Appendix: Blaming Workers for the Results of
Mismanagement
"Employee error," increasingly, is scapegoated for whatever goes wrong in today's
downsized, understaffed, sped-up workplace. Four items on the same theme:
1. SENATORS WERE WARNED OF LEXINGTON AIR CONTROLLER
UNDERSTAFFING1
JEFFREY MCMURRAY, ABC NEWS - Months before the Comair jet crash
that killed 49 people, air traffic controllers at the Lexington airport wrote to
federal officials complaining about a hostile working environment in the tower
and short-staffing on the overnight shift, according to letters obtained by The
Associated Press. In identical letters sent April 4 to Kentucky's senators,
Republicans Mitch McConnell and Jim Bunning, a control tower worker said the
overnight shift, or "mid," is staffed with two people "only when convenient to
management."
The Federal Aviation Administration's guidelines called for two people to be
there the morning of the Aug. 27 crash, but only one was present. "We had a
controller retire last month and now we are back to single man mids," wrote Faron
Collins, a union leader for the Lexington control tower workers. "I ask you one
simple question. Are two people needed on the mids for safety or not? If they are,
why are they not scheduled?" . . . Besides the letter to the senators, another
Lexington control tower operator wrote to the FAA's Accountability Board on
Dec. 1, 2005, complaining about a hostile work environment in the tower. That
employee requested anonymity, fearing discipline against him.
2. Dian Hardison. "I F-ing Warned Them!"2
I told them that the technicians and engineers were overworked. I told them
that there were too many managers and too many meetings and "dog-and-pony"
shows. I told them that their senior "face time" play games, while they spent all
their time plotting how to give each other pay raises, and left the guys on the floor
to struggle day to day with obsolete and overpriced and unqualified equipment,
was going to result in another Challenger.

1

ABC News. http://abcnews.go.com/US/wireStory?id=2427312&CMP=OTC-RSSFeeds0312 Link now
dead. Originally linked in Progressive Review; quotes are from originally quoted text preserved in blog
post: Kevin Carson, "Blaming Workers for the Results of Mismanagement," Mutualist Blog, Sept. 17,
2006. http://mutualist.blogspot.com/2006/09/blaming-workers-for-results-of.html
2
Dian Hardison, "Shuttle Crash & Smug NASA Managers 'I F-ing Warned Them!'" Counterpunch, Feb. 1,
2003. http://www.counterpunch.org/hardison02012003.html

I was there for Challenger.
I saw the same exact conditions happening again. Overpaid, lazy, irresponsible
managers concerned solely with their climbing up their ladders.
I told them they were skimping on inspections. I told them that the ground
crews were asleep on their feet from exhaustion. I made as much noise as I knew
how to make about the top-heavy bureaucracy sitting around in their fancy
panelled offices, giving whorish press interviews in their smugness, while they did
not have a clue what was going on in the real world where I was working....
Like Challenger, those who are most guilty are the ones who will attempt to
make the most political capital out of it. But the blame for Columbia lies entirely
and totally with the NASA administrators. They should all be investigated for
their criminal negligence. They should all serve time in jail.
3. MSHA Makes The "Wrong Decision" To Blame Workers For Accidents3
That management likes to blame worker behavior for accidents will come as
no surprise to American workers. That this "blame the worker" theory is not
consistent with the facts, that it doesn't get to the root causes of workplace
incidents is also not a surprise to American workers.
So this new Mine Safety and Health Administration program comes as a great
surprise to all of us.
MSHA Launches New Safety and Health Initiative4
ARLINGTON, Va.- The U.S. Department of Labor's Mine Safety and Health
Administration (MSHA) today launched "Make the Right Decision," a safety and
health initiative that helps miners and mine operators focus on human factors,
such as decision-making, when at work. The campaign encourages miners and
mine management to work together on safety and health issues.
"MSHA will increase its focus on safety decisions during this campaign,
which is not a limited-time initiative," said David G. Dye, deputy assistant
secretary of labor for mine safety and health. "We want miners and management
to make the right decisions to ensure the safety and health of America's miners."
So what's the problem with encouraging workers to make the right decision?

3

"MSHA Makes The 'Wrong Decision' To Blame Workers For Accidents," Labor Blog, July 28,
2005.http://www.nathannewman.org/laborblog/archive/003252.shtml
4
Department of Labor press release, "MSHA Launches New Safety and Health Initiative,"
July 13, 2005. http://www.msha.gov/MEDIA/PRESS/2005/NR050713.asp

First, the assumption of this program is that most accident happen because
workers make the wrong decisions. In other words, all you need is a little
education, training and enlightenment and all will be well. If accidents continue to
happen, they're caused by worker carelessness, incompetence, stupidity, suicidal
tendencies -- and just plain dumb decisions.
In other words, "Make the Right Decision" is just your same old "behavioral
safety" program under a new name. Behavioral safety theories say that worker
carelessness or misconduct is the cause of most accidents, and disciplining
workers is the answer. But behavioral theories don't hold up to a closer look at the
root causes of most workplace accidents: generally management system and
organizational problems that lead to unsafe conditions....
So what about these two "unavoidable accidents" reported last year? Would
they be alive today if they had just made the right decision?
Two miners killed in pair of incidents
After badly burning his hands in a coal-mining accident earlier this year in
Perry County, Edwin Pennington said he was finished with mining work, but he
returned for the money, his father said yesterday.
On Wednesday night, Pennington, 25, of Harlan County, was crushed to death
in a rock fall at a Bell County Coal Corp. mine — one of two underground mining
deaths hours apart in Eastern Kentucky.
Eric Chaney, 26, of Pike County, was crushed in a roof collapse early
yesterday at a Dags Branch Coal Corp. mine in Fedscreek in Pike County,
officials said.
The deaths were the second and third fatal mining accidents in Kentucky this
year, and the first underground fatalities. Nationally, 14 miners have died in
accidents this year.
***
Bill Caylor, president of the Kentucky Coal Association, an industry group,
said the two deaths were unavoidable accidents. "We don't want things like this to
happen, but they will," Caylor said. "Mining is very safe, but you have to be
careful because you're working around big pieces of equipment."
Or maybe Kevin Lupardus died because he made a bad decision:
Investigation of fatal accident at Boone mine continues

CHARLESTON, W.Va.- State and federal authorities are trying to determine
what caused a section of high wall to fall onto an excavator at a Boone County
surface mine, killing the machine's operator. The accident occurred at about 2 a.m.
Saturday November 21, at Independence Coal's Red Cedar Surface Mine near
Clothier. Independence Coal, a subsidiary of Richmond, Va.-based Massey
Energy, operates the mine as Endurance Mining, according to federal Mine Safety
and Health Administration records. Kevin Lee Lupardus, 41, of Mabscott, was
operating the excavator when a "large section" of the highwall fell onto the
machine's cab, said Terry Farley, an administrator with the state Office of Miners'
Health Safety and Training.
It is somewhat ironic that this program is starting now. Clearly acting
Assistant Secretary Dye hasn't read the June 2005 issue of Occupational Health &
Safety which contains an article by Fred Manuele entitled "Serious Injury
Prevention."
Manuele cites experts who point out that what may look like "human error"
are actually system errors:
R. B. Whittingham, in his book The Blame Machine: Why Human Error
Causes Accidents, describes how disasters and serious accidents result from
recurring, but potentially avoidable, human errors. He shows that such errors are
preventable because they result from defective systems within a company.
Whittingham identifies the common causes of human error and the typical
system deficiencies that lead to those errors. They are principally organizational,
cultural, and management system deficiencies. Whittingham says that in some
organizations, a "blame culture" exists whereby the focus in incident investigation
is on individual human error, and the corrective action is limited to that level. He
writes: "Organizations, and sometimes whole industries, become unwilling to
look too closely at the system faults which caused the error"
He notes that although humans may be involved in the errors that lead to
accidents, James Reason and Alan Hobbs, in Managing Maintenance Error: A
Practical Guide point out that one needs to look deeper:
Errors are consequences not just causes. They are shaped by local
circumstances: by the task, the tools and equipment and the workplace in general.
If we are to understand the significance of these factors, we have to stand back
from what went on in the error maker's head and consider the nature of the system
as a whole . . . this book has a constant theme . . . that situations and systems are
easier to change than the human condition
In other words, look at the safety systems and find the root causes. If managers

(and MSHA)continue to attempt to prevent accidents by focusing on human errors
and "wrong decisions," the same accidents, injuries and deaths will continue to
happen.
4. Labor Relations in the Health Care Industry for Nurses5
More Nurses Needed
* Understaffing: There are not enough nurses to do what needs to be done on
any given shift and the nurses who are on duty are exhausted and stressed. A 2003
study by the Institute of Medicine (IOM) found the environment in which nurses
work a breeding ground for medical errors which will continue to threaten patient
safety until substantially reformed. The IOM points to numerous studies showing
that increased infections, bleeding and cardiac and respiratory failure are
associated with inadequate numbers of nurses. A 2002 report by the Joint
Commission on Accreditation of Healthcare Organizations called the nursing
shortage “a prescription for danger” and found that a shortage of nurses
contributed to nearly a quarter of the anticipated problems that result in death or
injury to hospital patients.
* Low Nurse-to-Patient Ratios: With managed care restructuring the health
care industry in the 1990s, hospitals reduced staffing levels to lower costs. Nurses
care for more patients and patients who are more acutely ill due to shorter hospital
stays. One study of hospital staffing found that decreases in the number of
LPN/LVNs added to RNs’ patient load. Studies have linked low nurse-to-patient
ratios to medical errors and to poorer patient outcomes, as well as to nurses
leaving patient care. A 2002 study by Linda Aiken, et al., found that for each
additional patient over four in an RN’s workload, the risk of death increases by
7% for hospital patients. Patients in hospitals with eight patients per nurse have a
31% higher risk of dying than those in hospitals with four patients per nurse. The
IOM study recommends that nurse staffing levels be raised in all health care
facilities.
* Mandatory Overtime and Floating: Because of the nursing shortage, many
hospitals routinely require nurses to work unplanned or mandatory overtime and
to “float” to departments outside their expertise. On average, RNs work 8.5 weeks
of overtime per year according to a recent union survey. Mandatory overtime was
an issue in several recent strikes and 77% of RNs favor a law banning it except
when an emergency is declared.
* Burnout: Among nurses there are high rates of emotional exhaustion and job

5

Michigan State University, School of Labor and Industrial Relations, "Labor Relations in the Health Care
Industry for Nurses: Online Credit Program,"
http://www.lir.msu.edu/distance_learning/MNAArticleandWebPage.htm

dissatisfaction which are strongly associated with inadequate staffing and low
nurse-to-patient ratios. The Aiken study found each additional patient per nurse
corresponds to a 23% increased risk of burnout, as well as a 15% increase in the
risk of job dissatisfaction.
What's even worse, management's penny-wise, pound-foolish policies, which attempt
to cut costs by deliberate understaffing, don't really even save money:
Statistical model shows [sic] that when nursing units are understaffed the
additional costs associated with patients who develop complications are greater
than the labor savings due to understaffing....
While immediate personnel costs are less with short staffing, long term costs
were higher because patients with complications often stay longer in the hospital
and require other expensive treatments....
Institutions attempting to decrease costs through health care worker reductions
may, in the final analysis, incur higher costs as a result of higher rates of
nosocomial infection, longer hospital stays and use of expensive antimicrobials
and increased mortality.6
It's just another example of the MBA disease: stripping organizations of productive
assets and milking them in order to inflate short-term returns.
By the way: the healthcare industry has its very own "behavioral safety" approach to
hospital-acquired infections, directly analogous to the "human error" approach described
above in the mining industry. The spread of MRSA and other infections in hospitals is the
direct result of downsizing and understaffing--also the primary cause of patient falls,
medication errors, wrong site surgery, etc., etc., etc., etc., ad nauseam. Healthcare workers
know they need to wash their hands--but knowing and being able to do are two different
things when the only orderly on the floor is literally running from one call light to
another, and he's got three patients sitting on bedside commodes at the same time as two
other fall-risk patients are setting off their bed alarms. Rather than deal with the root
cause--the dangerous levels of understaffing that have resulted from the downsizings of
the past decade--hospital administrators resort to asinine gimmicks like the "Partners in
Your Care" program (designed by a manufacturer of hand disinfectants):
Patients and families are asked to be Partners in Your Care by asking all
healthcare workers that have direct contact with their family member patient “Did

6

Wisconsin Federation of Nurses and Health Professionals, "A Summary of Recent Research
Supporting the Need for Staffing Ratios and Workload Limitations in
Healthcare."http://www.wfnhp.org/setlimits/researchsummary.html [Link no longer active, but
available through Internet Archive]

You Wash Your Hands?” or “Did You Sanitize Your Hands?”7
Dilbert effectively parodied a similar program: the company response to on-thejob accidents was a "safety dog" who admonished "Woof, woof! Don't use scissors!"
Attempts to deal with safety issues through such behavioral approaches, rather
than by addressing the structural and process causes, are what Peter Drucker called
"management by drives" and Deming dismissed as "slogans, exhortations, and revival
meetings." But in the modern workplace, such slogans and gimmicks are likely to
appear on the very same bulletin board as kwality jargon from Six Sigma or ISO9000.

7

Official Steris corporate website. http://www.steris.com/aic/partners.cfm

