[…] elevators, by activity, 1992-2009 The following Figure 4 is the authors’ attempt to develop the taxonomy from the 110 people described in Tables 3 and 4 who died installing and repairing elevators between 1992 and 2009. It is necessary to show meaningful patterns with associated describers. This type of analysis is the starting point. The industry must be able to accurately describe the Class I problem and then come to understand the phenomena involved in the various taxons so that health and safety resources are appropriately directed. Quality descriptive data (supported by codified data, e.g., occupation) of individual events is critical to building a meaningful taxonomy to show that there is a desperate need for quality taxonomic information in the first instance to be able to understand the patterns and the relative importance of the mechanisms by which various energies are damaging people. Figure 4: Attempt at a taxonomy of lift fatalities Similar comments can be made when one looks at publications with respect to injury because they do not filter out the Class I non-fatal permanent damage. Current injury studies are useful in that they show the involvement of falls of people, musculoskeletal damage from manual tasks, etc. However, there is not sufficient insight in the data analysis to strongly direct health and safety activity. 4.1 Two Deaths Our own experience with two escalator fatalities is useful in that it gives the authors’ insights into one aspect of the mechanism of death and the associated controls, but those deaths do not get captured in a dataset that assists the industry in understanding the relative importance of the energies and mechanisms involved in fatal incidents. The following Figure 5 illustrates where the pathway of movement beyond the edge commenced. Figure 5: Where the pathway of movement beyond the edge commenced Figure 6: Reinforcing the mythology There is a common notion that such fatalities are due to bad behavior, lack of attention and carelessness. Figure 6 reinforces that mythology. Figure 5 shows the movement pathway of two deaths that the authors’ investigated. In one case, a child grabbed the rising part of the handrail and was lifted up and carried over and fell to their death. The second involved a young lady being embarrassed as her boyfriend went to give her a kiss in a public environment and she stepped back, and her clothing interacted with the rising part of the escalator handrail to lift her up and carry her beyond the handrail, causing her to fall to her death. In both incidents, a common feature was the exposed and rising part of the handrail. This becomes the first point of challenge: Both people were behaving reasonably. The exposed section of the rising handrail was essential to the incident, and the absence of a barrier to prevent them moving beyond the edge was also essential. Probably some 15 years after investigating those two deaths, the industry in Australia commenced to use safety barriers, but we still fail to address the rising part of the handrail. The authors are sure the two stories will create some disagreement, but the point being made is that, as an industry, we are not building useful datasets that aid in understanding and give insight into the relative importance of the different mechanisms by which people lose their lives or are permanently damaged as a result of using lifts and escalators. The view is supported by Ruibal, et al.: “There is a real need to collect reliable escalator accident data which could help identify potentially dangerous situations that can be sources of risk for users or technicians on escalators.” 5. Challenge Our Way of Thinking  As we think about Class I damage and come to better understand the pattern and relative importance of the different mechanisms of energy transfer, we will then need to challenge our thinking about individual damaging occurrences. It is not to say that some very significant thought and analysis of Class I damaging occurrences is not happening, but we do not think it is sufficiently widespread. There is a strong belief in accident prevention and the desire to stop situations moving out of control. Many of the outcomes of investigations are administrative in nature, and yet in the lift industry, we seek out controls that are operating as a situation commences to move out of control, is out of control and damage is occurring. The following Figure 7 illustrates the timeframes through which situations pass with the length of those time zones dependent upon the timeframe of the event under consideration. The timeline forms part of the InterSafe Essential FactorsTM model. Figure 7: Unscaled time diagram for an incident resulting in death or destruction of equipment. Incidents with less serious outcomes branch from this time diagram at any stage. The lift industry has many controls that operate in the metastable, unstable and damage time zones of Figure 7. Examples involve detecting the presence of the person in the pathway of closing lift doors. This is a control that operates in the metastable time zone. When a lift is in freefall and the safety brakes apply, the rate of application of the safety brake can result in very significant jerk (rate of change of acceleration), which results in permanent damage to people but prevents fatalities. The safety brake is a damage-reduction device. It is not an accident-prevention device. For the industry to make further progress, we must force our thinking into the fast timeframes of instability and damage and learn to think in terms of the concept of meta-stability. This is the timeframe in which the participants in the incident often consider the situation to be stable when, in fact, it is moving out of control but recoverable. Perhaps the concept is best demonstrated by example: The following case study (Figure 8) is in the public arena: Figure 8: Case Study If one were to read the Lessons to Learn (above), they are totally focused on keeping the situation under control and in the stable time zone of Figure 7. As the situation progresses beyond stability, it is often necessary to have a very strong focus on the machine and the work environment of the lift shaft. These components can be considered as information detectors, information processors and decision-makers, as the reaction times of people are often far too slow in the fast-time frames of unstable and damage. Technology has made rapid advances in the last 15-20 years in which equipment and the work environment can be considered as an information detector, processor and/or decision-maker. The lift shaft environment is very unforgiving when a person is in the travel path of either the lift or the counterweight. Perhaps there is real opportunity going forward that either the lift, the counterweight or the lift shaft itself can act as an information detector, processor and decision- maker, in that it recognizes that an object is moving toward a susceptible structure, e.g., a maintenance person, and that there is a need to intervene. The concept may sound abstract, but unless we are to apply increasing rigor with respect to personal damage, the stories depicted in the case study will continue with similar lessons learned and the taxonomy of fatalities will not alter. Another example is provided to challenge our thinking: The Hierarchy of Controls could be rebranded Control Options and placed on the event timeline as follows: Elimination: operates in the Predisposing time zone of Figure 7. Administrative: operates in the Stable time zone of Figure 7. PPE: operates in the Unstable/Damage time zone of Figure 7. Engineering: can operate in any of the time zones of Figure 7. A scientist’s models and language must be more neutral and objective. Control Options is neutral and objective. Hierarchy of Controls implies good and bad, best and least, and invokes value judgments. For the person who reads this paper and is interested in a more comprehensive range of control options, they are referred to the paper by William Haddon, “On the Escape of Tigers,” which lists 10 strategies for managing an energy exchange. What is fascinating is that the paper was written by a medical practitioner venturing into the province of energy and engineers. Haddon’s 10 strategies for managing an energy exchange effectively derive from the medical profession’s desire to intervene in the prevent phase of the disease, at multiple points of time in the event phase of the disease and then in the post-event phase. We have much to learn from the medical profession. Figure 9 illustrates Haddon’s 10 Energy Management Strategies overlaying the event timeline: Figure 9: Haddon’s Energy Management Strategy 6. Summary This paper is not intended to denigrate or detract from the significant work and gains that are being made in the lift industry, but to challenge some of the baseline thinking that allows opportunities to go unnoted as we study individual cases of personal damage. The paper joins others on the same subject that contend we are in desperate need of quality taxonomies of Class I damage associated with multiple fatality, single fatality and non-fatal permanent damage. The following recommendations are made for the industry with respect to a study of Class I damage: Firstly, the industry association to collect descriptive and codified data of fatalities and non-fatal but permanent damage (traumatic and over-time damage) and >60-days-lost cases* from: Insurers Large and medium-sized lift manufacturers and installers Government agencies *The taxonomies of non-fatal but permanent damage cases for other industries reflects ≥60 days […]