Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

Safety In the Tower of Babel


Even the less devote among us likely recall the story of the Tower of Babel.  As the story goes mankind grew so proud that a group of people decided to build a tower to heaven.  This angered God and He confounded there efforts by creating different languages.  Unable to communicate with each other the tower project collapsed into chaos.

It’s not my intent to pontificate or draw some smug moral conclusion here, but I think there is a lesson germane to safety in this story.  Recently I read several links in the safety, organizational development, and system thinkers threads on LinkedIn and was struck by the complete lack of a professional lexicon for worker safety.  Take the term “hazard” for example, in healthcare the term hazard can mean something very different that it does in manufacturing. When people talk about a hazard in healthcare they are typically describing a physical hazard, and while an exposure risk, sharps injury, or ergonomic incident may well cause injury, they are treated as discrete elements and the correction of those things are often assigned to different departments.  That seems pretty inefficient, but before we cluck our tongues at healthcare, there is a far greater problem in other industries.  A recent thread asked safety professionals to define the term “culture” and scores of responses, some similar and others very different.  The debate was heated and nothing was resolved.  A similar thread argued about hazards some claiming that unsafe behaviors were not hazards, rather a category unto themselves, while others held that a hazard is any thing with the potential to do harm.

For me the argument is more than just an irritating intellectual pursuit, it’s a real danger.  If safety professionals can’t agree on the most basic definitions of the trade then they can’t communicate them effectively to Operations, and when they can’t communicate in clear, concise, universally understood terms they lose all credibility with Operations and whine that the leadership doesn’t support them.

And we’re not making any progress.  The arguments rage on the academic/philosophical definitions to no avail, and thus we can never create a working organizational definition, and without that we will continue to measure the wrong things, misinterpret data, and misleading ourselves regarding our risks.

Unfortunately I don’t have a lot of answers.  There are so many vendors making a lot of money and perpetuating ideas that are scientifically and psychologically dubious that I think the field of safety is in real jeopardy of being seen as “warm fuzzy” psychobabble that lacks any sort of credibility with executives and Operations leadership.  The safety function, the safety discipline needs to be torn down and re-engineered and I would recommend that the new safety function follow very closely the tenets of Deming.  Forget safety incentives, forget safety slogans, forget safety culture, in fact, forget safety as an external function altogether.  Instead, work on hard-wiring safety into the day-to-day routine.

To build an organization that values safety one must start with doing a better job of managing talent.  Organizations must do a better job of defining specific safety duties and tasks in the job descriptions and recruit more judiciously against criteria that are predictive of a candidate’s views on working safely.  I freely acknowledge that I haven’t yet figured out just what those predictors might be, but just getting recruiters and hiring managers thinking about whether or not a potential hire would  exhibit the kinds of attitudes and behaviors conducive to a safe workplace is a major step forward.

Next, organizations need to rethink the way in which they orient new employees.  Too often the safety orientation is clearly delineated from the overall new employee orientation.  I understand there are laws requiring that certain courses be provided but there is no reason the requirements for Hazcom or Right To Know can’t be integrated into a session that deals with EOC, Sexual Harassment policies or similar legal or company mandated messages.  By integrating the “safety” training into broader topics around employee rights and responsibility, working safely becomes just another expectation that the company has of its employees.  And when safety becomes just another condition of employment workers will tend to internalize working safely.

Additionally, too often there is a disconnect between new hire, classroom safety training and quality on-the-job training (OJT).  There are reams of research on adult education that demonstrate that the most effective training is the lessons that most closely resemble the actual work being performed.  In other words, OJT (when well designed and effectively executed) is the single best way to train workers.  Unfortunately, OJT is far and away the most poorly designed and executed form of training.  In the best case, OJT typically consists of a new hire shadowing a veteran worker who walks the new worker through the job according to the Standard Work Instructions.  In the worst case, the new worker is thrown to the wolves and expected to figure the job out over time.

Many of you reading this may believe that your OJT is superior and truly does the job, but let me challenge your thinking a bit by asking a couple of questions:

1) How do you evaluate the effectiveness of the training? Do you do smile sheet evaluations? Pre- and posttests?

2) How long does it take for a new worker to become fully competent? Days? Weeks? Months?

3) Do you track indicators of the effectiveness of OJT as a safety metric?

4) How often does a worker get refresher training on the tasks covered in OJT?

5) How do you train your supervisors to judge the competency (including the ability to work safely) of people assigned to their teams?

Simply put quality job-specific training is the single greatest tool for ensuring worker safety, but sadly relatively few resources are typically deployed for making sure this happens.

Perhaps I’ve strayed from my point a bit, or maybe it appears as such, but all of this improvement in talent management and training can’t happen until the safety professionals operationally define safety.  Recruiters can’t screen candidates on the basis of the likelihood that a worker will take safety seriously until the safety professional educates the recruiter on the traits for which to look.  Human resources/OD can’t refine job descriptions to include key safety tasks and behaviors like identifying and removing hazards until the safety professional is able to operationally define the word “hazard”. And finally supervisors can’t coach workers on how to work more safely until the safety professional educates them on just what that means.

This is a challenge that is likely to haunt safety professionals for some time, because many of us don’t have a clue how to come to a full understanding of exactly what it means to have a “safe workplace”.  As long as we have pundits shilling the latest safety fad (most notably and recently the “safety culture” fad) and safety professionals trying to impress other safety professionals instead of tackling some of the fundamental issues that impede safety progress we will keep floundering.

I’m not saying that we should dismiss the idea that we need to improve our view of safety (i.e. “build a safety culture”), but I am saying that it is irresponsible, if not impossible, to try to lead a culture change employing people who aren’t qualified to do so.  It’s equally pointless for the safety professional to expect to do this alone or even to lead this change.  Ownership of safety by operations starts here.

Filed under: Behavior Based Safety, Performance Improvement, Phil La Duke, Safety, Safety Culture, Talent Management, Worker Safety, , , , , , , , , , , , , , ,

Safety is Bunk


I am continually surprised at how firmly people cling to Behavior Based Safety (BBS) as a way to improve workplace safety, despite increasing criticism and a growing body of evidence that BBS just doesn’t work (at least for long.)  I don’t have a vested interest in BBS, and I have (I think) made it very clear that I am a “process safety” proponent.  Even by process safety standards I am something of an outsider.

Perhaps it’s because I came from outside the field of safety.  My background before diving into worker safety was in organizational development and training. The position  I held meant that I was expected to fix organizational problems and process defects and to essentially ignore blaming people.  That sounds like sacrilege to many. I mean, how dare this guy (who isn’t a CSP, an MBA, or CHSP, or DDT, or ETC, by the way) come in to our organizations and tell us the emperor is naked?!? Simple: blame just doesn’t matter that much.

It Doesn’t Matter Who Did It

One of the first things they teach you in problem solving is to ask “How did this happen?”  This a subtle but important shift from the traditional “What happened?”  Knowing “what happened” is really about recording an event.  It creates the sense that somehow by knowing what happened we have accomplished an important measure.  By keeping a record, we think we are making progress.  Henry Ford reputedly said “History is bunk.”  Having grown up with a love of history, a stone’s throw from Greenfield Village and the Henry Ford Museum (for those of you who aren’t familiar with these terrific organizations they were founded and supported by Henry Ford,) I was always puzzled by the seeming contradiction.  But as I spent more time in problem solving and investigating worker safety, I realized that not only was there no paradox in what Henry Ford said and what he did, but:

History IS Bunk

If we view history as this static record of “what happened” and we list all the pertinent whos, whats, wheres, whens, how muches, and how manys, but we ignore the whys and the deeper hows, then we gain no insight. Without insight there can be no learning, and without learning our knowledge never rises above trivia, meaning there will never be any true wisdom or understanding. Those who record events without interpretation are merely bearing witness to history, and the adage that  “those who don’t remember the past are condemned to repeat it” not only becomes true but it doubly damns the observer, because not only does the observer lack any true understanding (i.e. can do nothing to avert a disaster from repeating,) but also runs the serious risk of misunderstanding the very nature of what he or she has seen.  The record itself is useless because the tale has been tainted in the telling.  This is true of many things, but when it comes to safety I think it, no pun intended, painfully true.

The Short Happy Life of Just Culture

So what are we left with?  It’s all well and good to talk about the Utopian “no-blame” culture, but what about situations where the outcome was catastrophic? Do we forgive a Chernobyl? A Love Canal? Can we get past Texas City with an “oops?” The self righteous indignation rises up in us and makes our blood boil.  When people act so stupidly, so recklessly, and so inexplicably we MUST get retribution.  While satisfying, that attitude is wrong-headed and stupid.  Just culture grew out of research that showed that: a) mistakes are inevitable, the brain functions in such a way that (and research here gets a bit fuzzy on the exact number) a person makes an average of 5 mistakes an hour.  That’s 40 mistakes a work day; 20o mistakes in a work week, and 10,400 mistakes in a work year.  Sometimes the mistakes are small and of little consequence, like ordering a cranberry muffin instead of a raspberry muffin.  Other errors are big mistakes with life altering consequences like marrying my ex-wife or forgetting to lock out and losing a hand. And still others get people killed.  The point is this:  no matter how much we try to stop it or how much money we spend, people will still make mistakes.  So there are many, many mistakes made (see my resume for a fairly detailed and recent list of mine) and yet only 2% or 3% are ever rep0rted.  Dangers lurk, and people know about them, but say nothing for fear of punishment.  The culture of blame created an environment where reporting an error would be akin to seeing a policeman and telling him that you blew three stop lights and were speeding most of the day. Honest yes; smart no. Reporting your mistakes invites punishment.

A fatal flaw of Just Culture as it was first conceived is that it didn’t satisfy people’s sense of justice.  People have tweaked Just Culture and it is seeing a resurgence in popularity (largely, in my opinion, based at least in part by the work of Dr. Patrick Hudson—now at Delft University of Technology  in the Netherlands) especially in the U.S. in health-care.  There is more right with Just Culture than could ever be wrong with it, but getting people to report near misses is only half the equation (if that.)  Just Culture without a robust process for investigating injuries is tantamount to bearing witness to history, recording the “what” without the “why.” It’s not useful, at least, not useful for preventing those injuries from recurring.  So while Just Culture is a leap forward (especially when one considers the work of Dr. Hudson et al) it needs to be combined with situation analysis to make it a viable tool in culture change.

And Then Along Comes Engagement

“Engagement” is one of those words that make me want to scream.  It gets bandied about by whoever is the latest and slickest pundit in a lexicon of jargon designed to make him/her seem smarter (and more valuable/useful) than he/she is in reality. Our eyes glaze over and he/she cashes checks.  But true engagement—call it embracing safety, hard-wiring excellence, or what have you,—is essential to sustaining a corporate culture where not only safety is of paramount importance, but so too are quality, delivery, customer service, cost control, and any other business element that organizations think are important.

The most important work on the subject of worker safety in the 21st century may well already have been written; and it’s not a book about worker safety (an admittedly sad commentary on my work, but I think once you’ve read it you will agree.)  Carrots and Sticks Don’t Work: Build a Culture of Employee Engagement With the Principles of RESPECT™ (by Dr. Paul L. Marciano) should be required reading for anyone working in worker safety in any capacity. In fact, it should be required reading for anyone working or interacting with people.  Maybe I’m over selling it, but seriously, if you are considering a BBS system or a safety rewards system, stop what you’re doing and read this book.  And get a copy for your head of HR and your CEO too. And no, I don’t have any stake in the sales. Marciano, like Hudson, has a gift for taking a fairly complex concept and breaking it down in simple, layman’s terms and practical tactics for building a cultural base wherein mutual trust and respect can make a blame-free, Just Culture not only viable, but workable and practicable.

Tying It All Together

I guess being deprived of this unfettered and unfiltered forum has made me a bit long winded, but please indulge me one last paragraph to tie this all together.  There are a lot of good ideas floating around that are too academic, too incomplete, or too impractical to ever reach fruition.  For some of us, that means a professional life fraught with frustration.  For others, it means trying to sell an incomplete solution and apologizing when it doesn’t work. And for everyone else,  it means chasing our own tails as we run from one expert to the next.  Meanwhile, Operations execs get more and more impatient with us are more likely to buy into junk theories and safety snake oil.  I think combining the theories of Marciano, Hudson, and a handful of other thought leaders is an essential next step.  I don’t have all the answers; no one does.  But if we can divorce ourselves from dependence on a single, “quick-fix,” methodology long enough to consider how these approaches might just fit in our organizations; and if we can get something that is simple, practical, and most importantly, fast; we might just finally get the results that the organization demands and the respect so many of us crave.

There is more, but this is enough,

Phil Read the rest of this entry »

Filed under: Behavior Based Safety, Loss Prevention, Phil La Duke, Safety, Safety Culture, Worker Safety, , , , , , , , , , , , , , , , , , ,

I'm Back!


After many months of deliberating whether or not to continue this blog I have decided (largely in response to the many of you who were kind enough to send me private messages of encouragement).  I won’t get into the reasons for my hiatus except to say that the circumstances that existed that made me consider discontinuing my blog are no longer concerns.

This feels like a fresh start so in that spirit I’d like to establish some basic expectations.  First, I will be making at least one new post a week.  The post will explore some element of safety that I find of interest, those posts will first appear Sundays at 4:00 p.m. although I reserve the right to post more often.

This blog will continue to focus on safety, but I will be expanding the scope a bit to alternate between worker safety issues dealing with aerospace, manufacturing, oil and gas, mining, and healthcare.  I find that there is much useful safety theory that doesn’t have good forum for read-across and that’s a shame.

Healthcare can learn much from manufacturing who can learn much from oil and gas etc.  I am attempting to bridge the gap and hope that I can provide a means for these industries to learn from each other.

There is more, but this is enough

Phil

Filed under: Loss Prevention, Performance Improvement, Phil La Duke, Safety, Safety Culture, Worker Safety, , , , , ,

I’m Back!


After many months of deliberating whether or not to continue this blog I have decided (largely in response to the many of you who were kind enough to send me private messages of encouragement).  I won’t get into the reasons for my hiatus except to say that the circumstances that existed that made me consider discontinuing my blog are no longer concerns.

This feels like a fresh start so in that spirit I’d like to establish some basic expectations.  First, I will be making at least one new post a week.  The post will explore some element of safety that I find of interest, those posts will first appear Sundays at 4:00 p.m. although I reserve the right to post more often.

This blog will continue to focus on safety, but I will be expanding the scope a bit to alternate between worker safety issues dealing with aerospace, manufacturing, oil and gas, mining, and healthcare.  I find that there is much useful safety theory that doesn’t have good forum for read-across and that’s a shame.

Healthcare can learn much from manufacturing who can learn much from oil and gas etc.  I am attempting to bridge the gap and hope that I can provide a means for these industries to learn from each other.

There is more, but this is enough

Phil

Filed under: Loss Prevention, Performance Improvement, Phil La Duke, Safety, Safety Culture, Worker Safety, , , , , ,

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