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TAKE 5 When Plans Change

11/15/2010

On December 29, 1972 an Eastern Airlines jumbo jet was attempting to land at the Miami International Airport. When the pilot put the landing gear down, a light bulb on the dashboard, which indicated the gear was locked into place, failed to light up.

The crew was not sure if the light bulb was burnt out or if the gear had not locked into place. While the pilot, co-pilot, and second officer focused on the problem of the light bulb, they failed to notice that someone had bumped the flight controls causing the plane to gradually descend. By the time they noticed they were descending, they were too late to stop the collision with the ground. 101 people died in the accident including the pilot and co-pilot. The final government report cited the cause of the crash as pilot error, specifically: "the failure of the flight crew to monitor the flight instruments during the final four minutes of flight and to detect an unexpected descent soon enough to prevent impact with the ground. Preoccupation with a malfunction of the nose landing gear position indicating system distracted the crew's attention from the instruments and allowed the descent to go unnoticed." The final tragedy of this story is that the landing gear was down and locked and the only problem with the aircraft had been a burnt out light bulb.

We have seen several injuries occur on our sites when crews encountered an unusual situation and have focused on fixing the problem before ensuring their own safety. Much like the pilots focusing on the light bulb at the expense of their passengers, we have seen crew members focus on solving short-term delays or unexpected occurrences without considering how their actions impact the safety on the job site. Unfortunately these decisions often lead to cut hands and other severe injuries.

When faced with an unusual or unplanned event on the job site, we need to apply the TAKE 5 system with all crew members:

Think Through the Task or Problem

Do I have the right tools?
Do I understand the steps to do the job safely?
Who else could be affected by this task?
Do I have the right permissions, permits, or authority?

Look for the Exposure to Harm

What if it falls, slips, breaks, spills, drops, shifts?
What if it is too heavy, too large, too small, sharp, hot, pressurized, energized, etc.?

Assess the Risk

Determine if the task can be done safely by looking at the probability of a failure and the potential consequences if there is a failure. If either the probability or consequences are high, check with your supervisor before proceeding.

Take Precautions and Remove the Risk

Eliminate the hazard if possible. If not possible, substitute it with a less hazardous process, engineer it out with guards or physical barriers, apply correct procedures, and use the appropriate PPE.

Do the Job Safely

Finally, complete the task safely while watching for changes to the difficulty of the task, the weather, personnel involved, or other environmental factors.
By applying these principles in any unusual situation, we can ensure we don’t focus on the light bulb at the expense of injuries to our crew or ourselves. Remember to keep your mind on the critical tasks and TAKE 5 when things begin to change.

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