Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

Misleading Indicators


trash graphs

“If you don’t know where you’re going, how do you know you aren’t already there?”

By Phil La Duke

Nearly every safety professional worth his or her salt has been told that he or she needs to look at both leading and lagging indicators; it’s good advice, in fact, it’s advice I’ve given many times in articles and speeches over the years.  But in my last post (two weeks ago—I spent the last week at a customer site and with the travel travails I just couldn’t bring myself to hammer out a post, deepest apologies to my fans and detractors alike) I questioned the value of tracking (not reporting or investigating, mind you, just tracking) near misses.  Well, as you can imagine the weirdoes, fanatics, and dullards came out in droves to sound off and huff and puff about things I never said (reading comprehension skills are at a disgraceful low these days).  Not everyone one who reads my stuff is a whack-job however, and some of the cooler heads insisted that tracking near misses was important because near miss reporting is a key leading indicator; it’s not…and it is, but like so much of life, it’s complicated.

Near misses in themselves aren’t leading indicators; they are things that almost killed or injured someone, and most importantly, they are events that happened in the past.  Not that anything that happens in the past has to be automatically counted out as a lagging indicator, but unless you still cling to the idea proffered by Heinrich that there is a strict statistical correlation between the number of near misses and fatalities, near misses are no more a leading indicator than your injury rate, lost work days, or first aid cases.  They simply tell you that something almost happened, and nothing more.  Now some of you might try to argue that if you have ENOUGH near misses you are bound to eventually have a fatality, but that does hold up to careful scrutiny.  Leading indicators are often expressions of probability, and like the proverbial coin that is tossed an infinite number of times, the probability of the outcome does not change because of the frequency of the toss.  If you were to toss the coin 400 times and it came up tails, the probability that the 401st toss would come up heads is still 50:50. So knowing that tracking near misses doesn’t really shed any light on what is likely to happen mean we should stop investigating near misses? Certainly not, but we really do need to stop thinking that the data is telling us things that it isn’t.  On the other hand, near miss reporting is indeed a leading indicator; if we accept (as I do) that when people report near misses they: a) are more actively engaged in safety day-to-day (and I suppose someone could argue that this doesn’t necessarily correlate) and b) the more the individual reports near misses the better he or she is at identifying hazards (again, this is a leap of faith, but  I believe in most cases this to be true.) So if you want to gage the robustness of your safety process I suppose the level of participation in near miss reporting is a good indicator.

The whole exercise got me thinking about indicators, and how often safety professionals (and everyone else on God’s green Earth for that matter) tend to be mislead by data because of the erroneous belief that the data is saying things that it isn’t.

Causefusion

Regular readers of my blog will recognize the concept of “causefusion”.  The term was coined by Zachery Shore in his book, Blunder: Why Smart People Make Bad Decisions which he uses to explain how people mistake correlation and cause-and-effect.  According to Shore, causefusion works something like this[1]: People who floss their teeth live longer than people who don’t floss or who floss irregularly therefore flossing your teeth makes you live longer.  It makes sense, right? Yes, except that it is wrong.  There are other possibilities for this correlation, for instance, isn’t it possible that people who are more interested in their health overall might be more likely to floss regularly? In a world where eager safety professionals provide data to Operations people who are hungry for quick fixes, Causefusion happens a lot; and it’s a real danger because it leads us away from the true causes of injuries and may blind us to real shortcomings in our processes.

Another way that we can be lead by indicators is the paradigm effect. When we think of the word “paradigm” we think of the definition, “a typical example” or “viewpoint”, but in the world of science paradigm there is another, lesser known definition, “a worldview underlying the theories and methodology of a particular scientific subject” Joel Barker pointed out how damaging paradigms (in the scientific sense) can be.  Barker believed that there were many instances where the worldview is so powerfully believed that any new evidence that does not support the worldview is ignored. Consider the dangers of ignoring critical new information relative to worker safety because you believe in a particular tool or methodology so strongly that you can’t even consider another viewpoint.

A third way that we mislead ourselves is when we see patterns that aren’t there.  This phenomena is wonderfully described in another book that I really believe is important to the world of safety, Why We Make Mistakes: How We Look Without Seeing, Forget Things in Seconds, and Are All Pretty Sure We Are Way Above Average by Joseph T. Hallinan. According to Hallinan—and the latest in brain research supports his contention—the human brain tends to see patterns even where there are none.  So in cases where safety professionals desperately seek answers and are under pressure to initiate action, the pressure to see patterns where there are none can be extreme.

Perhaps the most misleading indicator is one of the most common: zero recordables.  Too often safety professionals (and operations, as well, for that matter) see a trend of recordables as evidence that they are at far less risk of injuries and fatalities than they are.  This isn’t to say that they AREN’T at less risk, but there isn’t anything more than a correlation between the two elements; they might be good but they are just as likely to be lucky.


[1] The example is mine and mine alone, don’t get all huffy and bother Shore.

Filed under: Loss Prevention, Loss Prevention, Near Miss Reporting, Performance Improvement, Phil La Duke, Safety, Worker Safety, , , , , , , , , ,

Road Rash: Business Travel and Injuries


by Phil La Duke
Plane crash
Last Saturday and the Saturday before that I made no posts to my blog. It was an unfortunate result of my having been away on business. This is not an excuse mind you; I had every intention of writing and posting using the infernal timer that has vexed me every time I’ve tried using it. In hindsight I’m glad I waited. This week I’d like to talk a bit about an area of safety that I think goes largely ignored: safety while travelling.
While safety professionals understand very well that a injury sustained while travelling for business is, in fact, a recordable injury and a recordable injury effects your overall Incident Rate and DART irrespective if it happened in a hotel room, a rental car, or an airport. How big a problem is it? In the U.S. the most lethal jobs are consistently sales positions and automobile accidents are the leading cause of accidental death among sales professionals and while other parts of the world the problem isn’t nearly as severe as the U.S., many of the basic hazards that confront business travelers are essentially the same.
Those who travel for whatever purpose are at heightened risk because they are constantly bombarded with unfamiliar stimuli. The subconscious mind takes in millions of bits of information (much more than that actually) and sorts according to whether or not the information is indicative of a threat. The subconscious does this by comparing the information with other information that it has stored in a sort of a database that one collects based on one’s life experience when the new data matches up with benign memories the brain decides that the new data is harmless and disregards it. When the brain detects danger it activates the fight: flight response and floods the body with adrenalin (or releases it in little drips depending on the degree of perceived threat) and well, I think we’ve all heard wild tales of the fantastic feats of strength caused by a good adrenalin rush so I won’t belabor the point here. But when the brain doesn’t quite know what to make of a piece of information it assumes it’s a threat, in much the same way we tell our children not to take candy from strangers (even when everyone knows that strangers have the best candy!) Are most strangers a threat? Certainly not (although the 24-hour news machine often creates the impression that there is a greater danger out there than there really is), but if we assume a stranger is kind and harmless and he or she turns out to have malicious intentions our child is left unprotected and likely victimized, but if the inverse is true and our child avoids contact with a benevolent stranger there is no harm done.
When we travel we are bombarded with a barrage of unknown and uncategorized data and our brains treat that data as potential threats. As the brain collects more and more information that we are in danger it raises the adrenalin drip and our bodies get stressed. Stress, in addition to creating long-term health problems also inhibits our decision making process and causes us to make more errors. (So basically we are making poor choices AND making more honest mistakes.) Add to this the disruption of sleep from which so many travelers suffer and the resultant rise in risky behavior, and you have a circumstance where injuries are all but certain; in hazard recognition terms the likelihood of an injury is greatly increased. Depending on the activity, this cocktail of poor choices, human error, and at risk behavior can be a deadly drink indeed.
Perhaps the most dangerous activity is driving, and again, this is skewed against the U.S. and Canada where fewer business travelers are employing professional drivers, using public transportation, or riding in taxis (although if you have been on anything like some of the truly harrowing cab rides of which I have been a party and you would join me in wondering why there aren’t more business travelers killed in cabs.) Business travelers routinely drive rented vehicles that are largely unfamiliar to them and do so on unfamiliar routes.
Data on injuries of business travelers is seldom accurately collected. Neither the safety professional nor the traveler him/herself is mindful of the need to record near misses, first aid cases, or even recordable—it’s not that they don’t think it’s important they typically don’t think of these incidents as work-related. Think about it: when you are travelling for business where exactly is the workplace? It’s in the airport parking lot, the airport, the plane, the car rental office, in the rental car, at the hotel, at the customer site or remote corporate location, the hotel lounge, the restaurants, and…well you get the picture. And when exactly is a business traveler “off the clock” and does that even make a difference?
Several weeks ago I was on the road and awoke from a deep sleep with the typical dry mouth one gets when living the sweet life that is business travel. I got up to get a drink of water and while returning to my bed in the dark caught the corner of a poorly placed credenza and tore a painful but not life threatening scratch across my soft white underbelly (my side actually but I thought the former sounded better.) I took pictures and sent them to the hotel manager who acted like I was pulling the cockroach in the salad grift from “Paper Moon”. In short, he either didn’t believe me or couldn’t have cared any less, he went so far as to tell me “we searched the room thoroughly and can’t find the piece of furniture in the photo”.
And really should we care? I think so. While my injury was minor it could have been much more severe and had it been I would have had a recordable incident. Had my scratch become infected that too would have been a recordable incident. But the real question is, would I have thought to report it, and if I were to report it, how well received would it have been by my organization. In my case, I work for an organization that takes these matters very seriously, but what about those business travelers who work for companies who preach “thou shalt report” with one breath and “thanks for spoiling the safety BINGO” with the next? I’m not picking on safety incentives here, because, let’s face it, it doesn’t matter where you work nobody is excited to hear about the latest recordable.
Until we find a place where we can welcome injury reporting as a source of important information on our process weaknesses and not a gig against the person injured (and even in the most enlightened workplaces there is still a lingering resentment that our safety record was ruined by one stupid accident.) we will not be able to get a real sense of the risk we face. Sadly, business travelers are least likely to report an injury and at significant risk of injury.

Filed under: Injury reporting, Near Miss Reporting, Phil La Duke, Safety, , , ,

More Deming on Safety: Adopt the New Philosophy


Deming’s second point is “Adopt the new philosophy. We are in a new economic age. Western management must awaken to the challenge, must learn their responsibilities, and take on leadership for change.” In writing this point Deming could well be describing safety.  For years Japanese companies have viewed the worker as a resource, as the best source of ideas for improvement, but also long-term partners in business; certainly a wise organization would do everything in its power to preserve and nurture something so vital to its success.

Adopting the new philosophy in safety manifests itself in several important ways.

  1. Injuries are waste and need to be managed as such.  Far too many safety pundits are still preaching that “safety is the right thing to do”, they continue to preach about moral imperatives for companies to protect worker at all costs.  Whether or not companies have any compunction to protect workers is between them and the workers.  That having been said, organizations need to protect their competitiveness, their profits, and their efficiency and all this begins with a relentless pursuit of waste reductions.
  2. Stop worrying about changing the culture and start worrying about changing your processes.  Too often safety professionals stick with what they know and don’t venture too far beyond it. Unfortunately, safety professionals typically don’t know all that much about organizational development, transformational change, or organizational psychology.  Even so, that doesn’t seem to be sufficient to stop safety vendors from shilling half-baked culture change solutions to organizations. Nor does it stop internal safety professionals from championing initiatives of which their sole qualifications are limited to reading an article in the odd safety magazine or attending a session at a safety conference.
    That some organizational cultures inappropriately undervalue safety is indisputable, but making the leap that the Safety function is capable of changing that on some grand, enterprise-wide scale is laughable. On the other hand few safety professionals understand process mapping, value stream analysis, and the other tools and methods necessary for process improvement.
  3. Integrate the Safety Into Other Business Functions. The days where Safety is a separate business function are rapidly coming to a close.  Maintaining a safety infrastructure with Safety professionals must end.  Just as the Quality function evolved into a vehicle for process improvement so too must safety.  As long as Safety professionals see themselves as discrete from the overall operations and somehow able to operate in isolation from production it will always be at risk of being dropped from the corporate team.
  4. Leadership Must Advocate for Change. Leaders are often maligned by safety professionals. Too many times safety professionals blame their own failures on a lack of leadership commitment. In this case Safety professionals are right:  Leaders SHOULD be visible and outspoken advocates for safety and organizational change that supports it.  That’s not to say that safety professionals shouldn’t play a role in this initiative.  Safety professionals should provide expertise and guidance to leaders, many of whom, don’t know how to begin to advocate change.
    If safety professionals are going to be trusted counselors to the leaders there is much work they need to do:
    1. Quit pretending to know more than they do. Safety is an area of expertise that requires practitioners to have a deep understanding of a diverse range of disciplines, but there are limits to even the most learned safety professionals’ curricula verities.  There is a natural tendency (bordering on compulsion) for safety professionals to advise far beyond their knowledge base and once labeled a vacuous windbag it’s hard to been seen as having any opinion of value to offer.
    2. Research and Analysis. Perhaps the most useful service a safety professional can offer is comprehensive research coupled with razor-sharp analysis on the best way to leverage the things uncovered by the research.
    3. Offer Guidance, Not Advice or Opinions. One of the most important thing that I recently learned is that offering guidance is tough. Frequently, what we see as guidance is opinion or just plain butting in. Guidance is marked more by listening than by advising someone as to what they had ought to do.  Guidance is invited; advice or opinions are not.  Safety professionals need to transition to trusted counselors than pouting eunuchs that huff and sigh when they don’t get their ways.  But offering guidance requires trust, and trust takes time to build.
  5. Recognize the Realities and Challenges Endemic to the New Global Economy.  Deming developed his 14 points over 50 years ago, yet even then he was able to recognize that even then we were in a new economic reality.  Even as safety comes under increasing government scrutiny the scarcity of resources available for workplace safety continues to plague safety professionals.  The stark reality is that while the number of demands placed on safety increase, the resources are shrinking or trending flat.    
  6.  Improve the quality of safety training and ensure its efficacy. My background is in organizational development and training and I will say unequivocally that the most safety training is wholly inadequate for anything except for checking the compliance box.  The biggest opportunity to transform the safety of the workplace lies in the improvements that can be made in training.  The better a worker is prepared in the tasks associated with his or her job the safer that worker will be.  I wrote an article on how safety training could be improved, What’s Wrong With Safety Training and How to Fix It so I won’t revisit it here.

Deming’s work remains the quintessential guide to quality, but the lessons one can glean and apply to safety are timeless and substantial. In studying Deming’s thoughts on quality we can transform safety and in so doing our industries.

Footnote: Phil La Duke will be speaking at 1:30 p.m at the National Safety Council on October 31, 2011

About Phil La Duke.  Phil La Duke is a contributing editor and safety columnist for Fabricating and Metal Working magazine, an editorial advisor and contributor to  Facility Safety Management magazine, and a contributor to ISHN magazine.  La Duke is a highly sought after international speaker and author whose brash style and often controversial take on emerging issue is a favorite of the international safety community.

Filed under: Loss Prevention, Near Miss Reporting, Phil La Duke, Safety, Safety Culture, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

A Just Culture Starts With Just Leadership


Just Culture, a concept James Reason proffered decades ago is growing in popularity.  At its essential core Just Culture is pretty simple: people make mistakes and punishing people for making honest mistakes is a basic form of injustice.  Reason, and his successors, argue that organizations must foster blame-free environments where workers are encouraged to report mistakes and near miss if they hope to ever address the root causes of workplace injuries.

But implementing a just culture is far more difficult than merely deciding not to punish people for screwing up.  Far too many business leaders are unable to see past their petty biases and the traditional legal department party line that a blame-free culture needlessly and recklessly exposes organizations from malpractice lawsuits or other liabilities.  This is unfortunate.  So many business leaders are afraid to do what is right in favor of what is safe.

For a just culture to take hold and blossom organizations need a different sort of leader. A Just culture  needs to be led by what I describe as just leaders, and these executives are a rarity.

Traits of a Just Leader

Just leaders share characteristics that set them apart from the pack. These leaders see themselves as leaders first and foremost and they live there lives by a code of conduct that is set not be some artificial external criteria but by their personal values.

Courage

It takes a lot of moral fortitude to stand up to corporate attorneys who advise you on a course of action that pits you against your core values.  If the corporate attorney insists that you hang someone out to dry, it’s tempting to throw someone under the bus and blame the oily skinned legal department (or corporate communication or IT).  It takes real courage to stand up to the corporate pitch fork and torch toting mob screaming for the blood of some hapless bureaucrat who mad a bad decision in good faith, but that’s what a just leader does.  A just leader recognizes that courage lies not fearlessness, but in recognizing one’s fear and forging forward despite them.

A just leader is able to clearly articulate his or her values and institutionalize  those values into a work culture that is fair and just.

Vision

It’s scary what passes for vision these days. Corruption is rampant, which one could argue was always the case, but even when Chief Tammany bore witness through his lifeless wooden eyes, people recognized corruption, incompetence and dare I say it, corporate sin. Just leaders need vision and that vision must take them beyond what’s good for themselves and their stockholders.  Just leaders know that they cast long shadows and that to create an organization that will endure it takes more than their own skills and includes the skills of most everyone in the organization.

Recent years have seen the growth of a sickening cottage industry—executives who take companies into bankruptcy.  This is pointedly obvious in the auto industry.  There are a handful of executives whose only value seems to be screwing people out of money to which they are legally entitled via bankruptcy. These slim-witted weasels are hired to bankrupt a company not as a last resort reset of the company’s debts but as a corporate strategy.

A just leader looks beyond the goals by which his or her compensation is based  and instead focuses on how organizations can serve the needs of their stock holders, their environments, their employees, and their customers.  A good leader knows the importance of being a good corporate citizen.

Consistency

Rudyard Kipling once wrote “if you can trust yourself while all men doubt you while still allowing for the doubting too.” Just leaders do this by consistently holding the line as others in their industry are melting down in panic.  Because these leaders have a clear cut vision you can always predict what they will do in a crisis,  you can set your watch by them and trust they will do what is required even if it is painful

Consistency isn’t easy, especially when an industry is melting down.  But no one will ever admit mistakes without knowing exactly what consequences are likely to befall them. So unless a leader can consistently react to unexpected circumstances a just culture can never emerge.

Honesty

A just leader cannot expect others to be forth coming about their mistakes unless he or she clearly acknowledges his or her own mistakes.  Everyone makes mistakes and for a leader to gloss over his or her business faux pas is the height of arrogance and hubris.  Just leaders aren’t afraid to acknowledge their mistakes and the best of them learn from their mistakes and teach others the lessons they learned.

Honesty transcends being straight-forward with board members, the media, the workers, the unions, and the stockholders and reaches the depths of the just leader’s subconscious and lays bare the soul, in short the just leader is MOST honest with him- or herself.

Integrity

Just leaders don’t just know the difference between right and wrong, they also know the difference between right and legal. In this day and age it’s easy to hide behind the law and commit corporate atrocities.  For most leaders doing something heinous is softened a bit if you can get your corporate lobbyist to get it legalized first.  Just leaders worry about what is right, not what is legal.  And when they act with integrity and transparency they need not worry about investigations or accusations.

Just leaders hold themselves to a higher standard than the one to which they hold all others and the one against which society measures them. And when it comes to creating a just cultures having the right leaders is more important than having the right consultants, the right tag lines, or even the right policies.

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

You’re Only As Safe As You Feel


Abraham Maslow theorized that a one could only reach one’s full potential if one’s needs were met.  Maslow arranged these needs into his seminal work, the Hierarchy Of Needs.  The needs in the Hierarchy of Needs are arranged in a pyramid with the most basic human needs at the bottom and the more intellectual and social needs at the top.  According to Maslow, a person cannot achieve the higher needs until the more basic needs have been met.   At the top of Maslow’s Hierarchy lie creativity, problem solving, and autonomy—the very things we typically look for in workers we would describe as “empowered” or “engaged”.

While Maslow identified the most primal needs as the need for food, shelter, sex, and sleep,  he identified the need for safety and security as needs just above these in importance.  And unless these needs are met it is impossible to pursue higher needs.  This is interesting in the context of worker safety because many safety professionals are either unaware of Maslow’s research, ignore it outright, or fail to recognize how this research applies to the workplace.

According to Maslow, a worker who doesn’t feel safe (irrespective of the accuracy of that opinion) cannot possibly focus on process improvements, creative problem solving, or any of the other empowered activities we expect of today’s workers.

So what does that mean for safety? Plenty.  First, it calls into question the basic premise that safety incentives aimed at lowering injury rates.  If people don’t feel safe (which is a sane response to working in an environment where people are frequently injured) they are incapable of contributing any worthwhile ideas for process improvement.  We are not providing an incentive to work more safely we are providing a random reward that will confuse the workers and basic reward good luck and punish bad luck.  If we are rewarding outcomes at all; far more frequently we are rewarding people for concealing their injuries which in turn makes people feel less safe and more insecure.  Before anybody gets all indignant about my questioning the value of safety incentives, I will grant that incentives have their places—primarily in workplaces that have already made great strides and are less concerned about fixing a broken safety system and more concerned with sustaining hard fought gains. But in most cases, organizations provide incentives too early in the evolution and maturity cycle of their safety systems.

Beyond merely providing incentives, Maslow’s work have a profound influence on the type of incentives that should be provided.  Many organizations provide one of the most basic motivators available: money.  The trickiest part of motivation is that once a need has been satisfied, it ceases to motivate.  Money is a basic need and provided the worker makes a living wage, money will be less and less a motivator (unless the amount is continually increased.)

Some incentives are focused on meeting social needs—recognition, social appreciation, or contribution to a team.  Again this approach assumes that the workers feel safe, and secure or the incentive will fail.  But nonetheless incentives at this level can be effective if they are appropriately awarded.  Awarding a team for the accomplishments of single member may be less effective than singling out an individual.

Underlying all these factors is a basic question: does the person receiving the incentive find it valuable and worth winning.  I once had a worker describe safety incentive as “they buy us a pizza once a month if we don’t kill anyone”.  The worker went on to explain how condescending he found the incentive program.  Clearly the organization was not attuned to the needs of the worker.

Another thing organizations need to consider when analyzing their incentive programs in the context of Maslow is the concept of security.  Workplaces where workers believe their jobs are in jeopardy are far more dangerous than more stable environment.  Workers who believe they are eminent danger of unemployment are incapable of responding to higher level stimuli.  In other words, safety BINGO will not provide incentive to work safe to workers more worried about keeping their jobs; injury rates will likely fall, not because workers don’t want to miss out on the chance of winning a baseball cap, but because injured workers fear that they will be the first to be laid off.  It is true that in some environment injury fraud increases in the face of layoffs, but it is equally true that genuine injury claims are more likely to be concealed for fear of retribution.

So in very real terms, safety is not just about an absence of injuries, or even, as I have so often thundered, a presence of risk.  Safety is more than either of these.  Safety is about feeling safe and working in a place with so little risk of injury that your subconscious doesn’t trigger stress reflexes.

Filed under: Loss Prevention, Loss Prevention, Near Miss Reporting, Phil La Duke, Safety, Safety Culture, Worker Safety, , , , , , , , , , , , , , ,

Reluctance To Report Near Misses May Not Be Caused By Fear


Conventional wisdom tends to hold that people won’t report near misses because they are fearful of the repercussions of admitting that they screwed up in some way. I’ve been chewing on this for a while now and have concluded that this belief is, for the most part, wrong.  But before we get into that, I should define my terms a bit.  A near miss is any activity that almost resulted in an injury but didn’t.

Near misses provide us with an invaluable opportunity to learn about system failures and correct the root causes before a catastrophic incident happens (someone is killed or seriously injured or there is substantial property damage.)  But people are reticent to report these mishaps and safety professionals and organizations struggle to convince people to document near misses.  Why? Many, if not most safety professional land on “people are afraid they will get in trouble”, and I don’t doubt that is sometimes the case, but in recent weeks I have been working with a new organization and, as such, the pressure to conform to the new culture, while self imposed, is formidable. Three times in the past two weeks I have been involved with near misses and I did not report them.  Why? Was I afraid? I was afraid of negative job repercussions, in fact, in each case I did nothing wrong. In the first case I was trying to turn off a light in a cubicle and as I felt along the front of the light in an effort to locate the light switch I instead crammed my palm into the clear plastic light cover; it hurt, but it didn’t injure me.  Had I been hurrying or had the plastic been jagged or…a host of other conditions I could have been injured.  From a safety stand point I could have been cut, burned or even received an electrical shock.  Clearly this is a system flaw—I was not behaving unsafely or working out of process and yet the way cubes are lit is a poor design that encourages people to feel around for a switch instead of having the switch in plain view.  At a minimum this condition is likely to eventually damage the plastic covering which presumably has some purpose and function.

The second near miss was a slip on the snow walking down concrete steps into a traffic area.  I slipped but managed to grab the hand rail and while I was off balance I didn’t fall.  So another near miss.  I did a quick analysis and again, I as the worker was in no way negligent.  I wasn’t walking too fast, I was wearing appropriate footwear, and I was walking in an area intended for pedestrians.  The steps were sloped down and forward and being concrete and smooth the slightest moisture (never mind ice and snow) can easily cause a loss of traction.  To further complicate things, there is no pedestrian crossing marked, no stop sign, and now speed bumps.  There are also no sidewalks from this parking lot to the entrance forcing people to walk on the snow covered grass or in traffic. Not only is an injury probable but if an injury does occur the impact promises to be severe or even fatal.

The third near miss involved me catching the heal of my shoe on a step and falling forward.  In this case I was also able to catch myself using the rail and felt only mild discomfort in my knee and ankle.  Things most certainly could have been much worse but I was lucky.  In this case, as with the others, I was not distracted, I was following procedures, and I was not behaving unsafely.

As I’ve said, I didn’t report any of these near misses and I’ve spent significant reflection on why I didn’t report them.  Here’s what I learned:

  1. After the first incident I asked a colleague if the organization had a near miss reporting process.  She asked me what that was.  Clearly our safety jargon was getting in the way so i asked here differently, “how do we report injuries?”  She explained that there was a system but she didn’t know what it was and that I should ask the department head.  So reason number 1: Reporting an Near Miss is Hard.
  2. Sometime later I found the head of the department and I asked about near miss reporting and got the same general response: I don’t know.  When she asked me why I was inquiring, not in an accusatory tone, but in more of a concerned, “Did you want to report something?” sort of way, I found myself dismissing the near miss as too trivial to report (when was the last time somebody died looking for a light switch?) Reason number 2: Because there wasn’t any serious consequence resulting from the near miss it wasn’t worth reporting.
  3. After my near slip on the ice I noticed a group of people talking about the fact that the lack of side walks meant that they had to walk into traffic and that the few sidewalks that did exist were slick with ice. I shared my experience with the icy steps and one person responded, if you call facilities they tell you that you have to fill out a work order and even when you do they don’t do anything.  Reason number 3: Because people believe that even serious safety concerns are ignored so what is the point in reporting near misses? The organization does not value the information.
  4. By the time I caught my heal on the step and almost fell I was fully indoctrinated into a culture that did not report near misses, but I desperately wanted to avoid being one of those employees that ignored the problem.  I mentally resolved to find the process and report these near misses.  Then I mentally walked myself through the scenario of me reporting these three near misses and decided that I would look like a) an accident prone klutz, b) I would be seen as chicken little and c) nothing would be done with the information anyway.  Reason 4: The risk to reward ratio is stacked against me; I risk being seen as a fool and there is no reward for doing so. I thought I would be seen as ridiculous reporting something so trivial and I wanted to make a good first impression.

For the record, this organization has an amazingly nurturing and employee-centric culture.  Employees are developed and encouraged and training is a key priority.  And yet I was clearly and quickly “told” that near miss reporting was not a priority, not valued, and not concerned with my safety, despite none of these things being true.

So what did I take away? Several things:

  1. People feel foolish when they do something that results in a near miss even if they did nothing wrong, and people who feel foolish are unlikely to advertise it.
  2. People will only report near misses if it is easy to do so and ideally if doing so is anonymous.
  3. If you solicit people to report hazards or near misses you had ought to be ready to respond quickly and effectively to the hazard.
  4. Even a veteran safety professional is not immune to organizational and peer pressure.
  5. If you insist on safety incentives, a good use for them is to provide incentive for near miss reporting.
  6. The fear of being made to look like a whiner or a wimp is greater than the desire to improve the safety of the workplace.
  7. If you want people to report things you have to have a system that is easy, accessible, and valued by the organization.  Advertising the process is key.
  8. You absolutely must have a blame-free reporting process.  If I was reluctant to report something that happened for which I was in no way responsible, how much more reluctant will I be for an incident where my behavior played a role in causing the incident?
  9. My guess is that near miss reporting will most likely only happen in cases where it is virtually impossible not to report it.  This needs to change but unless near miss reporting is given the same priority as reporting a serious injury we are doomed to a world of ignorance.
  10. We get what we measure.  Nobody seemed all that interested in collecting my information so i was certainly not going to push it and risk a negative outcome.

Sadly, while we as safety professionals preach a good fight when it comes to near miss reporting we don’t do a good job in executing because many of us start with the assumption that people won’t report them because they are afraid.  Until we move beyond that mindset our organizations will be at significant risk and we will continue to significantly underestimate our risk of serious injuries and fatalities.

Filed under: Behavior Based Safety, Near Miss Reporting, Phil La Duke, Safety, Safety Culture, , , , , , , , , , , , , , , ,

Blogroll

broadcasts/podcasts

Guest blogs

La Duke in the News

Presentations

Press Release

Professional Organizations

Publications

Safety Professional's Resource Room

Social Networking

sustainability

Web Resource

Follow

Get every new post delivered to your Inbox.

Join 442 other followers

%d bloggers like this: