Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

Note to My Readers


By Phil LaDuke

Thank you all who expressed concern about my absence the last week. I am okay. I had a post I wasn’t completely satisfied and had intended to edit it and post it last Monday. I was travelling and working so the prospect was a bit on the wearying side. And then my daughter called me to tell me that, owing to a 500 year storm in my native Detroit, I had 18 inches of water in my finished (now in more ways than one) basement. The damage was extensive (upwards of $5000-$10,000) and left me with foul-smelling soggy remains of what were once my possessions. I spent the bulk of the weekend doing back-breaking work hauling stuff out of my basement.

I was blessed. After all, no matter what sentimental attachment I may have had to all of these things it was all just stuff. I was spared raw sewage back up and injury. As disheartening as it was, I was one of the lucky ones. As for the post, well I never did get happy with it and so maybe at some point it will see the light of day and maybe not.

Filed under: Safety

Update On This Week’s Post


Sorry folks my hastily produced blog article needs a good edit and I am too tired to do it tonight. Expect it tomorrow (Monday) instead.

Filed under: Safety

Let’s Not Mistake “Legal” With “Smart Business Practice”


Donner pass

By Phil La Duke 

I work in organizational development focused on worker safety and I have been employed as such for the better part of 20 years. I am essentially a safety strategy consultant, an architect, if you will, of safety infrastructures that help companies to build on the services I provide them and sustain gains in safety in a changing business environment. I say this because so many of you assume that I am primarily a safety blogger, theorist, or journalist; in short that I don’t have the standing to speak about much of anything. I realize a couple of sentences won’t sway the most ardent safety blowhards who believe that the only valid insights are theirs alone but every once and awhile I need to say it. It keeps me what passes for sane.

In this role of an architect for safety management systems custom-designed and built to fit the unique needs of a business sector, geographic location, and even site I am more frequently asked one question above all others, “What does the law say?” I am not a lawyer and frankly I don’t much care what the law says, when it comes to safety. That’s not to say I can’t recite chapter and verse this regulation or that; I can’t, but that’s not what I’m saying (I solicit the advice of one of my 5,000 plus colleagues at ERM who most often know the answer, or one of my 3,000 plus business contacts, or some other expert). I don’t care what the law says because I know what the business requires and often doing the bare minimum to achieve compliance does scare little in the way of smart business. Of course I care that my clients are at a minimum compliant, but let’s face it, compliance isn’t enough to smartly manage safety.

Three weeks ago I drove from San Francisco to Reno through the Donner Pass (the site where the Donner Party were stranded one winter and resorted to cannibalism. I really wanted to stop and get something to eat there but alas couldn’t find a suitable cannibalism-themed eatery.) The speed limit was 70 mph meaning that vehicles have a legal right to traverse the treacherous incline at a pretty high rate of speed. Legal? Yes; smart? No, at least for me (a man who doesn’t drive that well and who is unfamiliar with the route). The next day I was driving the congested expressways in San Francisco and Sacramento, California. In California it is legal for motorcyclists to zip between the lanes in traffic (usually at a high rate of speed) dangerously close to vehicles as they creep along. I personally witnessed several instances where cyclists engaged in such activity narrowly and miraculously avoided injury. They exercised there legal rights, but at least from where I sat, extremely poor judgment.

In my home state of Michigan, the last couple of years have seen decades of safety legislation systematically dismantled. We now allow fireworks in the hands of drooling idiots and motorcyclists are no longer required to wear helmets, legal? Yes. Smart? Absolutely not. I won’t argue the merits of the safety of wearing a helmet while traveling 120 miles an hour with a rocket on your crotch or one’s God-given right to blow off your finger with a M80, but I do think the point worth making is that just because something is legal doesn’t make it the right thing to do, morally ethical, or a smart thing to do, but many companies manage safety as if these things are synonymous.

I have met a fair amount of safety practitioners (someone about two months ago challenged me to stop calling them “safety professionals”) who will defend the practice of managing to compliance. Their reasoning tends to hinge on the fact that if it’s good enough for the Feds than it should be good enough for me; well it’s not. There are plenty of organizations that operate under substantial risk and yet to compliance programs like VPP as proof of having climbed the safety mountain. It’s a bit like the degenerate gambler who has a “system” for beating the casino. He will point to a pile of winnings as proof that his system can’t lose; until it does.

Compliance is important; but for me the lack of compliance is a merely a symptom of a larger problem, an inability to appropriately manage operations. Aspiring to comply is to aspire to mediocrity it’s akin to shooting for a D instead of an A, and while we may not all want to be world-class in safety, I’d like to think that very few of us want to do just barely enough to squeak by.

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Out of Focus: Is the Safety Function Focusing On the Wrong Things?


Out of Focus

By Phil La Duke

Since the advent of the Safety function, it’s been borrowing tools from other disciplines and building practices based on data gleaned from the earliest research in industrial psychology. For some, these most basic practices and methods are cherished and to suggest that any change to these is tantamount to heresy. For others, change may be possible, as long as we acknowledge that these practices are the cornerstone of the safety function and that they are necessary to some degree. While it’s true that in broad strokes we probably should retain some of our practices the philosophy that drives everything we do must change at a fundamental level.

The focus of safety for 100 years has been a centered around obsessions: obsession with eliminating injuries, changing worker behaviors, and identifying root causes of injuries. Simply put, this focus is wrong.

Obsessed With Preventing Injuries

Focusing on eliminating injuries is reactionary and treats symptoms. If we believe that our purpose as safety practitioners is to eliminate injuries we will find ourselves forever playing catch up, and what’s more, even if we achieve zero injuries most of us won’t really know whether this result is the product of hard work and sound safety practices or dumb luck.

Instead of focusing on injury reduction (an outcome) we need to focus on risk mitigation and severity reduction. In a discussion forum, someone asked the question “what is the behavior ‘safety’?” It’s a ridiculous question because safety isn’t a behavior; one does not “do” safety. Safety is an outcome and absolute safety, i.e. the absolute absence of risk of harm, is unachievable. Pursuing an unachievable goal is absolutely insane; you will merely frustrate your organization. But reducing the risk of harm to the lowest practicable level is achievable. We can, at least in many (perhaps most) workplaces lower the probability and severity of injuries below the threshold where injuries are no longer common and crippling but rare and minor. Our outcome (reduction of injuries) is the same but our strategies and tactics are focused not on the outcome but the causes (workplace risk factors).

Obsessed With Behaviors

Another object of fanatic obsession is “behaviors”; somewhere along the way, safety practitioners seized on the idea that the key to worker safety lie in modifying worker behaviors. Change the way the worker behaves, conventional thinking holds, and you can create a safe workplace. To be sure there are plenty of workers doing stupid things that get them hurt, but the obsession with behaviors assumes that worker behavior is a) a conscious and deliberate choice, b) something that can be changed through basic behavioral modification, and c) intrinsically safe or unsafe. We know that most behavior is not conscious, and is in fact subconscious habit, unintended behavioral drift, contextual, and difficult to change even when the individual desperately wants to behave differently. Additionally, far too many behavior-focused initiatives depend solely on psychology and ignore behavioral sciences that focus on behavior of populations (sociology, anthropology, et al) so focusing on individual behavior will force us to draw specious conclusions that feel right but that ultimately lead us far afield. Instead of focusing on behaviors we should be focusing on decision-making and problem solving. Instead of trying to change behaviors we should be focusing on building decision-making and problem-solving skills. If workers are able to make better decisions (which drive safer behaviors) and solve problems more accurately (instead of improvising when a problem prevents them from doing the job as designed) we are again able to reduce workplace risk and in turn reduce worker injuries.

Obsessed With Finding  Root Causes

The third obsession of safety professionals is finding the root cause of injuries and near misses. This focus on finding a single “root” cause is also problematic. Few injuries are caused by a single “root” cause, and are instead caused by multiple, inter-related causes and effects that grew gradually over time. In basic problem solving methodology, the first step in solving a problem is to categorize it as either broad, specific, decision or planning. Most injuries are caused by broad problems while most quality defects are caused by specific problems. I can’t think of an injury that is caused by a planning or decision problem (that doesn’t mean they don’t exist, but I am prepared to say they are exceedingly rare.) Once a problem is categorized the next step is to identify its structure; is it gradual, sudden, start-up, recurring, or positive? In safety, we tend to see injuries as being caused by specific conditions with a sudden structure. In some cases this is true, typically in mass production environments and where the worker is engaged in standard work. But in far more cases, injuries are caused by a broad problem with a gradual structure. In these cases, the situation continues to worsen until a threshold is reached and some catalyst is present that sets off a chain reaction. People tend to look at these types of injuries as “freak accidents” that could never have been predicted and they are right to some degree, because one cannot predict or prevent these incidents when one is using the wrong tools. Traditional root cause analysis focuses on identifying the one cause of an injury and tends to minimize contributing factors. This singular approach tends to cause a problem with a recurring structure to manifest. The reason for this is simple: by removing only one of the multiple, inter-related factors that contributed to the injury one raises the threshold at which an injury will occur. The problem seems to disappear but is actually lurking just below the surface. To use a medical analogy it masks the symptoms instead of curing the disease. Sooner or later the situation will again reach the threshold and cause another, perhaps more serious injury or fatality. We see this often in today’s workplace where organizations celebrate the achievement of zero-incidents, or extremely low incident rates only to later have a fatality (or multiple fatalities) catch them completely unaware. (Incidentally, if the organization would have approached the zero-injury, or acceptably low injury rate as a problem with a positive structure, and tried to understand the factors that caused this positive outcome, it could replicate the things that work in other locations and eliminate the things that its doing in the name of safety that are costing money but having no appreciable effect on safety.) This obsession with finding the root cause, before truly analyzing the situation and context of an injury seriously impedes our ability to create a workplace that has significantly less risk.

There is no denying that safety in the workplace has come a long way over the last 100 years, but I contend that much of that has to do with the Hawthorn Effect and picking low-hanging fruit. If we are to take worker safety to the next level, we have to rethink our focus and start focusing on the things that will have the greatest impact on worker safety.

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Okay, I’ll hang with it


By Phil La Duke

Immense thanks to all of you who have publically and privately offered your encouragement and support for my work. Readers from all over the world have written assuring me that my work is valuable, important, and useful. So with that in mind, I will continue posting and I will continue doing so in my signature brash, antagonistic, and provocative style.

My detractors have been strangely silent on the topic, but let me take a moment to address them. It seems that more than a few persons of note read my blog and cluck tongues because I’m not polite. First of all, etiquette differs from culture to culture and one man’s rudeness is another’s unvarnished truth.  The truth is sometimes ugly, mean, and disconcerting but as unpleasant as it can sometimes be, the unsweetened truth is essential not only to safety but to sustainability.  Sometimes we have to decry the emperor as naked, and tell people their baby’s ugly (figuratively speaking).

Having a polite conversation about safety (or the lack there of) is like having a polite conversation about Nazis in 1936 Munich; as long as simpletons persist in advocating for practices that take companies’ money and return no discernible value I will call them out. Could I do so in a softer, gentler way? Of course, but what good does that do. Social networking and political correctness has created an environment where absolute facts are put to a vote and if enough people don’t like the truth its simply voted down.  We live in a world where Wikipediots can post deranged harrangings and it is given the same credence of those who have researched topics carefully and methodically.  Peer-reviewed articles are given the same weight and credibility as self-published rantings of paranoid numbskulls. If I tell someone his or her opinion, methodology, or actions are idiotic it’s because I have researched the topic and believe them to be so.  Is it nice? Maybe not.  But it does create a visceral response in them that causes them to reexamine their position in a new light and try (usually in vain) to defend it. Often I goad people into revealing their true selves and let the virtual jury of their peers decide for themselves.  We aren’t selling candy, we are working to make the workplace safer and more efficient.  We save lives, reduce human suffering, and create more sustainable and pleasant places to work.  We can’t afford to mince words and wring our hands because someone might not like what we have to say.

If a company is lead astray by some slick talking snake oil salesman and spends money and effort on a schlocky non-solution when they could use those resources on reducing risk I will always speak my mind. So to all you detractors, especially to those of you who would stab me in the back: bring it on. I will make a living just fine.

Anyone who avoids speaking there mind about such an important issue because they worry that they may offend a potential customer is beyond cowardly.  Besides, what value does one provide a customer by telling them only what they want to hear? And this applies not just to me, or other safety bloggers, but to safety vendors and most especially to the safety professionals who work within an organization.  I get it, to some extent we worry for a living, but if we only pander to what the senior leadership wants to hear we are worse than cowards, we are cowards who risk the lives of those they are charged with protecting.

Yes men have no business in safety. Not in selling it; not in consulting with companies about it; and not in working in the internal safety function.

I used to say, “if you don’t like what I write, don’t read it” but now I think I was wrong in that.  Instead, if you don’t like what I write, read it and ask yourself what is it that I am saying that is so upsetting or threatening to you? Ponder it.  Rebut me, if you can, but don’t disengage from the debate and don’t tell me to shut up, or to change my style.

One of the greatest compliments paid to me is when a reader comments on a post with the qualification, “I don’t always agree with Phil but…” I hope no one out there agrees with me 100% of the time—I don’t even agree with some of the things I wrote years ago.  A true professional questions his or her most deeply held beliefs and asks if they are still true and relevant, and when they are not, he or she should be mature enough to change his or her position.

I’m not looking for adulation, and I am not looking to boost my readership (I like to think that while my readership may not be as broad as some of the other safety blogs out there my readership is a more enlightened breed, a cut above the rabble; and people who truly enjoy out of the box thinking. I don’t make any money from blogging nor will I. I refuse to accept any payment for my writing because then I would have to start worrying about what you, my readers find palatable, which might compromise my message. So if you find this valuable let it be known. Don’t be afraid to click the “like” button and rate the posts (that elevates the rating on WordPress and increases traffic volume). Write to your group managers on LinkedIn and tell them how you feel about them blocking my posts if they don’t agree with them.  I will fight the good fight, but all it takes for evil to triumph is for good to do nothing. Click the button at the end of the articles to share them—on Facebook, in LinkedIn discussion groups, or to emails to colleagues.  If the debate is important to you, then you have to help promulgate it.  If I promote it I am just a self-promoting windbag who likes to see his name in print, but if you promote it we might actually start to see real positive change in safety (which is desperately needed).  I can’t do it alone.

As long as I can ignore what polite society thinks I can remain the voice crying out in the blogosphere. Perhaps I take myself too seriously and give myself too much credit (I’m convinced such is the case.)

So look for me to continue slogging out posts, doing my best to foment debate on these crucial issues.

Again, thanks to all who supported me through this brief moment of self doubt.

Filed under: Safety

Maybe it’s time to hang this up


I haven’t posted for almost a month and nobody seemed to notice. Maybe it’s time to give this up.

Filed under: Safety

The Line Continues To Blur


blurred

By Phil La Duke

Two weeks ago I wrote suggesting that we in the safety community might want to consider putting aside all the models, and complexity, and theoretical excrement in favor of a simple safety model based on sense.  Not common sense, those of you who insist on believing in “common sense” had better stop reading this and start reading Risk Makes Sense Human Judgement  by Dr. Robert Long (No, I don’t have a financial interest in the book; I just happen to think it’s a great work and an important addition to any safety practitioner’s toolbox) but sense, good judgment, simple things that yield powerful results.

This column drew a fair share of criticism and praise, as many of my articles do.  I have a lot of people preference there comments with “I don’t always agree with Phil La Duke, but…” that’s good.  If you find yourself agreeing with me—or anyone for that matter—you need to stop and ask yourself why you are agreeing so much and if you are truly questioning your beliefs; after all, if you never question what you believe you are a candidate for fanaticism, and what the world doesn’t need is another fanatic.

I appreciate comments; it takes a lot of courage to put yourself out there, particularly when, if you’ve read any of my responses, you know you face a good chance that I will be pretty snotty with my response.  It’s telling that more people subscribe to the comments to my post than those who subscribe to the blog itself. Some take prurient interest in watching the comments and hoping that some hapless dim bulb will wander and post something that will put him in the buzz saw of my response; I won’t fault them for enjoying the responses, but you have to admit it’s a bit like being a fan of rat baiting (look it up).  There are others who read both my blog and comments with the sole intent of becoming uptight and offending, waiting in judgment for me to step over some imaginary line. Oh well, I can’t start censoring myself because some uptight goofball get’s worried that I might write something upsetting.  I digress.

One comment stood out.  One reader said, putting aside all the context of the article, “given that 8 out of 10 accidents happen in the home, why aren’t we doing more to improve safety at home?”  It’s definitely the kind of comment that would typically draw a venomous response.  WE AREN’T PAID TO KEEP PEOPLE SAFE AT HOME.  My first inclination was to fire off a “listen up half-wit” missive but then I got thinking.  Where exactly is the line between an injury at home and an injury at work? Ostensibly it is a pretty easy question.  You get hurt at work (even if you aren’t “on the clock”) and it’s a work injury, if you get hurt anywhere else; it’s not. I won’t go into the complexities here, I realize I have over simplified things and that the “it depends…” arguments are boiling up.  I don’t care about those arguments for this discussion.  What struck me was what about lifestyle contributors, leisure time activities that aggravate an injury, or pre-existing conditions that effectively make a worker either unfit for duty or more likely “marginally fit” for duty? What about “the straw that breaks the camel’s back” injuries? Should the employer be responsible for those injuries or should they be absolved?  How much does the employer or workplace have to contribute to an injury before it is held culpable?

Obesity

Take the case of Earl (names have been changed to abet the guilty) who lived most of his life morbidly obese. When Earl’s knee gave out in a work injury the doctors told him that he would have to lose a substantial amount of weight or he could not return to work.  His injury was ruled a work injury and he was placed on full and permanent disability.  Is it reasonable to believe that decades of strain placed on his knees weakened his joint and contributed to the injury? Might a thinner worker have been spared the injury? Maybe or maybe not, but isn’t it worth debating?

Sports Injuries

Mary Anne plays softball three nights a week in the spring and fall.  She is a good player and competitive. She has come home with a sore shoulder more times than she can remember but has never had a serious injury.  One day she tears her rotator cuff on the job, might we suspect that it happened playing sports and is either being fraudulently reported or perhaps happened some time ago and was not properly diagnosed? Should the employer be responsible for being the cause of her shoulder finally giving out?

Chat Finger

Billy is constantly on his phone chatting, texting, and posting to a social network, and when he isn’t texting he is logging marathon gaming sessions on his state of the art gaming system.  He also has a job that requires repetitive motion.  Invariably Billy contracts carpel tunnel is it because of the job or is it because of his lifestyle?

Diabetes

Millions of people needlessly contract diabetes, which in turn slows healing and worsens many injuries.  Should an employer bear the entire burden? Isn’t the worker at least somewhat culpable for not maintaining a fitness for work?

The debate get’s complicated and ugly.  While it’s true that employees come into work and claim that they injured their backs on the job when they hurt them roofing on the weekend, but maybe the cumulative damage their backs suffered contributed to the injury they suffered while at home.

The hard fact of the matter is that a large amount of injuries are cumulative stress/trauma injuries, and these injuries might never had happened had the employer taken reasonable care to protect the worker. It may sound like I am a bleeding heart, but when it comes to worker injuries the law tends to view it as in for a penny in for a pound. The line is blurred to the point where now, any injury where the work performed can be demonstrated to have contributed to the injury the injury is owned by the employer.  I won’t argue the fairness of this situation, and I hope the debate doesn’t center on it.  Let’s assume we decided that case management should fight any claim where the worker’s lifestyle substantially contributed to the injury; this would choke are legal system with lawsuits, waste valuable resources, and generally establish a cottage industry of professionals who seek to assign blame.

The best defense against lifestyle injuries is to reduce or eliminate ergonomic issues, remove workplace hazards, and work toward the lowest possible risk.

 

Filed under: Safety

Let’s Try “Sense Based Safety”


SENSE

By Phil La Duke

I belong to 50 LinkedIn groups and I am active in each of them. They range from groups catering to trainers and industrial designers to those focusing on specific industries in which I work.  The vast majority of those groups have one thing or another to do with worker safety.  Each day my in box is blown up by multiple emails from LinkedIn.  Some update me that one of my contacts has a new job or work anniversary while others announced the topic d’jour in one or more (mostly more) discussion threads, and increasingly the topic is centered around (fill-in-the-blank) based safety.  Since a cadre of companies made millions shilling Behavior-Based Safety and since the shine is off BBS, at least in some circles, saints and snake-oil salesmen alike are clamoring to create the next big thing. I’ve seen proponents of  Culture-Based Safety, Process-Based Safety (not to be confused with Process Safety) Values-Based Safety, Ethics Based Safety, Respect Based Safety, Change Based Safety, and more; it’s exhausting, and what’s more, it might be dangerous.

I like to think that I try not to get in the way of someone trying to make a buck, but when it comes to safety selling a system that you just “thunk up” without research or at very least having successfully implemented it somewhere else puts people at risk.  I warn you, dear reader, that I am in a cranky mood, even for me, and my patience is just about shot.  I’ve spent the better part of the last two months travelling relentlessly doing, what may come as a shock to many of you, actual work in the field of safety. It gives me a lot of hotel time where I can read about the latest fad masquerading as safety science in the threads.

Why can’t we just agree on a “sense-based” approach to safety? Do we need a complex model to lower our risk and make the work place safer? (Apart for lining the pockets of safety consultants who attach themselves tick-like on the soft, white underbelly of commerce) why do we have to reinvent the wheel every 6 months?

I’m not talking about leaving the safety of the worker in the hands of “common sense”.  I’ve written reams about how there is no such thing as common sense and the more of the dribble I read in the discussion forums makes me believe not only isn’t there common sense, there isn’t all that much uncommon sense either.

We don’t agree on basic terminology of our trade for crying out loud, words like “safety”, “hazard”,  “injury”, “incident” all seem to be subject to a public debate; it wearies the soul.

So what is so horribly wrong with approaching safety in a way that makes sense based on, it least in my arrogant opinion would be some universal truths about safety:

  1. No one wants to get hurt. So much of what we do in safety wrongly presupposes that people are getting hurt because on some level they want to blow their backs out, loose those pesky digits, or get some really cool scars. The reality is that few injuries are the result of deliberate actions by individuals fully mindful of the risks and consequences they face because of their actions.
  2. Your processes aren’t supposed to hurt people. I like to explain that safety is about things running smoothly.  When things go haywire bad things happen—products get scrapped, equipment gets damaged, deliveries are delayed, and yes, people get hurt. Rather than trying some new hair-brained scheme focused on redesigning human behavior how about we safety practitioners start working to keep the system running smoothly? Operations could use, and would appreciate, the help.
  3. People Make Mistakes. Sometimes we focus so much on how stupid people are, or how careless they are, or how clumsy they are, that we forget that in general people are no more stupid, careless, or clumsy than we are.  It’s easy to point fingers and say “if they would just do what we told them to do they wouldn’t get hurt” but how many of us have hurt ourselves (or almost hurt ourselves) doing something stupid.
  4. Punishing People For Making Mistakes Drives Errors Underground.  I have worked in safety for over 15 years and I have only seen a handful of organizations that grant immunity for self-reporting.  So if a fork-truck driver gets distracted and slams a post he or she is often forced with the decision to report the incident or to get the heck out of the area as soon as possible and hope nobody saw the incident.  We lose so much important information about weaknesses in our system because we shoot the messenger.  Should we hold people accountable? Yes, absolutely, but instead of disciplining them for making the mistake hold them answerable for identifying the best way for preventing others from making similar mistakes.
  5. Absolute Focus On a Task For a Prolonged Period Is Impossible. Whether it be driving screws on an assembly line or driving the idea that a person can remain intensely focused on a task is absurd, and brain research has found that prolonged focus leads to stress and fatigue.  We need to stop trying to combat this by hanging posters around telling people to behave safely doesn’t do anything except make the simple minded think that they are doing something when they are not.
  6. Incentives for Zero Injuries Lead to Zero Reporting.  Safety incentives aren’t going away, too many people LOVE safety incentives.  Sadly, more often than not paying people not to get injured results in the “blood in the pocket” syndrome where workers put a field dressing on their work injury and seek medical attention from their family physician.  Incentives make the numbers look good, the workers love them, and the company loves them.  Unfortunately, this leads to situations where workers only report the most serious injuries and where unidentified process risks lie lurking until, seemingly out of nowhere, someone is killed.
  7. Competence Is Key.  Worker competence—from the front line contributor to the CEO—is the single best way to ensure worker safety.  A person who has mastery level skills in doing his or her job is far safer than someone who can’t do the basic tasks associated with their job, and yet we still treat the safety and training functions as if they were completely unrelated.  The idea in many companies seems to be that anyone with a pulse can do training and anyone period can do safety.  We need competency at ALL levels or the system is at risk of failing.
  8. The Absence of Injury Does Not Denote The Presence Of Safety.  Safety is a relative term; we have to stop thinking in terms of something being “safe” or “unsafe”.  Safety is the absence of risk and is therefore never possible in an absolute sense.  We need to educate everyone in the company to see safety as risk and to ask, “is there a safer way to do this?”
  9. We Can’t Prevent Everything But We Can Always Mitigate The Risk.  There are two elements to safety: probability and severity.  In many organizations there is too much focus on prevention (i.e. lowering probability to zero) and not enough focus on reducing severity (i.e. installing redundancies that would reduce the extent of an injury to the least serious condition, for example: a bruised knee instead of an amputated leg.) Something has been lost in the argument over whether or not zero injuries is achievable and that something is that lowering the severity of the injuries that DO occur is at least as important as preventing injuries.
  10.  Most Of Us Don’t Have a Clue How to Interpret Indicators.  Lagging indicators, leading indicators, predictive analysis, the safety function is no slouch when it comes to gathering information.  Some of it is misleading (three data points do not a trend make), some of it is pointless when viewed in a vacuum (look how many injuries we had last year) some of it is pointless period (look at the Pareto chart of injuries I made!)  and some of it requires a working knowledge of statistics to draw any meaningful inferences, and yet we continue to festoon the workplace with pretty charts and graphs that make us seem smart, well that is, until someone asks us to explain what it all means and then we don’t seem all that bright.

Last week a lot of people reading this returned home from the American Society of Safety Engineers (ASSE) conference in Orlando with their heads stuffed with new ideas about how to reengineer the safety function.  Some of them may have gotten a legitimately good idea or two.  Many others are preparing to embark on the latest flavor of quackery.  All I am asking is for of you to think twice before getting swept up in the latest safety hustle.  We are after all, stewards of the funds with which the company have entrusted us; try not to waste it on snake oil.

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The Long, And Deadly, Ride Home


“In the U.S. today, June 15th, 2014, is father’s day.  nearly 12 years ago, my father, Arthur LaDuke, lost his battle with mesothelioma.  Rest In Peace Dad.”—Phil La Duke

tracy morgan

By Phil La Duke

Last week Walmart truck driver Kevin Roper struck a limo van carrying Tracy Morgan and other comedians.  Morgan was critically injured and fellow performer James McNair was killed. Roper has been charged with vehicular homicide and similar charges. According to CNN, a Walmart spokesperson has said that Roper did not violate any rules, and allegations have surfaced that Roper had not slept for 24 hours.  In true reactionary hysteria, the cry now goes out for stricter rules on truckers.

Of course the facts aren’t all in yet, and for many, Walmart will make a convenient scapegoat, but to them I say, “he who is without sin throw the first stone.”  Fatigued driving is something that many companies simply don’t want to talk about, particularly in the entertainment business, where long hours are often the routine.  But entertainment companies are far from the only organizations that don’t want to look too closely at how the sausage is made; from logistics companies, to Oil & Gas, to mining, to manufacturing, to sales, too many organizations turn a blind eye on worker fatigue and the role it plays in gruesome injuries and even fatalities.

It’s tough for some to acknowledge the problem when they know they don’t have a good solution; so they ignore it, or they get obstinate about it, challenging critics with “how am I supposed to get the job done?”

I’ve written extensively about the dangers of worker fatigue (both here and in published work) so much so that I see little value in repeating much of it hear, but companies and safety professionals seem to think this problem is just going to go away; it won’t.

Too often we expect employees to work 12-hour (or longer shifts) and pretend that these fatigued workers aren’t at increased risk of injury despite studies that show that a fatigued workers are far more likely to exhibit impaired judgment and are more likely to make errors. In the Tracy Morgan case the driver allegedly hadn’t slept for 24 hours and was probably unfit for duty, even motion sensors and alarms failed to alert him of the impending crash.  I am not one to blame the culture or the system that condones unsafe behavior, but I doubt that Mr. Roper decided to disregard the danger and drive despite his fatigue.  Fatigue, like alcohol, impairs one’s judgment and it is reasonable to expect that a fatigued worker might decide that he or she is okay to drive even when he or she clearly is not.  When a worker is fatigued he or she is not in a position to determine his or her fitness for duty; safety professionals and the company must have clearly articulated policies for avoiding working while fatigued.  Workers should have little discretion in determining whether or not to drive while fatigued.

Professional Drivers Aren’t the Only Ones At Risk

As companies struggle to do more with less, and remain reluctant to hire additional workers, workers tend to work more overtime and/or longer shifts.  Add to this the time a worker has to commute home after a long shift and you have a recipe for disaster.  Fatigued workers slogging through heavy traffic after working a double shift poses a hazard not only to him/herself but to anyone unfortunate enough to cross his or her path.

How Culpable Should The Company Be?

Let’s say a worker has just completed a double shift and has a 1-hour commute. By the time the worker leaves the workplace he has been spent at least 18 hours either working or in transit and then will embark on the long trek home, a drive that now sees the worker potentially as impaired as if he were legally drunk in most jurisdictions.  If the worker is responsible for a traffic accident, what, if any, responsibility does the company bear? From a legal standpoint, the accident doesn’t really involve the company; the employee wasn’t on the clock and was not representing the company in anyway, but what about ethically? Does a company have an ethical responsibility for ensuring that its employees get home safely? Some would say yes while others would argue against it.  What if, instead of fatiguing a worker, a company sponsored a function where they served an employee too much alcohol and then let the worker drive while drunk; would the company be liable? I’m no lawyer (although I do occasionally impersonate one in bars to impress women) but I would guess that the company would be sued and there is a good chance—in my opinion—that they would lose.  What’s the difference between requiring employees to work beyond the point where they are safely able to drive home and allowing them to drive after over-serving them alcohol?

It’s Not Just About Driving

Fatigue is a performance inhibitor; and when a worker’s performance is inhibited he or she is far more likely to make potentially lethal mistakes.  Beyond mistake making fatigue has also been linked to:

  • Lack of manual dexterity
  • Lack of alertness
  • Increased injuries

Multiple sources list fatigue as one of the top five causal factors in workplace incidents (Chan, 2010), so while experts may attribute upward of 90% of workplace injuries to unsafe behavior, most fail to answer the question of why a worker behaved unsafely. Increasingly, that answer is linked to a lack of sleep.

No Easy Answers

While it’s easy to cast blame for allowing companies to require employees to work while fatigued (and then commute home) there isn’t an easy fix to the problem.  Workers often eagerly accept extra shifts; companies can’t control the length of worker’s commutes; and workers often report to work without having logged the appropriate hours of sleep.

Maybe the answer lies not in controlling the length of time an employee works but in a better understanding of the symptoms of worker fatigue and an awareness of the risks associated with working while fatigued.

Related Articles

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OSHA has no regulation for sleep deprivation – but you must know who is fit for duty

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The Joy Of Blame


Mustard86

By Phil La Duke

What is it about blaming that feels so good? Why do we enjoy it so much? What’s that? YOU don’t enjoy blaming people; I’m sorry, I’m skeptical.  I have reason to be.  As a certified Just Culture practitioner who studied under David Marx (author of the book Whack A Mole and self-proclaimed “father of Just Culture”), a seasoned consultant in organizational change initiatives aimed at safety, and an obnoxious blogger who is seemingly pen pals with every kook and safety whack job, I see a lot of people who can’t wait to blame; from “stupidity” to “the culture” if its one thing the safety industry isn’t short on, its blame.

Blame satisfies a visceral and deeply ingrained need in people; it makes us feel as if some sort of justice has been meted out.  When we find the person or persons responsible for something we can shout “aha! We’ve caught you”.

Just Culture And Blame

Just Culture, more a corporate governance system than a safety methodology, doesn’t believe in blame.  Instead, Just Culture teaches that there are three basic kinds of human behavior: human error, at risk behavior, and recklessness. Human error are those good old fashioned “honest mistakes” that everyone makes at one point or another (in fact, a researcher I once saw speak at a medical conference, said that the average person makes five mistakes an hour, and if anyone out there can find the source of this research (my notes were literally destroyed in a flood) and send it to me you will have my heartfelt appreciation)).  A mistake, in Just Culture terms, is any undesired unplanned outcome. Some believe that mistakes are our subconscious minds way of testing the safety of rapid adaptation—that our brains deliberately, albeit subconsciously, cause us to err as a sort of experiment to see how safe it is to adapt. At any rate, if the mistake isn’t deliberate it is unjust to punish those who make them. (That’s not to say that one isn’t necessarily accountable, but we’ll get to that in a moment.)  Just Culture teaches that we should console the mistake maker instead of scolding, or worse yet subjecting them to a corporate disciplinary action.  Consoling someone for making mistakes sounds a bit warm and fuzzy, and it seldom satisfies people’s thirst for blood and blame.  Someone has to pay for the wrong that has been committed.  I taught Just Culture in healthcare and I was taken aback at how, sometimes decades after a lethal mistake, people would carry the sense of guilt, shame, and sadness over a mistake they had made that killed or crippled a patient.  Even so, many of us wouldn’t condone the killer (however accidental) of one of our loved ones being consoled.  No, we want to blame them; we want them to pay for what they did, even though cognitively we know that they can never pay enough to satisfy our bloodlust. Worker safety, at least in terms of mistake making, is similar to patient safety, if a worker forgets a critical step and causes a serious injury or fatality we too often judge the worker as either irresponsible or just plain stupid.  We seldom allow that mistakes happen, even though there but for the grace of God go any one of us; no, others must be blamed. They must be judged and punished.  We demand perfection from everyone but ourselves.

J’accuse

The second behavior, at risk behavior, also often produces a catastrophic outcome.  We see this all the time in safety; someone takes a shortcut, ignores a safety procedure or requirement, or simply decides that in this case the risk of injury is minuscule compared to the rewards associated with taking the risk.  The temptation to blame is far stronger now, we get angry because in this case, he or she KNEW better but decided to risk it anyway. Surely we must blame SOMEONE, we can’t just throw our hands in the air and say “Oh well, (expletive) happens”.  No, clearly someone must be held responsible.  In these case our bloodlust can whip us into a frenzy, driving us to type out angry missives in online threads that only a handful of people will read and about which far less will care.  People will rail against the molly coddling of the guilty, and spit venom at those who dare try to deflect the blame onto society, or the system, or…whoever.  Unfortunately, we need workers to take risks.  Calculated risks, well-thought out risks to be sure, risks that are proportionate to the rewards, but risks none-the-less.  Our policies and procedures can only govern about 75–80%[1] of the situations workers will face, and we want them to show sound judgment when confronted with situations that are outside the policies, in other words, we rely on them to take risks. We can’t expect people to take some risks and blame them for the outcomes. Under a Just Culture system at risk behavior would be trained and coached; we want people to take risks, but we want them to do so wisely.

The final behavior is recklessness, which is defined in Just Culture, as a behavior where the risk is so out of proportion to the reward that a reasonable person would judge it to be unjustifiable.  Neat definition, but so subjective that one man’s recklessness is another’s reasonable risk. Even here a Just Culture system wouldn’t blame the reckless, they would simply be disciplined; probably harshly.

Where’s the Danger In Blame

Blame shuts down conversation and investigation.  Continuing to research solutions after one has assigned blame is like continuing to look for your car keys once you’ve already found them—where is the point in continuing to ask why things went sideways when you already know who did it? In the cosmic game of Clue that is incident investigation, no one ever asks WHY Colonel Mustard did it in the Conservatory with a Candlestick, once the answer is revealed the mystery is solved and the game is over.  So too is the case with blame; once we’ve assigned it we can punish and shame the guilty and go about on our merry way. At least, that is, until the next time.

There’s another, larger, danger in blame.  I don’t know who said it, or even the exact quote, but someone (perhaps me) said that errors plus blame leads to criminality.  If we face blame and punishment we tend to conceal our culpability; we make excuses, we lie, we cover things up.  Nothing gets solved.  No actions are taken to fix the system problem and the hazards lurk unseen and undetected until something so horrific and catastrophic happens that concealment is impossible, blame avoidance ends up killing people leaving us with no one to blame except the dead and dying.

 

[1] Source: my anus; I made this statistic up, but until someone gives me a fat government grant to scientifically study the issue I’m afraid it will have to do.

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