Part 3:
What happens when training management goes wrong
Sadly, there is no shortage of incidents of inadequate or undocumented training causing serious harm and in some cases, death. Take a look at two cases below which involved training deficiencies:
Case 1
Well known confectionary manufacturer Hostess Brands faces a fine of up $298,000 following an incident in which an employee suffered the amputation of a fingertip in December 2022.
The employee had been reassembling a pump at a facility in Chicago when the incident occurred. A US Department of Labor investigation found that the injury could have been prevented by the employer ensuring to shut down and lockout the equipment to prevent it from unexpectedly starting during maintenance.
OSHA investigated and found the employer did not train workers on lockout/tagout procedures. The agency also found that the business failed to make sure shafts, sprockets and moving parts on equipment had the required guards in place.
Case 2
In the second case a worker was critically injured after falling from a height of approx. 21.5 ft from the ceiling area of a facility in which they were working in February 2017. Their employer, Ontario-based electrical systems integrator Cybertech Controls and Electric Inc, had been contracted to install new lighting fixtures in the facility.
Working alone and unsupervised, the worker used an elevating work platform to access the work area, which was located above the ceiling of the room being worked in. The worker fell through the ceiling of the room to the concrete floor below, where they were later found.
An Ontario Ministry of Labour investigation found that the worker had not received training on the use of fall protection equipment or working at height and had not received training on the use of elevating work platform.
Cybertech Controls and Electric Inc were fined $70,000.
Don’t forget about forgetting!
An often-overlooked element of employee training is that skills become forgotten over time. We naturally fall into habits or our own way of doing things and can sometimes become blind to hazards in environments we are familiar with. Skills can also diminish through lack of use.
Let’s take a hypothetical situation where a new paper company employee has received training and been signed off as competent on the use of small trolleys and larger roll-cages as manual handling aids.
For several weeks the employee is successfully using the small trolleys, but one day they are required to use a large roll cage. The employee is unaware that the roll cage is damaged and becomes difficult to move with heavy cargo. After much pushing and pulling the roll cage falls and injures the employee.
The learning and forgetting curve (see below) demonstrates how when we first start learning, we quickly become more knowledgeable or more skillful. Over time it becomes more difficult to take new information in, and we need a break (the top of the blue curve). Then we start to forget, quickly at first, then more slowly as time goes on. The green line shows the minimum we need to know to do something safely and effectively – we overlearn initially because we will forget.
If we refresh the knowledge before we have forgotten too much, we can cause our efficiency to peak again (the purple curves). The more often we do that, the less likely we are to lose our competence. The red line shows the day of the accident - for our employee, the purple curves show that repeated use of the smaller trolley meant that on the day of the accident she was still competent. The blue line shows where she was with the roll cage.
To decide how often to re-train you need to consider the tasks people do, the competency needed – and the consequence if it goes wrong.