Why admin controls will get you hurt!

The problem with administration controls is they rely on your working memory to implement. Typically a risk assessment is completed and the hazards is noted on the JHA/JSA and if it cant be removed, reduced or engineered out (which is many) beware of the hazard is listed in the controls. We load this control up into our working memory and there we hope it will stay for when we need it. Thats where the problem lies.

I was involved in a crane incident where its counterweights contacted a fixed structure. The crane could only be positioned where a slew anticlockwise meant collision. So a risk assessment was completed and everyone agreed the structure couldn’t be removed so the control was to slew clockwise and operate in the 2 o’clock to 4 o’clock arc.

During the cranes set up a wind speed measurement device needed to be fitted to the boom. This meant the boom had to be slewed to the 8 o’clock position and lowered to near ground so it could be fitted. Well the operator had a lot on his mind that morning and what had been discussed, agree, reinforced and put into the operators working memory went straight out again once he started using his working memory for other thing, like crane setup. He basically forgot what had just been discussed. Ever have that happen to you?

Well working memory is limited. Most people can only remember 5-7 things at a time, so once you attempt to use working memory for more than that something has to be dropped off. In this incidents case it was the control of “not slewing anticlockwise”. He hit the structure!

So whenever you see controls that rely on remembering a newly written down admin control, be wary. Our memory is prone to forgetting and that can get someone hurt.

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