By Phil La Duke
One glance at that title and it would seem I am back in my full arrogant splendor, but I hope you will reserve judgment until you’ve read my explanation. After last week’s post, in addition to the outpouring of sympathy and support, I received a personal, private email. As you may know, it is not my practice to publish or make public things sent to me confidence, so I won’t go into detail about the letter except to say that the author asked the question “WWPD (What Would Phil Do)” The author explained that in many cases throughout the course of doing business he we would ask himself WWPD? He further elucidated that as much as he respected me it was often difficult to arrive at any meaningful answer to the “WWPD?” question. First of all, it is humbling to think that anyone would find my work useful enough to ask that question even once, but the thought that that someone might use it as a means of guiding one’s decisions relative to safety just floored me. At a time when I was considering hanging it up (not just writing, but safety as a profession) and openly questioning whether or not I made any difference at all this was something I genuinely needed to hear.
I have mentioned before my method for improving safety. It has worked consistently for companies large and small and across diverse industries, but I think sometimes I get so caught up in pointing out the misguided efforts so prevalent in our industry that the “WWPD?” gets lost in the cluttered landscape of “WWP Not D?” and so I thought I would once again share what I believe as it pertains to safety improvement.
Let me begin by saying “safety” is an outcome, or more specifically, and “output”. Every process is composed of three kinds of things: inputs (things you start with) transformations (things that happen to them in the course of your process) and outputs (the things you are left with). Whether your process is as simple as tying your shoe or as complex as smelting iron, every process has these three elements. When your process produces unwanted outcomes we call these things “waste” and injuries are precisely that, waste.
For hundreds of years our colleagues in safety have talked about having a “safety process” or “managing safety”, but I have come to believe that such activities have little to do with producing the outcome of safety; at least not directly. Because these activities don’t directly influence safety they tend to be costly and produce very little in way of return on investment. We have to manage the actual work processes to reduce the injuries and produce the state of safety.
The goal of managing a process is to return a consistent, predictable, and desired result. Managing processes involve controlling variability (and unpredictability) in five areas: manpower, machines, materials, methods, and environment.
Manpower (sorry ladies this is an old term and I am not going to make it gender-neutral) refers to anything related to people. Ideally we start our process with an uninjured worker that is fit to work. As the process is completed the worker may be transformed (albeit probably not radically) by becoming hot, tired, sweaty, dirty, sore, etc. The change in the worker is not a desired outcome so it is waste.
Machines can be a simple machine (a screw, incline plane, wheel and axel, lever, pulley or wedge) or complex automated systems. When tools and equipment are worn out or damaged during the process they cannot produce a predictable result.
Materials refer both to the types of materials used and how they are delivered to the workstation.
Methods are the “recipe” that the process follows to complete a job. Policies and procedures (including Job Safety Analysis, Standard Work, etc.) are the methods by which we hope to get a predictable and desired result.
The physical working conditions of the workplace constitute the environment that we must manage to ensure a predictable outcome. Environment can include factors like heat, lighting, and humidity, the presence of exposure risks or biohazards, and similar physical conditions that workers work in and around.
There has been much debate as to whether behaviors are the primary cause of injuries; that’s not really something we had ought not debate. Injuries are most certainly caused by behaviors but so what? We can’t really influence (to any meaningful extent) the behavior of an entire population and pretending that we can has cost inestimable misery in the form of worker injuries and fatalities. But the 5Ms (hey, there’s an M in environment, I never said they STARTED with the letter M) are things that can be managed, and MUST be managed by Operations. It was out of that realization that I created my safety infrastructure framework. Safety can only be achieved by managing the 5Ms, with particular emphasis on:
- Workers must be skilled in their core tasks and the closer they are to having mastery level skills of how to do their tasks the more likely they are to produce and predictable and safe outcome. Recently I was challenged by someone on this. “So what? Don’t you just need people to be competent to perform their tasks? What does mastery level mean?” Competence, like many things in industry is less a binary component and more a continuum. Much of our means of measuring competence, particularly in Union environments is binary, i.e. “Is the worker able to do the job or not?” We tend to measure whether someone has awareness-level, or a working knowledge of how to do their job instead of mastery. It’s about variation of skill. Someone who can do a job, but only marginally, tends to perform the job with far much more variation than someone who has mastered the job; i.e. someone who can complete a task with very little variation. Most training in core skills trains to the lowest common denominator and once a person has been qualified there is very little effort to assess that person’s skills after the fact. Most companies don’t do a very good job of measuring competency, in fact, few even try. For example, an industrial vehicle driver may receive refresher training, but unless he or she has repeated violations or been involved in multiple incidents little thought is given to whether or not he or she is competent. Furthermore, most companies don’t measure the effectiveness of training beyond a level 2 evaluation (pre- and posttesting, and many are loathe to even do this) which is often more a test of reading comprehension than of actual learning; this is an issue because competency often degrades over time and there is no way of telling whether or not a worker has sank below the competency threshold. Then there is the related issue of physical competency; how are people evaluated on whether or not they are still physically capable of doing the work without injuring themselves or others? Most organizations address this through annual reviews which are almost entirely focused on performance and attitude than on skills degradation or physical competency. The only cases I know where the fitness to work is even considered are in return to work programs.
- Process Capability & Discipline. There are two elements of “process” that are key to safety: 1) process capability (how able is your process to return a predictable and repeatable result) and 2) process discipline (how strictly do workers adhere to the process). Companies can really only protect workers when workers do their jobs according to a predictable and robust process. Again I was challenged on this. I was told that this was “clearly not real life—and frankly untrue that a predictable and robust process is the ONLY way to protect workers; there will always be nonstandard situations that need to be managed.” On the face of things this sounds like a fair criticism, but you must consider that while there will always be non-standard situations that need to be managed (in fact, while many companies are loathe to admit it, there are far more nonstandard situations than there should be), but they must be managed using a robust process for managing nonstandard work. We can’t protect workers from things we can’t predict and a process that is out of control makes it impossible to predict what might happen.. One of the keys to managing worker safety lies in having processes and procedures and the discipline for workers to work within these processes. The point of this statement is that companies that don’t care about process variation are far less able to protect workers than companies that work to continuously improve, and thus make more predictable and safe, their processes. We design work and the workplace to be as safe as we possibly can; we employ the Hierarchy of Controls to organize the means of protecting workers but we do so under the assumption that the process is robust and that people aren’t working out of process. This should not be interpreted as saying that we don’t have a responsibility to protect workers in all cases, rather it is meant to underscore the importance of a good process that people follow. When people are unable to follow the process they should not be encouraged to improvise, rather they should be rewarded for stopping work until a safe way of proceeding can be determined.
- Hazard Incident & Management. Hazard reduction directly correlates to injury reduction. It sounds obvious right? Very obvious – yes? Yes very obvious, and yet one of the single most ignored elements of many safety management systems. Identifying, containing, correcting, and communicating hazards is central to safety; it’s obvious. The problem is that too many organizations treat all hazards equally and as carrying the same potential risk of injury. The risk of working on live equipment without the isolation of energy isn’t as risky as a blocked escape route (all other things being equal). Many organizations are blind to hazards. Without a simple means of managing hazards people become “normal blind” and things that would once have scared them silly now become part of the acceptable, normal landscape and are not only ignored but treated in such a cavalier fashion because “it aint killed nobody yet” that the risk is actually amplified. I don’t see a big distinction between risks and hazards. Clearly we direct need to focus more about controlling risks than on chasing injuries. Risk control is hazard management and vice versa and must be foremost in all safety management approaches, companies have to know the difference between being lucky and being good and to understand that difference one has to understand one’s risk.
- Accountability Systems. In Just Culture there are three basic behaviors for which people are held to various levels of accountability: human error, risk taking, and recklessness. Human error is the unwanted and unplanned outcome from an unintended action-the honest mistake. Since human error is unintentional there is no point in holding someone accountable for something they can’t control. (I have seen research in healthcare and aviation that puts the number of mistakes the average person makes at 5 an hour). That having been said, there are certain things that individuals CAN control that for which we can and should hold them accountable. These things are conditions that have been demonstrated to inhibit performance and increase the likelihood, frequency, and severity of mistakes. Factors like fatigue, reporting to work ill, stress, drug or alcohol abuse, hang overs, prescription drug use—general fitness to work issues. Obviously, supervision plays a role in whether or not people are allowed to work while impaired by these conditions but in any case these conditions must be confronted and addressed. These performance inhibitors also can influence risk taking. Risk taking in itself is not unwanted. Organizations need people to take risks routinely, but these risks should be informed risks and workers should be coached on the limits to which they are empowered to take risks. When workers take risks because they are improvising they are more at risk for being harmed. As for the reckless, they should be weeded out of the workforce for their safety and the safety of others.
- Employee Engagement. Workers must be intrinsically driven to make the workplace safer. To do this, workers must be capable of making sound business decisions not relative to safety alone. I think you misinterpret what we mean by making sound business decisions. This isn’t about business acumen as much as workers understanding how what they do impacts, not only their own safety, but the overall success of the organization. Studies have shown that the more highly engaged the worker the more safely the worker is likely to work. And it is tough to build engagement without building knowledge of the business. This knowledge enables workers to make informed suggestions for process improvement and to be a more productive and useful contributor. This takes safety away from being a functional exercise and creates a more holistic approach to safety.
So after all that, What Would Phil Do? This:
- Invest in competency. This means putting some work into creating better job descriptions, recruiting people who have the grey matter and muscle to do those jobs, and training them to mastery level skill. Once someone has been hired, implement a system to ensure that their skills or physical abilities have degraded to the point that they can no longer safely do the job.
- Collaborate With The Continuous Improvement Groups. Not only are improved processes more effective and safe, collaborating with those who are working to make process improvements also make it easy for Operations to see the value of safety.
- Demand that Leaders Enforce Requirements for Working In Process. Okay, now sometimes we CAN’T work in process, for example when a manufacture is out of a given part and has to work without it. But in these cases, Safety should help operations to assess the risks of working out of process and help to find ways to mitigate those risks.
- Train Leaders. Front-line supervision is the greatest resource in producing safe outcomes but from everything from core process training to training in Hazard Recognition to coaching workers on their performance this group goes largely ignored and are some of the most incompetent people out there. They are often selected because they shut up and do their jobs but with no regard to whether they have the skills and experience to effectively supervise others.
- Shift Focus Away From Injuries Toward Risk. We spend so much time arguing about whether zero injuries is possible, or whether behavior causes injury or whatever. We should make it real simple and look for ways to reduce risk in our lives every day. In the workplace, during the commute, at home with our families. We can do something about risk BEFORE we get killed or injured which, after all, is the point.
- Implement A Just Culture System. Just Culture allows people to talk about risk and dumb decisions in a repercussion-less environment. Until we stop trying to punish people for their mistakes and dumb decisions we can’t really focus on reducing risk.
- Treat People Like Partners In Safety Not As Our Responsibility. People aren’t quite as stupid, lazy, crazy, careless, or indifferent to their safety as we often treat them. When we learn to respect the people with whom we work and stop treating them like our mentally handicapped children we can partner with them to make the workplace safe.
So…that’s what Phil would do.