WHY DID MY DADDY DIE ? (Lessons from an Incident Investigation about personal motivation for safety)
2009… a year that heralded some interesting events and saw some watershed moments that will never be forgotten by some:
The worst wildfire in Australia’s history killed 173 people, injured more than a hundred and destroyed more than 900 homes in the state of Victoria.
Barack Obama was inaugurated as the 44th President of the United States of America becoming the USA’s first African-American President.
President Obama signed executive orders closing all secret prisons and detention camps run by the CIA, including the infamous Guantanamo Bay prison in Cuba, and banning coercive interrogation methods.
Michael Jackson, lifelong musician, pop singer, and superstar, died at age 50. He was found unconscious in his home, then rushed to a Los Angeles hospital where he was pronounced dead.
Air France Flight 447 disappeared somewhere off the northeast coast of Brazil with 228 people on board, en-route from Rio de Janeiro to Paris.
After striking a flock of geese, US Airways Flight 1549, en-route from La Guardia Airport, New York City, to Charlotte, N.C., was forced to land in the Hudson River. All 150 passengers and 5 crew members survived. The pilot, Chesley B. "Sully" Sullenberger III, was hailed as the "Hero of the Hudson" for his quick thinking and deft landing of the plane.
The World Health Organization declared H1N1 influenza strain, commonly referred to as "swine flu", as a global pandemic. In May of 2009, the first case of swine flu in Australia was confirmed in Queensland.
The world marked the 40th anniversary of the first manned landing on the moon.
Five Eurostar passenger trains got stuck in the rail tunnel between Britain and continental Europe during heavy snow, followed by days of train cancellations which left thousands stranded in Paris, London and Brussels.
The film Slumdog Millionaire won top prizes at the US Academy Awards.
The top two selling movies in 2009 were "Harry Potter and the Half-Blood Prince" and "Ice Age: Dawn of the Dinosaurs"
Octuplets were born to Nadya Suleman in Bellflower, California USA - all eight babies survived and broke the record of the longest ever octuplet survival.
Nancy Bird Walton AO, OBE, DstJ, a pioneering Australian aviator and the founder of the Australian Women Pilots’ Association died aged 93 years.
Australia’s Labor Party Prime Minister at the time was Kevin Rudd.
Dame Quentin Bryce AD,CVO continued as the 25th Governor-General of Australia and the first female to hold the position.
While all of these events may be of great interest and significance for some, the only event that two little boys (I’ll call Matty and Nicky for the purpose of this article), noted in 2009 was that was the year their Daddy (* Andrew) died in an industrial accident.
While all fatality investigations can be emotionally difficult, this particular investigation resonated closely with me. Matty and Nicky were four and five years old at the time they lost their father… my two sons, James and Jacob, were the same ages at that time. I couldn’t help but feel a real affinity with Matty and Nicky when I went to their home to interview their mum (* Sarah) as part of the investigation into Andrew’s death.
We don’t always interview next-of-kin. It’s a judgement call if it’s necessary. It may be that we have enough information from work sources, however, sometimes comments are made or health / personal issues need to be pursued as part of the investigation. In the case of Andrew’s death, we had so far found very little in regards to work issues during the investigation.
Andrew held all the appropriate qualifications / tickets and was very experienced, the content and dissemination of information for the particular work procedure and risk assessment for that operation was good, drug and alcohol testing came back negative, there was no undue pressure for the task to be completed, the equipment was all mechanically and structurally sound, there were no operations nearby that may have had an impact, weather was not a factor etc. etc. At that stage of the investigation, it appeared for little apparent gain, that Andrew had placed himself in a hazardous position during the operation and paid the ultimate price. During interviews with work mates, comments were made about some issues and habits of Andrew and it was at that stage we made the decision to talk to his wife, Sarah.
People often comment that it must be extremely difficult to go and interview a family member as part of an investigation. I generally find that family members in the early stages of their grief, are so appreciative that something is being done to work out why their loved is gone, that they are very welcoming, readily open their doors and are very open. It’s only later, when the reality sets in, that the anger and anguish makes the interview extremely difficult.
Anyone who has interviewed next-of-kin, knows that as hard as it is, you have to put up an emotional brick wall up when you conduct these interviews. A sage colleague once said to me “You can feel sympathy when meeting family members Jo, but work hard not to feel empathy or it will eat you up.”
The terms empathy and sympathy are often confused, and with good reason. Both of the words deal with the relationship one has to the feelings and experiences of another. Both sympathy and empathy have roots in the Greek term páthos meaning “suffering, feeling.” The prefix sym- comes from the Greek sýn meaning “with, together with” and the prefix em-derives from the Greek en- meaning “within, in.”
To sum up the differences between these two terms: sympathy is feeling compassion, sorrow, or pity for the hardships that another person encounters, while empathy is putting yourself in the shoes of another. That day I interviewed Sarah, I remember feeling that sometimes it’s not so easy to separate the two.
The interview with Sarah started well. Despite the loss of her husband, she was extremely welcoming. Sarah had fresh coffee brewing and her parents had come to offer support and help look after Matty and Nicky while she spoke to us. Sarah asked us to sit in the living room while she went to the kitchen to get the coffee. As I sat down in the living room, I noted family photographs all over the walls and mantel.
The photographs chronicled Sarah and Andrew’s life from the beginning of their relationship with just the two of them, through to the photos with their little boys. Most of the photos were of them at the beach or on a boat, with Andrew obviously being a keen fisherman. Sarah, an enthusiastic photographer, had taken some beautiful pictures over the years.
Matty and Nicky had blonde hair and blue eyes, just like my two boys. Most of the photos captured the joy and exuberance of her two little boys with their father. When Sarah returned, I commented on the gorgeous family photos and that’s when she asked me “Do you have any children?”. I told her about James and Jacob and she smiled and seemed to relax when she found out my boys were four and five years old, the exact ages of her two boys. We both laughed about having “Irish twins” - a pair of siblings born less than 12 months apart and what it had been like to have two babies under a year old. As Sarah talked, we found out we were the same age, had similar interests and just seemed to bond instantly.
The interview went well. Sarah was very open about Andrew’s personal issues and comments he had made at home about work. Some of this information highlighted issues we would subsequently follow up to find were key contributing factors to the accident.
As we stood up and thanked Sarah for her time and again offered our sincere condolences for her loss, I saw her two little boys had come into the room. Sarah introduced Matty and Nicky to us and told them that we were there helping to find out more about their father’s accident. I knelt down to say hello to the boys and when I put out of my hand, both of them gave me a hug. Matty then solemnly looked at me and said these words, which still haunt me to this day; “Why did my Daddy die? Why couldn’t the doctor save him?”.
As I struggled for words to respond to Matty and felt Nicky’s arms around my neck, I knew the emotional brick wall I usually put up was crumbling and this would be one of those investigations that wouldn’t be so easy to leave behind once the investigation was complete and report was written. I gave Sarah my business card as we left and told her to call me anytime if there was anything else she remembered or if she had any questions.
A year went past after the accident when Sarah rang me one day, out of the blue and asked if it would be alright just to chat. We didn’t talk about Andrew or the accident. I made sure that the ground rules were clear in the beginning that I couldn’t discuss anything from the investigation. The conversation revolved around her, our children and common interests. We discussed the children and various milestones etc. such as our eldest boys starting school. After that, Sarah and I kept in touch every now and then until I would say that today, eight years after we first met, she is not just someone that I know, but she is my friend.
When Sarah and I were talking recently, she asked what I was doing and I mentioned I was starting to write an article I’d been thinking about in relation to personal motivation for safety at work. Sarah asked me a lot of questions about it and later that night sent me an email, offering that I use anything in it for my article if it would help get the message across to others and possibly save other families going through what she and her boys had.
Everything Sarah had written was exactly the point of what I had been struggling to convey effectively about the impact of an accident and the reasons and personal motivation we should always think about in relation to safety. So with Sarah’s permission and blessing, I have included the entire email, which read:
“Eight years ago, my husband Andrew made a decision to deviate from an established work procedure which ended up with him being in a hazardous position, with no controls in place. He’d talked at home about doing it before and jokingly said it made the job easier and he could finish quicker. I didn’t think too much about it, after all I thought, he knew what he was doing. Everyone always said that Andrew was a ‘gun operator’ and the ‘best of the best’. Unfortunately, despite knowing he shouldn’t be doing it, the odds finally caught up with him and that decision by Andrew led to fatal consequences for him one day and life-long consequences for me and our two boys, Matty and Nicky.
The town was very supportive after the accident. People were very helpful, funds were raised, dinners were brought to our doorstep and Andrew’s work colleagues said they would be always be there as ‘substitute Dads’ for the boys. But, you know, as time marches on, people become busy and suddenly it seemed like we were on our own again. I don’t blame anyone. They all had their own families to focus on. One of Andrew’s mates actually said to me he found it too hard being around us because all it did was remind him he’d lost a good mate. I felt like screaming at him that we’d bloody well lost a husband and father and it wasn’t so easy for us to just get away from that. But I didn’t… I simply smiled and said I understood as he walked away.
Losing your husband to a work accident is not something you can just ‘get over’. You don’t wake up one day and think to yourself, ‘Well, enough of that, time to get on and be happy now’. Time doesn’t actually heal and it’s never actually over. Sure, the all-consuming shock and grief does ebb, but you still have to live your life – with a part of you never the same.
My boys were so young when they lost their Dad, just babies really. They will never have the benefit of a father in their life during their formative years. They never got the opportunities of their Dad teaching them how to fish, how to ride a bike, how to read or play football. One of the most upsetting things to me, more than eight years later, is that they can’t really remember him now. Their memories are just from photographs and when I ask them if they remember going fishing every weekend or how their Daddy liked to make up silly, funny bed time stories before tucking them into bed, they just shake their head and say ‘No’.
Our lives changed irrevocably that day when we lost Andrew. Our family routines changed – the little things you do as a family unit. I tried for a while to do the things that Andrew used to do. I tried to make up silly, funny bedtime stories just like Andrew had done each night. But I couldn’t replace Andrew and couldn’t do it how he’d done it. Andrew used to always cook pancakes on Sunday mornings. That first Sunday after his accident I tried to keep the routine going but remember burning the pancakes and my boys sitting at the breakfast bench sadly looking at me while I cried over a stupid bunch of burnt pancakes. To this day, I’ve never eaten pancakes again. I feel guilty that we started a new routine of having bacon and eggs every Sunday morning together, without Andrew. Another family ritual gone…
My two bubbly, little rascals seemed to lose a spark overnight and turn into introverted, quiet little boys. Gone were the ‘squealing little banshees’ that we often jokingly called our two boys. I often wonder what they may have been like if not for the loss of their Dad in 2009 and the chaotic, turn-around in our lives.
I’ve had to be the strong one and put my grief to the side while I focused on bringing up my two boys by myself. There wasn’t another parent who could take over when they cried themselves to sleep. There was no back-up when the boys were sick or had two different sporting events at two different locations at the same time. It’s all the little things that just add up when you lose a partner suddenly and have to do it alone.
Now that my boys are a bit older, they've had so many experiences in life and I feel so sad that they didn't have their Dad there to see the special moments. They've learnt to ride bikes and swim. They've played football and cricket. Matty has started high school and Nicky will be there next year. They’ve had their first crushes… and their first heartbreaks. Not too far away, I can imagine they’ll be driving and dating and going out into the big wide, world. I’ve tried my best, but I know that I could only ever be the best mother I could be and could never replace their father - who may have offered more comfort and wisdom to them as they grow into young men.
Eight years later, I’m still sad about losing Andrew, but I will be totally honest and tell you I can admit now I am also angry. So angry, that my husband thought he was ‘bullet proof’ and could break the rules, full well knowing that he would be placing himself in a position he shouldn’t. I’m angry that he didn’t stop and think ‘What if…’ and I’m mystified that of all people, Andrew knew the risks better than anyone. I found out during the coronial inquest that he had actually helped write the risk assessment for the task being done. He bloody well knew what he was doing, but maybe thought because he was the expert on-site he could handle the risks. I’m angry that I’ve had to help and cope with my children’s grief all these years and have seen my boys suffer.
If I could think of one thing that may make sense of what happened to Andrew, it’s that other people learn from it and realise that an ill-advised decision not only could have ramifications to you – but to your family. When my good friend Jo was talking to me about personal motivation for safety at work, I think companies and organisations get it wrong when they focus on how people should be safe at work. Because the reality is that for most people, personal motivation for safety at work, is not even at work. It’s at home. Everyone has to remember that the reason for safety at work is being able to leave safely at the end of the shift and get home to their loved ones. To share each other’s lives and see your little children grow up and be there for them. That’s the true motivation for people to work safely.
I would be so sad to think that other little children have to endure what Matty and Nicky had to. If he had his time again I know that Andrew would hate to think he could ever do anything to hurt me or his boys. He just didn’t stop and think. He’d done it before and it all turned out OK. But the risk was there and one day it didn’t turn out OK. Please, the next time you think about breaking the rules, taking a short-cut, doing something contrary to the procedure or changing the job to make it a little bit easier… just stop and think what it could mean to your family, your wife, your husband, your parents, your siblings or your children. Think about safety and remember the reason for doing it right is to leave work safely to get home to your loved ones.”
After reading Sarah’s poignant words I knew there was nothing I could add to try and convey the importance of safety and the personal motivation we should all have in this regard. The personal impact of not getting it right should be reason enough for everyone to actually get it right. None of us would ever like to think that our children may ask the questions that Matty did that day: “Why did my Daddy die? Why couldn’t the doctor save him?”.
* = Names changed to protect the family’s identity.
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ABOUT THE AUTHOR- Jo De Landre (Chief Operations Officer)
After 15 years with the Bureau of Air Safety Investigation (BASI),which became part of the multi-modal Australian Transport Safety Bureau (ATSB), Jo started co-facilitating ICAM training with Safety Wise in 2001 as the Principal Human Factors Consultant.
In 2005, Jo was promoted to the position of Executive General Manager of Safety Wise and beyond providing human factors specialist services and ICAM training and Investigations, she is now involved in strategic activities such as project management and developing safety management programs.
Jo has been the Safety Wise Lead Investigator for many high profile accidents, including multiple fatality investigations. She has a Bachelor’s Degree in Applied Psychology and a Graduate Diploma of Psychology, and has published papers in aviation, mining and police journals and publications.
Joanne has also been Secretary of the Australian Aviation Psychology Association (AAvPA) for close to a decade.