Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

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

Asleep On The Job

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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Political Correctness Can Get People Killed


 

Forrest Gump

By Phil La Duke

Is political correctness putting workers at risk? I’ve been wondering if in our ever so polite drive for inclusiveness we aren’t actually creating a climate where, in an attempt to give no offense we are putting some workers at risk.

Several weeks ago I wrote an article in response to a remark made by an Oil & Gas company executive who said, “You Can’t Fix Stupid”. The post set of a storm of responses and I think we may have wandered off point. The following post is not for the faint of heart, so those of you are easily offended do us both a favor and stop reading now.

To describe my writing as provocative is to perhaps under sell it; I have always written in a way that elicits a visceral, emotional response. I believe that only when we really get to the point where we are uncomfortable can we ever shift our thinking. Some people find my style refreshing and some are put off to the point where they can’t even consider my point because they are so offended by how I worded things. The “stupid” post was one of those topics.

In addition to the usual cadre of mouth-breathers who write poison pen hate mail dripping with grammatically incorrect and poorly spelled threats to “get me” there was a backlash I hadn’t expected. My message was pretty simple, “we can’t use stupidity as a root cause for injuries”. I wouldn’t have thought something so innocuous would set of such a rage.

One of the threads on LinkedIn had people shouting “at-a-boys” although, since so many never actually READ my work and react to a brief synopsis or even a title, most were supporting me for the wrong reasons. Most of the posts talked about how there wasn’t any such thing as stupidity. They were answered by the inevitable link to the Darwin Awards or similar smug, oh you bet there are stupid people. Then one poor unfortunate group member posted that she had seen some incidents that could only be described as stupidity. I posted a response that was censored; I was stunned. This post was not filled with my characteristic sarcasm, and I didn’t use course language, or attack anyone in any way. Why then would some self important, puffed up group manager decide that my post wasn’t suitable for grown-ups to read and discuss like mature adults? Because I said that there were INDEED stupid people in the workforce, and these people deserve to be protected with the same diligence and priority that one would show in protecting so-called, “smart people”.

Most of the posters claimed that the workers weren’t stupid, rather inadequately trained. I spent most of my career working doing training of one sort or another with adults and I can assure you that no amount of training will ever miraculously transform someone who is “stupid” into someone who is “smart”; this is an immutable law of basic physiology, it just can’t happen.

According to http://www.edublox.com/iq-test/iq04.htm 25% of the population are below average in intelligence. (NOTE: I want to thank Steve Ramsay for implying, at least I inferred his meaning, that this statistic cannot be correct; average would mean the half way point.  Let me explain the reason for what appears to be, but is not, an error.  The site lists anyone with an IQ score of 80-110 as being “average” which accounts for about half the population, leaving 25% above average and 25% below average; but if you prefer to think of 50% of the people as below average and 50% above average go ahead (leaving no one EXACTLY average), it better proves my point and tells me which side of the line you fall)  In other, less politically correct terms, 25% of the population is “stupid”. As I said in my original post, “there are people with Down’s Syndrome, brain damage, or simply fall at the lower end of the intellectual continuum, that prevents them from doing tasks that others are able to do easily. Many of these people hold jobs and function just fine in the workplace despite their relatively low intellect.” Add to this that some tasks require far more intellectual capability than others (I freely admit that there are jobs out there that I am just flat out too dumb to hold.)

Apparently, this statement, however true was scandalous and could not be seen in a public forum. Some of you reading this agree and some of you do not; good. Disagreement is the foundation of public debate and an informed democracy, if all the population does is agree nothing good can come of it. To be clear, there are a lot of hurtful and ugly words that we use to describe people who are below average in intellect, and I didn’t use any of those words in my post. The mentally impaired are also the subject of a lot of tasteless jokes, and I didn’t make light of anyone who was below average in intelligence. Despite this, my words were squelched. I don’t really care about having a post censored; if one posts in a thread controlled by another one has no expectation of freedom of speech, so in much the same way that I submit my work to editors who change things, omit things, and even add things, I accept the fact that occasionally a group manager (likely with no more ulterior motive than to save him/herself a barrage of hate mail) will prevent a post from making it to the thread.

But how can we protect people who aren’t as bright as we would like from harm if we pretend they don’t exist because we don’t want to hurt their feelings? We can’t. We can pretend that they just need extra training, but that won’t change the fact that many people aren’t mentally equipped to do a job and in pretending that they can if they just try hard enough puts these people at risk. What’s more, workers who are not intellectually capable of doing a job also put others at risk. I am not advocating discrimination against anyone who has limitations that make working more difficult, and—at least in the United States—there are laws requiring employers to make reasonable accommodations for workers with disabilities. What I’m saying is that political correctness is putting workers at risk. If we pretend that there are no “stupid” people working in the workplace because we don’t want to be seen as insensitive then we won’t take measures to protect them.

Stupid Is As Stupid Does
The beloved film character, Forest Gump, struggles through life because of his slow wits, but when people call him stupid, he responds with “stupid is as stupid does” and I think there is a lot of truth to that sentiment. Let’s face it, no matter how intellectually gifted we think we are (and Joseph Halliran, will tell you that most of us think we are a lot smarter than we are) we all do stupid things from time to time. Everyone makes mistakes; that’s why they put erasers on pencils. This political correctness that forces us to pretend that everyone is smart, well intentioned, and makes good decisions leads to the idea that people who are injured doing something dumb sort of deserve it. This political correctness leads to the belief that people die doing something stupid are doing society a favor, in fact, that is the very premise of the Darwin Awards—people who die doing stupid things are improving the gene pool. We can read them and have a good laugh, or we can read them and ask ourselves how is this different from the Nazis executing people with intellectual (and physical) disabilities? I for one think that as ugly or uncomfortable some people find this topic it is something that we in the field of safety need to openly discuss. Not everyone can be a genius, but we don’t have the right to rejoice in the death or dismemberment of someone who is less intellectually gifted as the average person. So the next time you think about shutting down unpopular speech in the interest of political correctness or decorum remember that in so doing you may be putting a worker at risk.

I’m not saying that we should encourage bigotry or bullying or any speech or act that demeans those who struggle with a disability but when you pretend that everyone is on a level intellectual playing field you diminish and trivialize the struggle intellectually impaired individuals face, and when you are a safety professional who does this you might even get them killed.

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Articles you Might have Missed


Today I contributed my first article to Entrepreneur Magazine http://m.entrepreneur.com/article/234106 and a couple of weeks ago I co-authored a piece for ISHN Don’t Get zapped http://www.ishn.com/articles/98498-dont-get-zapped—six-electrical-safety-scenarios. And I had a guest blog last week http://www.ishn.com/blogs/16-the-ishn-blog/post/98623-if-the-middle-class-continues-to-shrink-safety-loses-an-important-ally

Filed under: Safety

Maybe You REALLY Can’t Fix Stupid


By Phil La Duke

In a recent blog entry on the blog, Fuel Fix http://fuelfix.com/blog/2014/05/12/human-errors-account-for-80-of-offshore-accidents-exec-says/  Oil & Gas executives were quoted as saying that 80% of offshore accidents were caused by human error.
According to the article, Jim Raney, director of engineering and technology at Anadarko was addressing the Ocean Energy Safety Institute at the University of Houston when he said, “You can’t fix stupid…what’s the answer? A culture of safety. It has to be through leadership and supported through procedures — a safety management system.” I’m careful not to use the stupid brush to tar too many people in worker safety. Are their stupid people out there working? I think it’s safety to say yes. But can we blame 80% of worker injuries on stupidity? I don’t think so, at least not among the rank and file. Let’s face it, if 80% of your injuries are because of human error, as the article later suggests, you have some big issues and I would be careful who you go around calling stupid.
Even Smart People Make Mistakes
I’m not going to beat up on Jim Raney. My guess is that at his level he isn’t doing the incident investigations personally, and therefore he is being fed conclusions by his safety practitioners that lead him to believe that the vast majority of the incidents are because he has a bunch of idiots working for him. But stupidity is not the same as making a mistake, and while everyone makes mistakes (it’s a biological imperative) no one should have to die because of it. If there is stupidity in this process it lies with the person who designed it; he or she either refused to believe that people make mistakes or knew people would invariable make mistakes but refused to protect those that did. Stupid? It’s damned near depraved indifference and gross negligence.
Dispelling the “Operator Error” Myth
For years I taught problem solving courses as part of lean implementations. For generations engineers (the folks typically charged with finding out what caused a quality defect) would ultimately conclude that someone screwed up; the report would conclude that “operator error” was the proximate and root cause. The problem was that the engineer never asked “why?” the operator screwed up. I’ve written reams on performance inhibitors, those things like worker fatigue, stress, distraction, drug use, et el, can cause even the smartest people to make mistakes so I won’t revisit them now. But I wonder how many of those 80% of the people working on offshore rigs had been working long hours without a day off or with inadequate sleep? Keep anyone up for days on end working 16+ hour shifts in the elements and even the brightest among them will seem like a drooling idiot. Simply denouncing the people as stupid and then doing nothing about the system issue will not create a culture of safety, it will create a culture of stupidity. If I can go off on one of my well celebrated tangents for a minute, why are Oil & Gas companies hiring so many stupid people? While you may not be able to fix stupid, you don’t have to hire it, you don’t have to seek out the dumbest in society and offer them a job.
Injuries Are Seldom Caused By a Single Root Cause
A part of the problem solving training that I taught for many years dealt with selecting the right tool from the tool box. Traditional root cause analysis, repetitive whys, and similar tools are designed for use in solving problem of a specific structure and a sudden occurrence, that is to say, issues that develop rapidly and happen in response to a single cause. Situation analysis, fishbone analysis, and other tools, are better used for problems of a general structure and a gradual occurrence, in other words, incidents that are the product of a multiple, inter-related elements. In these types of incidents, many factors have to be present to cause an injury, and it is only after a threshold is reached that we see a process failure. In my experience, injuries tend to be the product of multiple factors that contribute to the incident. As long as we continue to use inappropriate tools to find the cause of injuries we will continue to mask hazards instead of removing them. The fact that Oil & Gas executives are concluding that 80% of the workers’ injuries are caused by “human error” leads me to question their methodology used to identify injury causes. Yes people make mistakes, but if those mistakes are leading to injury you have more at play than stupid people, you also have a process that hurts people when they make mistakes.
Protect the Stupid
We may not all be stupid, but we all do stupid things from time to time—we make poor choices, take unreasonable risks, allow distraction, fatigue, or other factors to impair our performance, or generally act in a way at odds with our safety. Some seem to forget that not all safety is about prevention; probability of interaction is only PART of the formula, there is another key component, reduction of severity. Engineers use this formula when identifying which of the hierarchy of controls to apply to everything from the machines we use in the workplace to the consumer goods we use every day. If the probability of interaction is high (people will almost certainly interact with the hazard) but the severity is low (most of the people who interact with the hazard won’t be seriously injured) they will generally slap a “no-kidding?” warning label on it. But if the probability of interaction is low, but the severity is lethal, they will take greater measures to protect people. I don’t believe that 80% of the Oil & Gas injuries are the fault of stupid people making mistakes; frankly it sounds suspiciously close to Heinrich’s Pyramid. But if the processes used in Oil & Gas are so fragile that human error is going to result in injury, the safety practitioners had better take bold initiatives to make these processes safer.
They Have the Answer; They Just Don’t Know It
The last part of Raney’s statement, “It has to be through leadership and supported through procedures — a safety management system” is right on. Unfortunately, organizations can’t achieve a sustainable safety management system that is built on the belief that you can’t fix stupid. Leadership has to drive good decision making and has to reward and encourage worker engagement based on respect; and describing workers as “stupid” is far from respectful.

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Are You Practicing “Nod & a Wink” Safety?


by Phil La Duke

There are two extremes when it comes to safety practitioners: overly protective simpletons who see certain death lurking around every corner and those who practice “nod-and-a-wink” safety. The former are the much maligned safety cops who seem to have the singular goal of eliminating risk by eliminating work and putting the company out of business; we hear a lot about them, mostly well-deserved criticisms. The latter however, don’t get much ink, and they are perhaps even more of a threat to the credibility of the safety function than anything. Nod-and-a-wink safety practitioners manage to turn a blind eye to some seriously dangerous activities that they KNOW pose significant risk to workers and even the general public.
If You Can’t Come Up With A Solution Why Try?
Nod-and-a-wink safety isn’t necessarily an evil plot; in most cases it’s not. These people are depravedly indifferent; in most cases they just don’t have a viable alternative to the current state. How many of us, when criticizing something has been asked, “do you think you can do any better?” It’s a fair question, but it doesn’t address the concern. It’s a way of shouting down the criticism without really engaging in a meaningful dialog; a way of bullying your way out of an uncomfortable or awkward conversation.
“Sure it’s not the best way to do it but it’s all we got”
Safety pundits, myself included, (at least to the extent that I can be called a pundit) have been preaching about the importance of the safety function enabling business instead obstructing it and the nod-and-a-wink set have taken this to heart. It’s easy to justify doing nothing in the name of cooperation. If I don’t have a safer way to do the job, it’s easier to walk away then it is to be put in the position where I alone am responsible for solving the problem. The overly zealous will fight to stop the practice even if there is no viable alternative, where as the nod-and-a-wink practitioners ignore the issue all together. A better solution is to say, “no, I don’t have a better solution, but we can’t just ignore the dangers here. Let’s work together to find an answer.”
Surely Not I?!?!
Too many reading this doesn’t see themselves as nod-and-a-wink practitioners when they are. It’s tough to recognize yourself or your organization when you have been looking the other way so long that it’s tough to recognize the danger any longer. Consider the following dangerous working conditions that are largely ignored by some companies:

  • Distracted Driving. I’m sure were all good and tired of hearing about distracted driving. We know dangers of distracted driving and yet many companies turn a blind eye to it. In fact, in a recent National Safety Council study, over 70% of the people responding said they’d ignored or violated their company’s distracted driving policies. I acknowledge that this policy is difficult if not impossible to enforce, but while this is true, consider the demands we place on people when they’re on the road for protracted periods of time. Sales people are expected to respond to emails, texts, and make phone calls when they’re in transit. We can’t have it both ways. We can’t expect quick response times and distraction free driving; when we do we are practicing nod and a wink safety
    Worker Fatigue. A far more insidious and potentially more deadly problem is worker fatigue. No worker or is immune to the effects of worker fatigue—we’ve all worked long hours at one point or another in our career. But nod-and-a-wink safety practitioners allow, and sometimes even endorse, long hours followed by long commutes that place the worker at significant risk. This issue has been a problem in the workforce since the workforce existed. People have been asked to work double shifts (and then return to work their normal shift), work long hours seven days a week, work swing shifts, and generally work longer and harder than we expect. On top of that, we forget that the workers have to get home somehow. When calculating the work day we seldom include the worker’s commute, and even a short commute can be deadly
    Contractor Training. As I was walking my dogs the other day I watched aghast as roofers worked on a neighbor’s house. I mentally counted at least ten major hazards that put the workers’ in harm’s way. I did mention to the crew leader some of the more egregious violations and he thanked me and I walked away. The next day the crew was right back at it, nothing had changed. Much the same goes on in the workplace. nod-and-a-wink practitioners are often deliberately ignorant of contractor behavior and when the contractors screw up, it’s not always them who get killed.
    All of these situations have something in common: the workers, safety practitioners, company and customers have a vested interest in not taking too close a look at the situation. In effect, they collude to perpetuate these dangerous situations. The worker may not enjoy long hours, but many are generally willing (or even eager) to work the overtime to earn extra money, the company wants to get the job done, the customer doesn’t want to pay the added cost associated with adding more workers and doesn’t want to delay the project, and the nod-and-a-wink safety practitioner will go along to get along. These issues are so pervasively ignored that worker fatigue or distraction are seldom identified as causes in incident investigations.

What’s the Solution?
If these issues are going to be solved, we need engagement at all levels. Senior leadership needs to understand that there’s a connection between distraction while driving and the demands the organization put upon drivers, to understand that overworking the workforce has a cost, and to recognize the interrelationship between contractor safety and overall safety in the workplace. Safety Professionals need to try to minimize the risk by proposing better solutions that are practical, and workers must take more active role in their own safety. Getting engagement starts with respect; preaching isn’t the same as teaching and awareness is the same as commitment between two adults.

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If A Temp Dies On The Job, Does It Count?


By Phil La Duke

 “There’s a sense that a new guy’s life isn’t worth as much cos he hasn’t put his time in yet.” Chris Taylor, Platoon

“Temp” as in temporary; a temporary person. The designation shows how much value we tend to place on those in the workforce who won’t be around very long. It doesn’t make much sense to throw away money on something you don’t intend to keep, and so it is for the safety of a growing number of temporary workers and contractors who, in the eyes of so many employers (and too many of their safety professionals) don’t count as much as long-term employees.
Increasingly, companies have been out-sourcing the dirtiest, most dangerous jobs to smaller firms and replacing full time workers with contract employees or temporary workers, “temps”.
I urge you to watch the attached youtube video. It tells the story of a young worker, Larry Daquan “Day” Davis, who landed his first job as a temporary worker at a Barcardi plant in Florida. Spoiler alert: he is killed 90 minutes into the first job he has ever had. The video is brief, and it isn’t overly melodramatic and won’t try to manipulate your emotions by tugging at your heart strings.
http://www.youtube.com/watch?v=cNcsTRQNZLE 
Who’s to blame for young “Day” Davis’s life? An executive who refused to invest in a safer workplace? maybe. A plant manager who failed to correct a known hazard? maybe. An over-zealous operations manager who valued production at all costs? maybe. The foreman who sent Davis into harm’s way unsupervised? maybe. The human resource manager who decided that Davis didn’t need adequate training (and before someone sounds off that I don’t KNOW that he had inadequate training, let me just say that if you are placed in a position that can kill you 90 minutes into your first job you probably haven’t been trained well enough. I will even go so far as to say that if you get killed on the job in this way you don’t have the skills to even be on a manufacturing floor, let alone crawling around in a machine’s blind spot.) maybe. Or even an indifferent safety professional who figured he or she had enough to do and didn’t have time to worry about the safety of a “temp”? maybe.  I don’t know that any of these things were true on that fateful August day, but I DO know that these attitudes toward tempory workers and contractors exist in enough workplaces to make this a problem; a big problem.

It Was An Accident
No one, at least so far as can be ascertained, set out to kill young Day Davis on his first day of work, not even two full hours into his first shift on his first job. Never-the-less, Davis died horrifically before he even got his first paycheck. This happened, August 16, 2012, and the fallout wasn’t exactly earth-shattering. OSHA cited Barcardi with 12 violations and recommended a fine of $192,000; the price you pay for ending a young worker’s life. There was no public outcry, no one organized boycotts against Barcardi, no criminal charges were filed; when it comes to temps nobody seems to care all that much. The death of a temp is a shame and little else.
Because Contractors “Don’t Count”

Years ago I was talking to a safety professional about the death of a contractor at one of the facilities for which he was responsible. When I asked about the fatality he said, “it was a contractor, so it didn’t count” he said before catching himself. I won’t beat up on him, he felt worse about the death than a lot of people would have, but his immediate reaction is telling. We as safety professionals (and companies) have become so concerned with measurements and statistics that we are losing touch with the human side of safety. When our first reaction at the death or serious injury of a contractor is relief that it doesn’t count against our body count we have lost our way; we are seriously out of touch with all the safety slogans, and philosophies, and zero-injury goals that plaster the wall.
It’s easy to see how the idea that contractors and temps “don’t count” developed. Laws against “co-employment” muddy the waters regarding just who may be legally trained without violating the tax code and who may not. For the record, as I understand it, employers have a shared responsibility for training temporary workers and contractors on safety. What then, constitutes safety training? I doubt that Day received the basic training required by law, given that he was killed less than two hours into his career, but suppose he had? Would Hazard Communication and Right-To-Know or some hackneyed safety orientation have saved him? I doubt it. But if he had been given training such that he would have understood how the equipment worked and what it did he might have recognized the dangers and been able to save his life.
The Client-Company Must Step Up
Too often companies hire contractors and hope for the best, when it comes to worker safety. They count on the employers of record to meet the government standards for safety, but too often the contract house or temp agency lacks the resources to provide adequate training to their workers, and many and more couldn’t care less. The contract employment business is a cut-throat industry where clients squeeze margins tighter and tighter and temps and contractors are increasingly forced to cut costs just to survive. What’s more, many contractors have few enough employees that many government regulations may not apply to them. The end result is that increasingly, young workers, immigrants, and working poor are put at severe risk.
While I don’t let the temp agencies and contract houses off the hook they don’t often know the specific working conditions in which one of their workers will be placed. In many cases, minimally trained recruiters race against the clock to get workers placed in their client’s facilities. And the worse the safety of the client the higher the turn over, creating a churning of workers; it’s a perfect situation for disaster.
It’s A Matter of Ethics
Some will argue that temp workers and contractors fill a valuable niche and that some industries would be unable to compete were it not for these workers. I say that companies who employ temps to avoid becoming employers of record, or who churn employees every 89 days to prevent them from becoming full time, or who otherwise look for the cheapest labor and balk at even the smallest investment in safety should be run out of the business.  Many temps work in a climate of fear so pervasive that the merest mention of a reluctance to work in an unsafe situation brings the threat of dismissal.  A worker (not a temp) once told me, that we have to get our safety under control or the company will move our jobs to a country that doesn’t care about safety, but in the minds of temps they already live in  a country that doesn’t care about their safety.

If You Don’t Act Who Will?

Before you dismiss this as more of my ranting and outrageous provocation consider the fate of your children, or grandchildren as they enter the workforce desperate for work and grateful for their first jobs. Imagine your pride as you see them go off to what will be the first step towards a long and successful career, and then imagine them dead on a filthy factory floor, crushed to death like Day Davis. Imagine them killed, because in the minds of too many employers they were nothing more than temps, who, after all, just don’t matter.

p.s. Bacardi’s fine for the death of Day Davis was since reduced by $80,000; temp agency fine was $0.

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Why We Violate the Rules Revisited


 

By Phil La Duke

I thought I would close out distracted driver awareness month with a bit of a tangent, because frankly, I’m probably even more tired of writing about it as you are of reading about it. But as tangential as this post is, there is indeed a connection to driving while distracted.

Several weeks ago I spoke at the Michigan Safety Conference on Why We Violate The Rules based on an article I wrote for my column in Metal Working & Fabricating. It was a popular article and it has become a widely requested speech.  After the presentation, one of the true thought leaders in worker safety and a very accomplished safety professional whom I admire and respect asked one[1] of the best questions I have ever been asked and it was related to driving while distracted: how do you enforce an unenforceable rule.  The context was relative to a conversation that grew out of the answer to a previous question and the discussion centered on enforcing rules that prohibit the use of smart devices and texting while driving.  I read a statistic recently that over 70% of the respondents admitted to violating or ignoring their companies’ rules limiting or prohibiting texting or cell phone use.  My answer was quick, as is my nature, and extemporaneous which is fairly characteristic of me, and I’d like to think, pretty close to on the money. I said that if you want a rule to be followed irrespective of the possibility of enforcement the rule has to be value-based.

Values-Based[2] Rules versus Compliance Based Rules

There are two different kinds of rules[3]: Values-based rules are the guiding behaviors that are an outgrowth of the population’s shared values.  We tend to follow these rules because we believe that not following them is morally wrong, outside our cultural norms, or otherwise intrinsically distasteful.  While I’m fond of saying, jokingly, that the only thing keeping some people alive is the laws against killing them, I believe that most people would not commit murder, or rape, or assault if it were legal.  These are rules that are values-based and we follow them because we judge doing so as the right thing to do.  Compliance-based rules are different; we follow them because we don’t want to risk the unpleasant consequences.  Many people exceed the speed limit, drive like they have been pithed or violate any number of traffic laws; and yet few of these people feel like they have done anything morally repugnant. So either most people who violate traffic (or parking laws) are sociopaths or, and I think more likely, they are merely complying when they fear enforcement is imminent.

Violating a values-based rule can turn a person into a social leper and a pariah but violating compliance-based rules can turn an individual into a folk hero. The basic and essential difference is we care very deeply about values-based rules and really don’t give a rip about compliance-based rules[4].

Is a rule really a rule if there is no reasonable expectation of compliance?

Can we really say that something is a rule if over two-thirds of the population ignore it with impunity? There is some precedence in English common law that could be interpreted as saying that if the law (or for our purposes the rule) is neither followed nor enforced that it is, in fact, not a law at all.[5]  In organizations an employee disciplined for violating a rule that over 70% of the company also violates could construct a pretty solid argument for selective enforcement[6].  So why have a rule that people aren’t going to follow? Well for one, it makes us feel better.  It appeals to the three-year old in all of us who is going to run and tell.  It also appeals to the cranky old man in us who shakes his craggy fist at the sky and rails about how there oughta be a law! Like so many other things in safety it makes us feel like we are doing something of substance when we aren’t really doing anything at all.  And before you say that it “covers your…assets” consider that the widespread failure to comply and likewise failure to enforce opens you up for potential asset damage.

Making the compliance-based value-based

My first instinct is to say, throw out rules that are merely compliance based unless the compliance is rooted in the law. If you’re employee handbook is choked with rules because some vacant suit in the executive suite went off his meds and had a conniption fit because someone committed the sin of committing one of his pet peeves or atavistic rules that try to preserve the good old days of polio you are better off getting rid of the rules.  But if the rule is something like “don’t use your cell phone or text while driving”, you have to change the rule from being a compliance-based rule to a values-based rule; this can be tough with rules like this because the rules are lagging behind societal norms.  A reasonable person (hell a completely unreasonable baboon) could have predicted that texting, reading emails, dialing phones, and any of the other things associated with driving while seriously distracted would lead to disaster, and yet we missed that.  We had to wait until people started dying at an alarming rate, until railroad engineers had to derail the trains they were driving killing scores of people, in short, until the problem had reached epidemic proportions.  Even so, many of us did these things without killing anyone, or even almost killing someone, so the behavior continued until it became socially acceptable.  I don’t have the space this week to offer suggestions on how to make the socially acceptable socially unacceptable, but I promise to revisit the topic and share some tips.  I warn you though, reversing the course isn’t easy once the genie is out of the bottle, but then, what choice do we have?

[1] I say this not to suck up, but to establish that this wasn’t just some crackpot trying to play stump the speaker and I’m not going to name drop, especially since he doesn’t know I am writing this.  Not that I am above name-dropping mind you, but only if it suits my purposes.

[2] Technically this should probably be “value-based” instead of “values-based”; the change is deliberate. I want to distinguish between values as in those deep-seated beliefs that govern our decisions and behaviors versus a rule that we place some sort of contrived value.

[3] I’m sure if I gave it enough thought I could come up with a metric ton of kinds of rules, but for today’s purposes let’s just deal with two.

[4] I think it’s worth noting (and essential to ward off the mouth-breathers) to point out that the two types of rules need not be mutually exclusive.  One can follow a rule because it is deeply ingrained in one’s values AND because one fears enforcement.

[5] I’m not a lawyer, I have no license to practice law, (although I often lie about being a lawyer to impress women) and anyone who construes this as legal advice is so stupid they are probably worth more to society in parts.

[6] The practice of using the rules to persecute individuals who you dislike or to mask discrimination against a protected class.

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All Distractions Are Not Created Equally


 

By Phil La Duke

Continuing my series on driver distraction (April is National Distracted Driver Awareness month in the U.S.)

I’m alarmed at how cavalier U.S. drivers have become about risk. I travel via car a lot and have seen some really recklessness on the road. While much of that recklessness is related to driver distraction I am also alarmed at what I see is a knee-jerk reaction to the risks of driver distraction. The use of smart devices while driving, even when using hands-free devices, present a significant risk to driver and pedestrian safety, but it seems like the safety pundits have extrapolated that ALL distractions while driving pose approximately the same risk; and this is just another example of the kind of reactionary thinking that creates unenforceable and irrational policies.

Most People Ignore Smart Device Policies

A recent poll by the National Safety Council found that 70% of respondents admitted that they knowingly violate their companies’ policies regarding the use of smart devices while driving. This is an alarming statistic until you really think about it. Ask yourself have you ever sent a text while waiting at a stop light? Does that constitute texting while driving? I don’t really have a dog in this fight. My company has a policy that forbids the use of smart devices while driving and it is very specific in its wording, so I know that texting at while stopped at a traffic light is forbidden. I follow our policy, but it wasn’t easy at first. I found it irritating and distracting that I couldn’t check my email while stopped at a light, and I was irritated by the time wasted in long drives where, I reasoned, I could get more done if I could just talk on the phone. But my company culture is very strong on this issue and because I was new to organization, the drive to conform was strong. I soon found that complying took a lot of stress out of my day and that my car rides were less stressful.

The Cry Goes Out Against “Other Distractions”

And so the witch hunt against driver distractions begins. What about conversations with passengers? What about gawking at an accident? What about a pretty girl in a short skirt? What about playing with the radio? What about GPSs? What about…just about anything you can think of that can distract you? There are already companies with initiatives underway to ban all driver distraction. With these efforts there is a renewed question in the minds of the organization: are safety professionals naturally soft in the head? It’s a fair question, when people see policies that ban everything from reading a book while driving to changing the station on the car radio it begs the question “how far out of touch is the safety function”?

Driving While Distracted Remains Dangerous

There has been a spate of recent studies that confirm that distracted driving is a serious threat to public safety, and the findings are troubling:

  • Studies have shown that driving while distracted is roughly as dangerous as being moderately intoxicated, but this is a dubious finding.
  • Further studies have shown little to no difference in driver distraction while using hands-free devices instead of traditional cellular devices
  • There are even studies that show that talking to a passenger is as dangerous as being distracted by phone use while driving.
  • Finally there are studies that find that numerous other distractions pose significant risk—from the use of global positioning systems to fighting children.

So if we combine these findings we essentially conclude that driving with any amount of distraction is as dangerous as driving while impaired by alcohol use. Unfortunately, this conclusion is completely wrong, and here’s why:

  • Distractions that cause the driver to take his or her eyes of the road are far more dangerous than distractions that don’t. Studies (I know AGAIN with the studies) have shown that the dangers of texting while driving are INCREASED by laws against texting. Why? Because the prohibition didn’t stop the behavior, in fact, people who ordinarily used to text while holding the phone such that they could keep their eyes on the road would now text while holding the phone down to avoid detection. The unintended consequence was that incidence of texting while driving did not fall the dangers associated with it increased.[1]
  • The amount of time distracted is more of a hazard than the distraction alone. According to the National Safety Council it takes, on average, 15 seconds to send a text message and roughly the same amount of time to receive and read one. Imagine closing your eyes for 30 seconds while driving 70 miles an hour. I’ll do the math: 70 mph=.58 miles in 30 seconds=103 feet per second, or the length of a football field for ever text processed while driving. Compare that to looking over at a passenger while you converse with him or her. If your passenger is sane and you look at them for 30 seconds while going 70 miles an hour they are likely to yell, “watch the (expletive) road you (expletive) maniac”!! I don’t have a study to support this assertion, just a proverb, two sets of eyes are better than one. I think it’s irresponsible for pundits to perpetuate the idea that talking to a passenger in a car is as dangerous as texting.
  • There is always some level of distraction; we have to pick our battles. Before we had phones and GPS systems that could provide us turn-by-turn directions we had Mapquest (and before that Triptix or the good old fashion maps) There aren’t any studies to tell us how much more dangerous reading directions from a piece of paper are as compared to operating a GPS or using turn-by-turn directions. The base line data was never collected because people reasoned that maps on paper where the only way people were going to get to an unfamiliar location. While I’m sure that there were numerous accidents caused by people reading maps there is no way to support that turn by turn directions are safer. I will say that turn by turn directions require the driver to take his or her eyes of the road far less frequently than a paper map and intuitively I believe it to be safer.

Instead of fighting driver distraction beyond texting and using a phone without hands-free capability I say we begin a campaign against driving like an ass. Over the last ten years I have seen a marked increase in drivers who don’t use turn signals, make illegal turns, speed, follow too close, cut off other drivers, and generally drive like a drug-addled baboon. They weren’t distracted; they were inconsiderate jerks who live without consequences. As long as we remain silent instead of notifying our local police departments that more people need to be stopped and ticketed for these behaviors the problem will only get worse.

[1] This is not to say that texting while watching the road was a safe or smart practice but it was marginally less unsafe than before the law was passed.

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