. This type of ladder also requires a rest platform every 150 feet or less, a cage or well, and multiple ladder sections not more than 50 feet in height.

Workers must be trained to use ladders safely. This training should be done by a competent person and provided before a worker uses a ladder. The training should help workers understand:

  • What causes falls
  • The proper selection, use, placement, and care of ladders
  • How to properly erect, maintain, and disassemble a ladder
  • The maximum intended load-carrying capacities of ladders

Knowing this information helps workers identify risks and the steps necessary to prevent hazards from causing an accident.

Ladders allow construction workers to work at heights, which is essential to their job because workers need to build a building at all levels. This puts workers at risk of falls. A fall from even six feet can result in the death of a worker. Additional information can again be found in OSHA Publication 3124, titled “Stairways and Ladders.” This booklet can be found at


Before the Alaska Occupational Safety and Health Review Board, (accessed December 08, 2016).

Pre-Installation Preparation Job Aid, (accessed December 08, 2016).

Safety Meeting Topic: Ladder Safety, (accessed December 08, 2016).

Stepladder Safety – Ladder Mart, (accessed December 08, 2016).

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A Soldier’s Christmas by Michael Marks


Twas the night before Christmas, he lived all alone,

in a one bedroom house made of plaster & stone.

I had come down the chimney with presents to give

and to see just who in this home did live.


I looked all about a strange sight I did see,

no tinsel, no presents, not even a tree.

No stocking by the fire, just boots filled with sand,

on the wall hung pictures of far distant lands.


With medals and badges, awards of all kind

a sober thought came through my mind.

For this house was different, so dark and dreary,

I knew I had found the home of a soldier, once I could see clearly.


I heard stories about them, I had to see more

so I walked down the hall and pushed open the door.

And there he lay sleeping silent alone,

curled up on the floor in his one bedroom home.


His face so gentle, his room in such disorder,

not how I pictured a United States soldier.

Was this the hero of whom I’d just read?

Curled up in his poncho, a floor for his bed?


His head was clean shaven, his weathered face tan,

I soon understood this was more than a man.

For I realized the families that I saw that night

owed their lives to these men who were willing to fight.


Soon ‘round the world, the children would play,

and grownups would celebrate on a bright Christmas day.

They all enjoyed freedom each month of the year,

Because of soldiers like this one lying here.


I couldn’t help wonder how many lay alone

on a cold Christmas Eve in a land far from home.

Just the very thought brought a tear to my eye,

I dropped to my knees and started to cry.


The soldier awakened and I heard a rough voice,

“Santa don’t cry, this life is my choice;

I fight for freedom, I don’t ask for more,

my life is my God, my country, my Corps.”


With that he rolled over and drifted off into sleep,

I couldn’t control it, I continued to weep.

I didn’t want to leave him on that cold dark night,

this guardian of honor so willing to fight.


Then the soldier rolled over, whispered with a voice so clean and pure,

“Carry on Santa, it’s Christmas Day, all is secure.”

One look at my watch, and I knew he was right,

Merry Christmas my friend, and to all a good night!

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