by Phil La Duke
I am a loud (some might say obnoxious) and ardent supporter of prevention. In fact, I one of my core values is “Prevention is the key to sustainable safety.” So given my vocal advocacy of prevention, you might be surprised to learn that I believe that in many cases prevention has gone overboard and that in many cases companies would be better served by doing LESS prevention and more contingent planning. Heresy? Consider the organization that spends tens of thousands of dollars each year preventing accidents that would likely have little or no chance of ever happening. These companies have 20-person safety committees that meet once a week to argue about why an over-burdened maintenance department hasn’t fixed a low-priority hazardous condition.
Prevention costs money and resources that may well be better spent elsewhere in the organization—and not necessarily safety. Equally damning, organizations that continue funding convoluted safety bureaucracies that unnecessarily add heads, complexity, and cost in the name of preventing injuries. Too often these efforts focus on one of the most misunderstood sources of injuries in the workplace today: human behavior. These systems seldom deliver what they promise (that is, a sustainable change in human behavior) and can actually impede important business processes and the delivery of goods or services in the misguided attempt to control human behavior; it can’t be done, so stop trying.
I’m not suggesting that we return to reactive safety practices, far from it. What I am saying is that there is a time and a place for prevention, but its is not a panacea. Simply put, you can’t prevent every accident, and in some cases you should be looking for ways to protect workers when your best efforts to prevent an accident fails INSTEAD of wasting time on prevention.
Variation in Human Behavior
As organizations, we’d all like to think that we hire smart, capable people, and for the most part we do. We spend days (and thousands of dollars) screening candidates: we ask them probing questions to find out how they reason, how they solve problems, and how they think. We do background checks and ask professional references whether or not the candidate is worth offering them a position. We screen the candidate for illicit drug use, criminal misdeeds, and the things in life that indicate that whether or not the candidate has sound judgment. In the end we confidently hire the candidate and invest time and money training the new hire so that he or she can meaningfully contribute. And then it happens. The person that we spent so much time screening and training gets hurt and we think to ourselves, “if only that idiot would have…” Huh? Now because the employee got hurt he/she’s suddenly an idiot? You may read this and think that you are immune to such thoughts, but the majority of the people I hear describing injured workers as idiots are safety professionals.
They Call Them Accidents For A Reason
As much as we would like to assign accountability for injuries, the fact remains that in almost all cases whatever happened to injure the person was unintentional, or at very least, the person who committed the unsafe act didn’t fully comprehend the potential consequences of his or her actions; the accident was an unintended outcome; in short, the injury was an accident. Accepting that things will go wrong, that people make mistakes, is a bitter pill to swallow. We are taught to believe that making mistakes are bad, subject to punishment, and indicative of poor judgment or out-and-out stupidity. But everyone makes mistakes—we learn by trial and error and without mistakes there can be no learning, at least not organic learning that lasts.
Everyone Makes Mistakes, But No One Should Have To Die Because of A Mistake
I’ve read (I can’t remember where) that the average person makes 5 mistakes an hour. Multiply that by the 2080 hours in the average work year and you have a boat load of mistakes. Some theorize that because biologically speaking change is reckless and dangerous (nature tends to have a “if it aint broke don’t fix it’ approach to survival; if a species is thriving it resists change. In fact, change is so dangerous, that our bodies are hardwired to resist it, when we are confronted with change it triggers our flight/fight response and causes us stress. Conversely, species that are unable to change are unable to adapt to changes in their environments and are driven to extinction. So it would appear that we are damned if we do and damned if we don’t. But if the research that found that the human brain will make 5 mistakes an hour is correct what possible advantage would there be in these mistakes? Making tiny subconscious, non-cognitive mistakes could be our brain’s way of testing the environment by disrupting our routines in small ways. If the mistake leads us to a better way of living we make serendipitous discoveries and innovations but if the mistake leads to an undesirable outcome we see it as an error. But in both cases our brains learn about the safety of deviating from its routine and we are better able to safely adapt.
Variation Leads To Errors
Experts in quality, particularly in manufacturing, cannot emphasis the danger of process variation strongly enough; when the process varies things go sour very quickly. Manufacturing and process engineers have made huge strides in reducing mechanical variation, but the variation endemic to human behavior is so pervasive that it’s all but impossible to eliminate it, or substantially reduce it. Outside of the military (and quasi military—police, security, etc.) it is very difficult to control human behavior. Even variation in cognitive behavior is difficult; how many companies have problems with poor attendance? Certainly at least some of the causes of absenteeism are cognitive decisions where the offending employee simply chose not to come to work.
Focus On Contingency Not Prevention
Okay, relax. I know that I preach prevention above all things, but when it comes to variation in human behavior you just can’t prevent most of it. If we could there would be no crime, no traffic accidents, and no medical malpractice. And to make things even more complicated, human behavior can be very tricky to predict, and even more difficult to prevent. We have to stop pretending that all our problems can be solved through preventive measures; sometimes—despite our best efforts—things go sideways and when they do we had ought to have some contingency in place to prevent a mishap from becoming a disaster or a tragedy. When it comes to contingency versus prevention it doesn’t have to be an either or decision. I used to teach problem solving and we used a very simple tool for determining whether to use a preventive countermeasure or a contingency countermeasure. We would rate both the probability and severity of an error in terms of high, medium, or low. If the probability that the particular failure mode (engineering speak for a screw up) is high—in other words it is almost certain to happen under the given circumstances—then one should definitely find a preventive action. If the probability is low (fairly remote, but possible) one would need to temper the response after considering the time and money it would require to implement. Similarly, if the failure mode’s severity was high (if it DID happen the consequences would be severe) than one would have a contingency in place to protect workers, property, and inventory. Of course if the severity was expected to be low one would again determine whether the protection offered would be worth the cost of the required resources.
Because one rates the severity separately from the probability, one ends up with two scores that must be considered together. Certainly if the probability is high AND the severity is high one would implement both preventive and contingency controls. On the other end of the spectrum, if both the probability and severity were low, one would likely only take action if the countermeasures were cheap and easy to implement. But the scores that are in between (medium probability and low severity, etc.) are subject to a lot more judgment-based decision making. This may seem like a serious weakness to some, but on the contrary, this subjectivity allows an organization to customize it’s countermeasures to its unique environment and situation.
It would be great if we could accurately predict and prevent injuries, but the reality is we can’t. We have to be pragmatic and take important steps to ensure that when someone does have an accident, protections are in place to keep the injury from becoming life altering or fatal.
Filed under: Behavior Based Safety, Loss Prevention, Phil La Duke, Safety, accident prevention, Attitudes toward safety, Behavior Based Safety, contingencies for safety, Criticisms of BBS, culture change, focus on prevention
I agree with this premise. While it may not be deemed a ‘life-critical’ field, I’ve written a bit about this topic in the context of web operations and engineering: http://www.kitchensoap.com/2010/11/07/mttr-mtbf-for-most-types-of-f/
I think the more we can take the “life-critical” aspects out of safety and deal with it rationally and intelligently the more likely it is that we can find real insight. I look forward to reading your work. Thanks for reading mine and thanks for your comment.
phil
I agree, Phil, that for the most part we can’t predict accidents. However, through sound use of metrics we can zero in on areas where an accident is more likely to occur. This is why good accident investigations and data collection/analysis are such an important part of any safety management system. A combined focus on protection and prediction might lead to better results. But I think you are absolutely correct in that we should not put all of our efforts into just prevention; protection just makes good sense. Thanks for continuing to freely share your insight into effective safety management.
absolutely Mike, unfortunately most safety professionals lack the skills to design or interpret measurements of any real sophisticated. We have really have to think in the context of lowering risks not in preventing accidents. It’s a semantic argument, I concede, but an important one. After all, by predicting the things most likely to cause serious injures, containing those items, and permanently correcting them we lower the risk. But we can never lose sight of the fact that we are always one step behind the hazards. Safety is a moving target.
As always, thanks for reading and thanks for your astute comments.
I totally agree with your views on this subject but once emotions get involved and the legal boys get their hands on it things could get sticky. Whatever is done to either prevent the accident from occurring, or, to mitigate the consequences, had better stand up to serious scrutiny once the legal profession gets hold of the issue via the trade unions or whatever. There must be a paper trail starting with the sort of premises you made in respect of probability and consequences and that the workforce agreed to this, and then properly motivated and documented reasons for taking or not taking certain actions. In my country (South Africa) this may not be that critical but I’m sure that in the USA and UK this would be very necessary.
I’ve been employed in the oi/gas industry for 52 years, first of all on a Dutch oil tanker, then in the oil refining sector for many years in various countries, then a stint in gas and NGL plants in the UK followed by a stint in marketing/distribution operations in 6 African countries. For the last 12 years I’ve been active in the production sector, both on- and offshore and all over the world, and get very troubled by the lack of “daring” displayed by workers in this industry. 2ppm H2S in air and they run screaming for respirators and personal monitors. Hotwork required – only after shutting down the platform and depressurising it. Working at an onshore oil production facility and you cannot get into the place unless you have a valid BOSIET certificate – Basic Offshore Safety. Etc. All in the name of safety first. Never any thought of how it can harm you, how it can be done in a SIMOPS way or considering the necessity for it. I’m absolutely appalled by this nannification, which is all designed by the industrial safety profession (HSE) in the name of accident prevention and in many cases is the easy way out.
Maybe if we started to look at things a bit differently we might reach a compromise between the extremes of safety measures.
Rob:
Your comments and concerns are right on. And the key to protecting yourself from litigation is containment. Containment (for those unfamiliar with the concepts) are temporary measures that reduce either the probability of accident or severity of injury. But because containment measures are meant to be temporary they need to be carefully managed and periodically inspected to make certain that the measures remain adequate until a permanent corrective action can be taken. Too often people contain a hazard and forget it as if they have permanently corrected it. Because containment measures are temporary and typically “quick fixes” or “Band-Aids” they don’t last very long and their effectiveness quickly degrades over time. This creates a situation where a lawyer (or criminal investigator) can point to a circumstance where the organization clearly understood that a danger existed but didn’t adequately protect workers from it.
Thanks for reading and thanks for your comment.
Phil
The one word missing: common sense
Don:
Point taken, but read Risk Makes Sense by Dr. Robert Long. He makes a compelling argument that there is no such thing as common sense (in that the term implies a single understanding and interpretation of a situation.) Some also point out that common sense isn’t always common practice. For my part, I like to say, they called it common sense when sense was common.
Thanks for reading and thanks for your comments.
~Phil
Reblogged this on EHS Safety News America and commented:
Another interesting post by Phil La Duke.
Phil,
Thanks for posting. I’m a “deep think” type as well. My thougts: Life is about balance and pragmatism, wich, of course, are subjective. A given organizations view of balance and pragmatism is a compilation of its leaders views, with often different weightings by title (i.e. CEO can have more influence if they choose, by authority). I’ve worked for multiple companies, three of which are among the biggest of the biggest. I’ve learned to recognize each companies risk culture and provide my serives to that end. I should say, I have resigned from (big) companies, because my personal beliefs did not allign well enough w/ the companies (or locations that I served). None the less, certenly companies, divisions of, locations specific staff, or individuals can (and do) make efforts (time/money) that do not offer a good return on investment (risk/reward) in the name of safety. I find it mildly entertaining in situations in which I express the concept or risk / controlling risk, and a person (or people) in the converstation express surprise the “Safety” person is not expressing a zealot type response to safety. My humor (self chuckle) is of course, stems from the FACT life is all about risk taking, and we live in a finite world (business world). Like you, I consider myslef a very strong advocate of prevention, particullarly skewed to higher severity/frequency type loss events. However, (perhaps more so then ever in our life times), we have finite time/resources/staff to manage safety risk. We (as safety professionals) need to guide our companies in what is worth the investment most (relative risk). The risk dynamics means we will always be subjected to criticism / scrutiny when a relatively lower probability (but high severity) type loss occurs. An example of this happen recently in my oganization in which we had China expats, driving a rental car in the U.S., get into a serious (at fault) accident (No serous injury…..lucky). For us, we don’t have a lot of such employees (China expats), but do we require a short term visitor from China to go through U.S. driver education, before they can drive (for work) in the U.S. (What about other country nationals)? Not practical or neccessary in my opinion. Yes, it is a risk, but reasonably acceptable relative to much higher ferquency type risk in our organization. None the less, we, as safety professionals need to parse risk for those who don’t have a good handle. Fortunately, most (not all) senior managers get to be senior managers, in part, because they can rationally look at risk and make good business decisions. You won’t get far in an organization (climb the ladder) if you are a safety zealot. Does not make rational sense. Cheers to safety continual improvement!
I understand where your coming from
I agree some companies either spend too much time and money of senior level management and complex programs – when much of the funding could be placed in other areas.
That more focus needs to be put on using a preventive countermeasure or a contingency countermeasure – even if workers don’t like it.
I disagree that most employees hired try to consider the safety risks in their workplace; for themselves and others. (maybe I misunderstood you here – but this is how I read it)
In my work I find that for the most part people do not think an accident will happen to them and this is the core problem.
People do not think about over stacking heavy boxes so that the next person – who might be not as strong or tall – might have an incident or accident if they try to get the top box.
Or if they are using a slicer improperly – they often say it is their business because they will get hurt. HOWEVER – they do not think about how an accident of looking at blood and chopped off fingers might impact a child watching in a grocery store, that the blood a biological agent contaminating the work area, slicer and if it gets into a co-workers or customers eyes – then their is another element of the incident to be managed.
I think generally people do not consider how being unsafe can have an impact on not only their own health and safety – but other innocent bystanders in some situations.
Stepping back and thinking – so what might the outcome be if I do stack it too high and it falls on me or someone else…. or if I miss and my finger does hit the blade while cutting the meat.
They say – “it is ok I know what I am doing – don’t you worry about it” oh and “f*&^ off” is a frequent quote used.
I do not think people are “idiots” not at all – they just are not taking the time to pull back and consider the repercussions of unsafe practices – actually I don’t think they even think about it and that is the core problem!
Tamara:
I think we are on the same page, but are saying slightly different things. I believe that most people want to work safe and BELIEVE they are working safe. But in many cases they are wrong, and that’s where the danger comes into things. Yes, there are plenty of workers who will cope the “well it’s my life” attitude, but as you point out, the harm caused by an injury goes much farther than the loss of the individual’s life. There are extreme financial costs (even when blood doesn’t contaminate the product) and while a person may be within their rights to risk their lives (which is debatable) they clearly DON’T have the right to put the organization at risk.
But to your point about over stacking boxes or misusing a slicer, every worker in every workplace has a responsibility to work within the defined standard. But too often workers don’t even KNOW the defined standard because they have never been adequately trained. In too many cases people believe that safety is common sense and people shouldn’t have to be trained not to stack boxes above a certain height or to otherwise behave safely. If I don’t know the safest way to do a job, and am not held accountable for not taking unnecessary and unreasonable risks, I will generally do the job in whatever way is easiest and fastest. We need to stop preaching to people about the pain and suffering they will cause if they get injured and start holding people accountable for working within standards.
I see and agree from where your coming from.
I think there are people as we both describe.
My frustration is when I try to guide or motivate people to practice safer practices; I often have to struggle through rude and sometimes offensive remarks by staff, department heads and at times management.
In addition, I often find out they are getting poor or incorrect information from the Senior Safety Manager to people at different levels this adds to the pot of problems.
This is a very complex and hard area to deal with.
No quick fixes my friends – but we can build a safer workplace with our efforts – cheers