Why Write about Safety Incidents?
Let’s talk about WHY we unpack safety incidents here, which has important implications for HOW we do it, and also for the big picture question of what IS safety?
But first, let’s talk about truck peels. What’s a truck peel? Here’s a 50 second video loop -- please watch it (you might find it oddly soothing).
Behold the Norfolk Southern–Gregson Street Overpass, aka “the Can Opener Bridge” and “the Gregson Street Guillotine”. Here’s how its Wikipedia entry describes it:
“...designed in the 1920s and built in 1940, the 81-year-old bridge allows passenger and freight trains to cross over South Gregson Street in downtown Durham. The bridge was built with a clearance for vehicles of 11 feet 8 inches (3.56 m). This was a standard height at the time it opened. The standard clearance, since 1973, has a minimum height of 14 feet (4.27 m), which is 2 feet 4 inches (0.71 m) higher than the bridge as built...Despite numerous warning signs about the low clearance, a large number of trucks, buses, and RVs have collided with the overpass at high speed, tearing off roof fixtures, and at times shearing off the trucks' roofs...In October 2019, the North Carolina Railroad Company, which owns the bridge and tracks, raised the bridge by 8 inches (20 cm) to 12 feet 4 inches (3.76 m) to reduce collisions (although that is still well below standard height)...The bridge gained fame as a nearby office worker, Jürgen Henn, set up cameras in 2008 to track the collisions with the bridge. As of April 2021, Henn has recorded over 160 collisions with the bridge, and the YouTube channel he set up to showcase his recordings has 150,000 subscribers and more than 50 million views.Despite the number of crashes, there have been only three injuries reported, making rebuilding of the bridge a low-priority concern.”
If you watch some of the other videos on the YouTube channel, you’ll note that not only does the bridge have multiple warning signs about clearance posted along the road, it actually features a big neon flashing marquee that says “OVERHEIGHT MUST TURN”. And yet, vehicle after vehicle barrels towards its fate. 167 crashes and counting!
I think the Can Opener Bridge is a great metaphor for safety.
Unfortunately, a lot of how we approach acupuncture safety issues is the equivalent of posting warning signs that say “11 feet 8 inches clearance”. When the incidents that we want to prevent keep happening, we make more signs, and then bigger signs. When they still keep happening, we try flashing neon. I’m sure there are plenty of punitive consequences for truck drivers who accidentally peel off their vehicle’s roof because they didn’t read the signs. Maybe the warnings and the consequences reduce crashes to some degree, but I bet raising the bridge 8 inches reduced them more!
However, the crashes will continue (to the delight of YouTube subscribers), as long as there’s a road that trucks can drive on that leads to a bridge they can’t fit under.
Many if not most safety incidents involve structural elements. You can post warnings, you can shame people, you can punish people, but none of those things will ever resolve a structural safety problem. And so one good reason to unpack a safety incident is to figure out if anywhere in it there’s the equivalent of a Can Opener Bridge, so at the very least we don’t blame the individuals involved, and at best maybe we figure out how to raise the height clearance.
Another good reason has to do with trauma informed care. As noted earlier, what we’re advocating for on this blog is a predictable, neutral approach to acupuncture safety that’s grounded in being 1) well-organized and 2) tolerant of humans being human. Many safety incidents involve trauma and triggers. Discussing those in a neutral way is part of normalizing them and reducing stigma.
Which is all to say that approaching safety issues the way we want to approach them, from a structural and a trauma-informed perspective, requires significantly more effort and more communication than the approach of “something scary happened, let’s find somebody to blame!”
Unpacking safety incidents is more valuable if you start out by acknowledging that 20/20 hindsight is an amazing thing, a superpower really. We would all do things differently if we had access to 20/20 hindsight in the present, but we don’t, that’s the point. And so we can only create more safety through a laborious process of dissection -- “well if I’d known X, I’d have done Y, so next time I’ll do it differently”. This means you can’t fault anybody for what they did in the moment. The process of unpacking safety incidents isn’t about holding up anybody’s actions as an example of what not to do, it’s about carefully unwinding the various threads that contributed to an incident so that we can all learn more about what those threads are and how they came together.
I’m starting to think of safety almost like a quilting bee: a collective project that involves stitching together our individual vulnerabilities to make something more resilient than any of us could make alone. It's cooperative, not competitive. Everyone’s boundaries are a work in progress, and everyone needs to work on being aware of their triggers -- everyone. Safety’s always a process, never a product. Thanks for reading.