Lessons from losses: Training - why pretty good isn't good enough

By: Courtney Rosengartner
Sr. Risk Solutions Specialist

Failure to understand instructions, especially because of a language barrier, is a recipe for disaster. For a Taiwanese food production worker, it proved fatal. As a supervisor, you may assume that a worker from another country has a pretty good grasp of English. The following story shows why pretty good isn’t good enough. 

What happened

A 54-year-old food production worker who was employed by a New York state pizza dough manufacturer died of severe neck lacerations and blood loss after he was struck by an energized cutting blade while cleaning a dough machine. The victim had turned off and locked power switches controlling the machine before he and a co-worker proceeded to clean it. The plant lockout/tagout procedure called for setting the control buttons of the dough chunker to “off” and “manual.” However, the victim set those controls in the “on” and “auto” positions. At one point the co-worker asked the victim for the key to unlock the main power switch for one of the machines, so the dough bowl could be raised. The victim was bending over and extended his head through the bottom opening of the hopper when his co-worker activated the power switch. Hearing noises, the co-worker rushed to the victim and observed that he had been partially decapitated by the energized steel blade. The worker died at the scene.

The Investigation

Investigators determined that the company’s lockout/tagout training program included viewing a 35-minute video in English along with some text training and hands-on training. During some of the training sessions, the victim’s employer had hired professional translators to translate written training material into Mandarin Chinese for three employees at the plant. However, the hands-on training sessions were conducted solely in English. The plant manager and safety coordinator said each worker had been taught how to shut down a machine and isolate its energy source, release any potentially hazardous stored energy, test to verify that the energy source was isolated, and lock the energy control device securely in the “off” position. The plant safety coordinator said the victim had seemed to understand English fairly well. 


Their recommendations included the following: 

  • Periodic inspections should be conducted to ensure that company procedures are being followed. 
  • Employees need retraining in the event of an incident, a near miss, or changes to procedures or equipment. Those workers whose first language is not English should receive both text training and hands-on training in their native language. 

Bottom line 

Appearances can be deceiving. Assuming that a worker has adequate English language comprehension to understand complex instructions involves taking a big leap of faith. It’s a risk you cannot afford to take. Make sure training is offered in a language your workers understand.

Source: SafetyNow, SafeSupervisor, January 2022 newsletter


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