Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

Reverse Engineering Safety Offerings


By Phil La Duke

I don’t have all the answers; not about safety and not about anything else. Furthermore, as much as it may seem to the contrary, I don’t even THINK that I have all the answers, but there are people in the world of safety who seem to think that they do. Several weeks ago I spoke at the National Safety Council in San Diego, CA. It was a hot, afternoon session on the connection between housekeeping and safety that about a hundred people endured. Thank you to of you who sweltered through a mediocre presentation.

When you speak at the conference, in way of a thank you, you are given free admission to the entire conference. It’s a nice perk; especially since many European conferences expect you to pay all your expenses, forgo a speaking fee, and PAY admission to the conference. I turned down speaking at Loss 2010 because my out-of-pocket expenses amounted to over $10,000 and I’m sorry, but it just wasn’t going to be worth it. (I didn’t realize the theme “Loss” would be applied so directly and acutely applied to me).

Those of you who have never attended the National Safety Conference Annual Congress and Expo you really should. The vendor hall is so large it takes more than a day to go through it all and the speakers present on a wide range of safety (of all aspects not just worker safety) that influences policy across the globe. The topics really caught me eye this year. I saw topics ranging from the very specific to the vague to the point of being almost meaningless. One topic got me thinking about how what people shill through their presentations represents what they think is the key to a safer workplace. I thought I would reverse engineer some of these topics to see what people believed were the true source of unsafe workplaces.

The first topic that grabbed my attention was something called Motivating People to Work Safe (or something similar). This struck me as odd. Are there people out there who aren’t motivated to work safely, in other words, are there people out there who would work safely, but can’t find a compelling reason to, after all, what’s in it for them? How absurd, patronizing, and arrogant is it to assume that workers aren’t already intrinsically motivated to work in a way that will keep them from getting killed. Certainly people seem to lack motivation for working safe, but I think that is more a product of our perception than the reality.

The second topic that caught my eye was related to the first topic: getting people to value their safety. One of the keynote speakers even went so far as to lay out the four secrets to safety that all, more or less, amounted to ways to get people to value their safety. PLEASE! Safety is one of the most basic needs on Abraham Maslow’s Hierarchy of Needs, and Maslow believed that this need would be an intrinsic motivator until it was filled (Some in the BBS field openly criticize Maslow, but I don’t know of any who criticize the designation of safety as a basic human emotional need).

We should also be mindful of the fact that the primary role of the human central nervous system is to keep people from harm; it’s hard wired into our bodies to avoid things that will harm us. We even have the fight or flight reflex that floods our bodies with adrenaline to enable us to protect us from danger. I reject the beliefs that people either lack sufficient motivation work safely and/or people behave unsafely because they don’t value their safety. Both fly in the face of proven science and the less hard science of behavioral psychology. People are designed to keep themselves alive.

So why do people behave unsafely? Lots of reasons, actually, but off the top of my head here are some of the most common:

  • Human Error. People just plain screw up. They make mistakes without thinking. People forget to complete a key step, misread an indicator, or accidentally put themselves in harms way. Some believe that human error is our subconscious minds experimenting with the safety of rapidly adapting, but in any case, it’s not about motivation or not valuing our safety.
  • Poor Judgment. Sometimes we deliberately do something risky because we erroneously believe the risk is lower than it is. Why? Because:
    • We are acting on imperfect information—we thought something was true when it wasn’t or we thought something wasn’t true when it was. When we don’t have all the facts it’s tough to make a good call.
    • We’ve taught ourselves that something was safer than it is. Every time we do something unsafe and don’t get hurt we teach ourselves that the unsafe act is in fact safe; so we do it again and again, each time believing that it is less and less risky.
    • We’re Improvising. Too often we don’t really know how to do the job and are forced to figure it out on the fly.
  • Inappropriate Risk Taking. Generally speaking, people take risks incrementally.  People seldom take a huge, stupid, reckless risk before taking smaller less dangerous risks.  Little by little, people’s risk tolerance increases until either something happens that jars them back to better decision making or they cross the injury threshold and hurt (or kill) themselves or others.  Think about how you drive.  As you get more comfortable speeding, talking on the phone, texting, etc. you engage in these activities more frequently or for greater durations until you reach some line known only to you that causes you to rethink your risk taking.  It could be a ticket, or it could be a serious accident.
  • Weak Leadership. Leaders (including the safety practioner, who if not a leader should get out of the business) have the greatest influence on safety than any single individual.  And when it comes to safety, companies tend to get the level of safety that their leaders demand.  If the leaders look the other way when they see safety issues or infractions, or if the leaders roll their eyes when someone voices a safety concern the population will tend to mimic the leader’s and at very least try to act in a way that pleases the leader.

We have to be careful listening to the latest theory from the latest expert (myself not only included but singled out for special scrutiny). Theories are just that: theories, not facts. Theories are opinions irrespective of how loudly they are argued. We need to challenge and questions these assertions if we will ever grow in safety.

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WWPD (What Would Phil Do)?


WWPD

By Phil La Duke

One glance at that title and it would seem I am back in my full arrogant splendor, but I hope you will reserve judgment until you’ve read my explanation. After last week’s post, in addition to the outpouring of sympathy and support, I received a personal, private email. As you may know, it is not my practice to publish or make public things sent to me confidence, so I won’t go into detail about the letter except to say that the author asked the question “WWPD (What Would Phil Do)” The author explained that in many cases throughout the course of doing business he we would ask himself WWPD? He further elucidated that as much as he respected me it was often difficult to arrive at any meaningful answer to the “WWPD?” question. First of all, it is humbling to think that anyone would find my work useful enough to ask that question even once, but the thought that that someone might use it as a means of guiding one’s decisions relative to safety just floored me. At a time when I was considering hanging it up (not just writing, but safety as a profession) and openly questioning whether or not I made any difference at all this was something I genuinely needed to hear.

I have mentioned before my method for improving safety. It has worked consistently for companies large and small and across diverse industries, but I think sometimes I get so caught up in pointing out the misguided efforts so prevalent in our industry that the “WWPD?” gets lost in the cluttered landscape of “WWP Not D?” and so I thought I would once again share what I believe as it pertains to safety improvement.

Let me begin by saying “safety” is an outcome, or more specifically, and “output”. Every process is composed of three kinds of things: inputs (things you start with) transformations (things that happen to them in the course of your process) and outputs (the things you are left with). Whether your process is as simple as tying your shoe or as complex as smelting iron, every process has these three elements. When your process produces unwanted outcomes we call these things “waste” and injuries are precisely that, waste.

For hundreds of years our colleagues in safety have talked about having a “safety process” or “managing safety”, but I have come to believe that such activities have little to do with producing the outcome of safety; at least not directly. Because these activities don’t directly influence safety they tend to be costly and produce very little in way of return on investment. We have to manage the actual work processes to reduce the injuries and produce the state of safety.

The goal of managing a process is to return a consistent, predictable, and desired result. Managing processes involve controlling variability (and unpredictability) in five areas: manpower, machines, materials, methods, and environment.

Manpower

Manpower (sorry ladies this is an old term and I am not going to make it gender-neutral) refers to anything related to people. Ideally we start our process with an uninjured worker that is fit to work. As the process is completed the worker may be transformed (albeit probably not radically) by becoming hot, tired, sweaty, dirty, sore, etc. The change in the worker is not a desired outcome so it is waste.

Machines

Machines can be a simple machine (a screw, incline plane, wheel and axel, lever, pulley or wedge) or complex automated systems. When tools and equipment are worn out or damaged during the process they cannot produce a predictable result.

Materials

Materials refer both to the types of materials used and how they are delivered to the workstation.

Methods

Methods are the “recipe” that the process follows to complete a job. Policies and procedures (including Job Safety Analysis, Standard Work, etc.) are the methods by which we hope to get a predictable and desired result.

Environment

The physical working conditions of the workplace constitute the environment that we must manage to ensure a predictable outcome. Environment can include factors like heat, lighting, and humidity, the presence of exposure risks or biohazards, and similar physical conditions that workers work in and around.

There has been much debate as to whether behaviors are the primary cause of injuries; that’s not really something we had ought not debate. Injuries are most certainly caused by behaviors but so what? We can’t really influence (to any meaningful extent) the behavior of an entire population and pretending that we can has cost inestimable misery in the form of worker injuries and fatalities. But the 5Ms (hey, there’s an M in environment, I never said they STARTED with the letter M) are things that can be managed, and MUST be managed by Operations. It was out of that realization that I created my safety infrastructure framework. Safety can only be achieved by managing the 5Ms, with particular emphasis on:

  • Workers must be skilled in their core tasks and the closer they are to having mastery level skills of how to do their tasks the more likely they are to produce and predictable and safe outcome. Recently I was challenged by someone on this. “So what? Don’t you just need people to be competent to perform their tasks? What does mastery level mean?” Competence, like many things in industry is less a binary component and more a continuum. Much of our means of measuring competence, particularly in Union environments is binary, i.e. “Is the worker able to do the job or not?” We tend to measure whether someone has awareness-level, or a working knowledge of how to do their job instead of mastery. It’s about variation of skill. Someone who can do a job, but only marginally, tends to perform the job with far much more variation than someone who has mastered the job; i.e. someone who can complete a task with very little variation. Most training in core skills trains to the lowest common denominator and once a person has been qualified there is very little effort to assess that person’s skills after the fact. Most companies don’t do a very good job of measuring competency, in fact, few even try. For example, an industrial vehicle driver may receive refresher training, but unless he or she has repeated violations or been involved in multiple incidents little thought is given to whether or not he or she is competent. Furthermore, most companies don’t measure the effectiveness of training beyond a level 2 evaluation (pre- and posttesting, and many are loathe to even do this) which is often more a test of reading comprehension than of actual learning;   this is an issue because competency often degrades over time and there is no way of telling whether or not a worker has sank below the competency threshold. Then there is the related issue of physical competency; how are people evaluated on whether or not they are still physically capable of doing the work without injuring themselves or others? Most organizations address this through annual reviews which are almost entirely focused on performance and attitude than on skills degradation or physical competency. The only cases I know where the fitness to work is even considered are in return to work programs.
  • Process Capability & Discipline. There are two elements of “process” that are key to safety: 1) process capability (how able is your process to return a predictable and repeatable result) and 2) process discipline (how strictly do workers adhere to the process). Companies can really only protect workers when workers do their jobs according to a predictable and robust process. Again I was challenged on this. I was told that this was “clearly not real life—and frankly untrue that a predictable and robust process is the ONLY way to protect workers; there will always be nonstandard situations that need to be managed.” On the face of things this sounds like a fair criticism, but you must consider that while there will always be non-standard situations that need to be managed (in fact, while many companies are loathe to admit it, there are far more nonstandard situations than there should be), but they must be managed using a robust process for managing nonstandard work. We can’t protect workers from things we can’t predict and a process that is out of control makes it impossible to predict what might happen.. One of the keys to managing worker safety lies in having processes and procedures and the discipline for workers to work within these processes. The point of this statement is that companies that don’t care about process variation are far less able to protect workers than companies that work to continuously improve, and thus make more predictable and safe, their processes. We design work and the workplace to be as safe as we possibly can; we employ the Hierarchy of Controls to organize the means of protecting workers but we do so under the assumption that the process is robust and that people aren’t working out of process. This should not be interpreted as saying that we don’t have a responsibility to protect workers in all cases, rather it is meant to underscore the importance of a good process that people follow. When people are unable to follow the process they should not be encouraged to improvise, rather they should be rewarded for stopping work until a safe way of proceeding can be determined.
  • Hazard Incident & Management. Hazard reduction directly correlates to injury reduction. It sounds obvious right? Very obvious – yes? Yes very obvious, and yet one of the single most ignored elements of many safety management systems. Identifying, containing, correcting, and communicating hazards is central to safety; it’s obvious. The problem is that too many organizations treat all hazards equally and as carrying the same potential risk of injury. The risk of working on live equipment without the isolation of energy isn’t as risky as a blocked escape route (all other things being equal). Many organizations are blind to hazards. Without a simple means of managing hazards people become “normal blind” and things that would once have scared them silly now become part of the acceptable, normal landscape and are not only ignored but treated in such a cavalier fashion because “it aint killed nobody yet” that the risk is actually amplified. I don’t see a big distinction between risks and hazards. Clearly we direct need to focus more about controlling risks than on chasing injuries. Risk control is hazard management and vice versa and must be foremost in all safety management approaches, companies have to know the difference between being lucky and being good and to understand that difference one has to understand one’s risk.
  • Accountability Systems. In Just Culture there are three basic behaviors for which people are held to various levels of accountability: human error, risk taking, and recklessness. Human error is the unwanted and unplanned outcome from an unintended action-the honest mistake. Since human error is unintentional there is no point in holding someone accountable for something they can’t control. (I have seen research in healthcare and aviation that puts the number of mistakes the average person makes at 5 an hour). That having been said, there are certain things that individuals CAN control that for which we can and should hold them accountable. These things are conditions that have been demonstrated to inhibit performance and increase the likelihood, frequency, and severity of mistakes. Factors like fatigue, reporting to work ill, stress, drug or alcohol abuse, hang overs, prescription drug use—general fitness to work issues. Obviously, supervision plays a role in whether or not people are allowed to work while impaired by these conditions but in any case these conditions must be confronted and addressed. These performance inhibitors also can influence risk taking. Risk taking in itself is not unwanted. Organizations need people to take risks routinely, but these risks should be informed risks and workers should be coached on the limits to which they are empowered to take risks. When workers take risks because they are improvising they are more at risk for being harmed. As for the reckless, they should be weeded out of the workforce for their safety and the safety of others.
  • Employee Engagement. Workers must be intrinsically driven to make the workplace safer. To do this, workers must be capable of making sound business decisions not relative to safety alone. I think you misinterpret what we mean by making sound business decisions. This isn’t about business acumen as much as workers understanding how what they do impacts, not only their own safety, but the overall success of the organization. Studies have shown that the more highly engaged the worker the more safely the worker is likely to work. And it is tough to build engagement without building knowledge of the business. This knowledge enables workers to make informed suggestions for process improvement and to be a more productive and useful contributor. This takes safety away from being a functional exercise and creates a more holistic approach to safety.

So after all that, What Would Phil Do? This:

  • Invest in competency. This means putting some work into creating better job descriptions, recruiting people who have the grey matter and muscle to do those jobs, and training them to mastery level skill. Once someone has been hired, implement a system to ensure that their skills or physical abilities have degraded to the point that they can no longer safely do the job.
  • Collaborate With The Continuous Improvement Groups.  Not only are improved processes more effective and safe, collaborating with those who are working to make process improvements also make it easy for Operations to see the value of safety.
  • Demand that Leaders Enforce Requirements for Working In Process.  Okay, now sometimes we CAN’T work in process, for example when a manufacture is out of a given part and has to work without it.  But in these cases, Safety should help operations to assess the risks of working out of process and help to find ways to mitigate those risks.
  • Train Leaders.  Front-line supervision is the greatest resource in producing safe outcomes but from everything from core process training to training in Hazard Recognition to coaching workers on their performance this group goes largely ignored and are some of the most incompetent people out there.  They are often selected because they shut up and do their jobs but with no regard to whether they have the skills and experience to effectively supervise others.
  • Shift Focus Away From Injuries Toward Risk.  We spend so much time arguing about whether zero injuries is possible, or whether behavior causes injury or whatever.  We should make it real simple and look for ways to reduce risk in our lives every day.  In the workplace, during the commute, at home with our families.  We can do something about risk BEFORE we get killed or injured which, after all, is the point.
  • Implement A Just Culture System. Just Culture allows people to talk about risk and dumb decisions in a repercussion-less environment.  Until we stop trying to punish people for their mistakes and dumb decisions we can’t really focus on reducing risk.
  • Treat People Like Partners In Safety Not As Our Responsibility. People aren’t quite as stupid, lazy, crazy, careless, or indifferent to their safety as we often treat them. When we learn to respect the people with whom we work and stop treating them like our mentally handicapped children we can partner with them to make the workplace safe.

So…that’s what Phil would do.

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Worker Injuries May Take Years to Become a Fatality


By Phil LaDuke

I have more than a couple of people question my motives in writing about safety. I have had more than a few criticize me for not being more polite, professional, or whatever euphemism for telling people what they want to hear you care to put to it. Despite having worked as a teamster delivering parcels, and an autoworker; building 1700 seats a day on a back-breaking assembly line, day-in-and day out working in demolition, tearing out stores in malls so another soulless retail outlet could try its luck in that space and having spent the past15 years consulting on safety in companies big and small that I don’t have standing to speak, that I am just some safety journalist, some academic, or some theorist who doesn’t know how the “real world works”. Many agree with what I have to say; just as many do not. That’s okay, it’s a free world. I scare a lot of people and scared people try to get other people not to listen. But safety isn’t just some academic exercise, some abstract that we can argue over brandies. Safety is personal. Workplace injuries or occupational illnesses have killed my father, both grandfather, my brother-in-law, a great uncle, my brother’s best friend, and many co-workers and acquaintances. I carry that with me every day. And yesterday the workplace claimed another one.

Yesterday I learned that another person close to me died as a result of injuries/illness inflicted upon him. My ex-father-in-law was found dead at his home; he was a month past his 69th birthday. Despite my acrimonious divorce from his daughter and bitter custody battle over his granddaughter, “Red” was always decent and even a friend to me. It’s not clear what killed Red. He had been on permanent disability for over 20 years. For the last 26 years we shared a bond deeper than marriage, the love of his two granddaughters.

Red was a boiler maker and as such worked around asbestos much of his career, and while that may well be what killed him that is only part of the story. 20 or so years ago read was working at a construction site when a supervisor dropped something (the details were always sketchy and my memory isn’t what it was, so I trust you will cut me just a bit of slack on the details) some said a tool, some said an angle iron, but what all agree on was that what was dropped was heavy and struck him with enough force to shatter on vertebrae and drive a second into a third. The doctors who examined him painted a bleak picture. If they did nothing he would soon die. If they did operate he would be in a body cast for a year after which he would probably never walk again. Red wasn’t one to take bad news lightly and when his buddy suggested he see a doctor who was experimenting with spinal surgery using cow bones, he quickly investigated. This doctor told him that if the surgery was successful he would be able to walk and live a fairly normal life, although he would have limitations. When the doctor told him that he would never be able to lift more than 50lbs, Red was characteristically nonplussed, “No lifting anything heavier than 50lbs? Doc, how am I supposed to take a piss?” That was who Red was.

The cow bone surgery was successful, but it left Red in excruciating pain that came and went, worsening over time. It wasn’t long before Red was hooked on painkillers, his physical limitations grew more and more debilitating and the pain more and more difficult to control; the life that Red once enjoyed essentially ended the day of his injury.

To all you BBS zealots out there: Red did nothing wrong. There wasn’t supposed to be anyone working above him and he was wearing the appropriate PPE (as determined by the company’s PPE risk assessment) the worker who dropped the object that would forever alter the course of Red’s life was, in fact, the site supervisor who was neither qualified nor allowed by the Union contract to be doing the work. So what good would it have done to have one of Red’s peers watch him work and provide feedback on his performance? None that’s what. And I can already see some of you smug bastards smiling that “aha, gotcha!” smile as they are about to say, “yes but supervisor behavior is still behavior” So what? If we only focus on the behaviors of the individuals and we ignore the larger context than it doesn’t matter whose behavior set things in motion. It becomes an intellectual exercise.

Red’s life went from bad to worse. His lawsuit against the parties involved went from a slam-dunk big money pay out to a far more modest settlement that was less than he would have earned in two years on the job. You see the site was a municipal project, funded by the government; one by one the plaintiffs were let off the hook. Payouts from Worker’s Compensation and medical social security (coupled with poor decisions and greedy third parties quick to step in and victimize a man with a lot ready cash that sapped Red of his settlement). Red lost his house and his life savings quickly dwindled. In the end his family is struggling to scrape together the $1500 for a basic cremation. There will be no fancy casket, no funeral procession, no memorial service; there just isn’t money.

Two years ago, Red was diagnosed with both lung cancer AND mesothelioma he declined treatment and was told that he had only months to live. And yet he did live, such as lying in bed whacked out of one’s head on pain medication can be described as living.

Red’s case is sad, of course, but the ramifications of his injuries go far deeper. His injury played a role in the deterioration and ultimate end of my marriage. It led to drug abuse not just by him but others around him. It created an epicenter of misery that sucked in so many people.

Red died on the job. Oh sure, he didn’t usher forth the death rattle on the dirty boards of a construction site, but his was a workplace fatality nonetheless. And all the arguing and squabbling between safety snake oil salesmen and safety theorists and those who would sell you this system or that failed Red, they failed my daughters, they failed all those who loved him; they failed me.

Just what any of us are supposed to do with this I’m not sure. It’s got me ready to quit safety. At the end of the day I’m just another guy who preaches safety to people who care more about arguing than they do about saving a single life. I’m tired of watching people die why smug safety practitioners’ brag about how injuries are down and fatalities are flat. I’m tired of the the inane arguments about safety versus system, and all the blah blah nonsense that passes for intellectual discourse in our field. But mostly I’m tired of grieving for people who did nothing more than go to work, a decision that ended up killing them.

The day after tomorrow I will take the podium at the National Safety Council, perhaps for the last time. For all the writing (published and blogs) I’ve done and all the speeches I’ve made I don’t seem to have made any difference, I don’t seem to have changed a single mind. I’ve stirred the pot but all the while knowing that eventually the pot will just settle back into its old pattern.

Footnote: There was a memorial service for Red last Friday.  The remnants of his shattered family gathered for one last bewildered goodbye.  I talked to his brother who told me that he too was forced to leave the boilermakers after 36 years.  “I loved my job for 32 of the 36 years I worked it” he told me, and then while looking away he added, almost shamefully “until I hurt my back and after three years I just couldn’t do it anymore.” We also talked about his other brother who preceded Red in death by a couple of years; he died of lung cancer. Job related? At this point, who cares?

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The Problem with Safety


By Phil La Duke

Last week’s post that asked why Heinrich’s Pyramid was so popular across all industry segments despite being largely discredited by many in the safety industry angered up some of your blood. I don’t mind, if I didn’t get some of you cantankerous old coots’ blood moving some of you would be declared legally dead. I’m not complaining; anytime anyone challenges any of the cherished charms and totems of BBS one is likely to get blowback. So great is the backlash from the zealous and paranoid torch-and-pitchfork crowd that I know of at least three safety journalists who won’t touch the subject. But in the froth and fury to spew forth on on-line threads one persistent argument kept coming up: are injuries causes by multiple causes or by a single root cause. The answer is “yes”.

Before joining the glamorous and sexy world of safety I spent half my career in performance improvement—both human performance improvement and process improvement—and in the course of my duties I taught problem solving. Problems, you see, can’t be neatly wrapped up in one neat little box.

Categories of Problems

I don’t see problems (any difficult situation to be settled or resolved, a question for discussion or solution, or a discrepancy between fact and observation) as any different from injury causes. Both problems and injuries are unexpected outcomes of a process and both require the organization to find out what happened and why. Problems come in four categories: Broad, specific, decision, and planning.

Broad Problems

Broad problems are difficult to get your arms around because typically they have multiple causes and effects, grew over time, and have visible, known causes. Think of problems like world hunger; the causes are known and visible, but they are just too enormous to easily fix. Broad problems are typically the “system errors” that so many safety professionals argue are the causes for injuries. In many cases they are right, but not all injuries are caused by broad problems. Ergonomic injuries are good examples of broad problems that should be attacked using tools like Situation Analysis, fish bone diagrams, etc.

Specific Problems

Specific problems pertain to a specific object and a specific defect. In the case of safety the specific object could either be the person injured or the means by which the injury was caused while the specific defect is the kind of injury that was caused. Specific problems have a sudden occurrence—things are going along just fine until something happens and someone gets hurt. In these kinds of problems/injuries there is generally a single root cause and the cause is typically unknown. Slip trip and falls are good examples of specific problems that cause injuries.

Decision Problems

Decision problems are those issues that arise because of poor decision making practices. In safety decision analysis should be more widely used to generate an understanding of why people make poor decisions that end in injury and to teach workers to make better decisions. Failure to lockout or to tie off while working at heights are good examples of injuries resulting from poorly solved decision problems.

Planning Problems

Planning problems are those situations that are so complex that a failure to plan introduces process variation and risk and too often results in serious injuries. A good example of injuries caused by planning problems are those cases of workers injured doing nonstandard work. The lack of a robust plan often results in deadly improvisations.

Structure of Problems

Understanding the category of problem is only half the battle. Next we need to understand the structure of the problem. Problems can be any of many structures but the most common are:

  • Problems with a gradual structure begin with performance at the desired state (or at a minimum within the process control limits) and gradually deteriorate, or drift, away from the standard until a failure threshold has been reached and a failure (injury or near miss) happens. Sydney Dekker explores this phenomenon in the book Drift Into Failure. Essentially we let things get out of hand until failure is all but a matter of time. Think of workplaces where little hazards abound and where any one of these hazards taken on its own, is no big deal, but when working with other hazards can cause a chain reaction of deadly events. Consider, for example, the factory fires where emergency equipment is in disrepair, the alarms aren’t working, emergency exits are blocked, and escape doors are locked. None of these things in and of themselves will injure or kill a worker, but each makes it more likely that should a fire breakout lives will be lost.
  • A sudden structure of a problem manifests as everything operating at the desired state until something sudden and unexpected plunges the operation into failure. Think of a flat tire. You are driving along just fine, hit a pot hole and blowout your tire, one minute your cruising up the boulevard and the next you are on the side of the road cursing your teenage son for making off with the tire jack.
  • Start-Up. Whenever we start a new operation we generally have a period where we struggle to get to, and remain at, the desired performance standard. This is not a license for us to hurt workers, but it should be an incentive to better protect workers by focusing on mitigating severity in addition to trying to predict start up issues. Too many companies misunderstand start up issues and will dismiss any concerns as a need for “work hardening.” Work hardening is the practice of having employees build muscles and generally get used to back breaking work that causes excruciating pain and usually ends in ergonomic injuries.
  • Problems with a recurring structure should be of paramount interest to safety practitioners because, most often, a recurring structure is indicative of a misdiagnosed cause. When you treat the symptoms instead of the cause you frequently see an initial improvement only to see the problem gradually return, sometimes with deadly results.
  • Some problems don’t seem like problems at all. Problems with a positive structure are those situations where the outcome is actually better than expected. But because the situation is better than expected it must be researched so that the positive results can be replicated. Think in terms of a major cause of injuries suddenly falling dramatically. Unless you know WHY you saw the improvement you can never be sure that you won’t degrade back to your old ways.

So What?

Think of all the good that we could be doing instead of arguing about whether injuries are caused by systems or behaviors, multiple causes or a single root cause, or whether a hair-brained pyramid has “at least some useful parts” and concentrated on using a tool-box approach to injury reduction? As the great Peter Drucker said, “the most common source of mistakes in management decisions is the emphasis on finding the right answer rather than the right question.”

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The Power of Pyramids: How Using Outmoded Thinking about Hazards Can Be Deadly


LaDukes Pyramid

 

By Phil LaDuke

 Gallons of virtual ink have been used in writings condemning Heinrich’s Pyramid. But even though a significant population in the safety industry question its validity not only does the malarkey still persist, it thrives. What’s more, people believe accept it as a universal truth in industries where Heinrich had no standing. Throughout my storied career as an organizational change agent and safety strategy consultant I’ve met with resistance in the form of “that won’t work here, we’re not…” fill in the blank. Whether it be mining, Oil & Gas, Chemicals, Aerospace, Heavy truck, the entertainment industry, construction, or logistics the first time I worked in those industries (and yes, I have actually WORKED in those industries) I was met by this objection. Early on I believed that the objection was absolute hogwash but eventually came around to a way of thinking that caused me to stop hawking my one-size-fits-all solution in favor of co-designed and co-developed, shaped interventions that consider the challenges of a given client culture, geographic location, industry, and even site. The solutions tailored to the specific needs of a customer are universally better (or at least as good) as something that the safety conglomerates and mom-and-pop snake oil salesmen have been successfully selling for decades. I even defend this in another blog post In Defense Of Not-Invented-Here-Thinking.

 

If executives in Oil & Gas, Mining, Energy, and Construction et al, rightfully believe that other safety tools and methodologies are not necessarily applicable to their worlds why are they so quick to drink the Heinrich Kool-Aid? Before I answer that, I guess I should provide a bit of background information.

 

For the uninitiated, Herbert William Heinrich was an American statistician who in the late 1920’s and early 1930s studied worker safety in an industrial setting (specifically manufacturing) He created a pyramid based on his “law” that for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injuries. He arranged it in a neat little pyramid and claimed that because many accidents share common root causes, addressing more commonplace accidents that cause no injuries can prevent accidents that cause injuries. He also found that more than 80% of all injuries were caused by unsafe behaviors. It makes sense which is what makes it so dangerous.

 

Heinrich’s Pyramid became a mainstay of safety theory and was largely unquestioned for 80 years or so until Fred A. Manuele reviewed Heinrich’s “research” and found real problems with it. Like Heinrich, Manuele retired from the insurance industry albeit many years later. In his book, Heinrich Revisited: Truisms or Myths, Manuele openly called much of Heinrich’s work into question, specifically:

  1. No one seems able to find Heinrich’s files on his original research making it impossible to peer review (and is accepted practice in scientific research today) impossible. This doesn’t necessarily mean that Heinrich wasn’t spot on, but it does mean that we can never know how he came up with his conclusions and ultimately if there is any scientific or statistical validity to his work. We would never accept these conclusions
  2. Heinrich’s studied accidents that happened in the 1920s, in a manufacturing environment that bears little to no resemblance to the workplace of today.
  3. Heinrich placed a disproportionate emphasis on psychology which impeded his ability to remain impartial. Heinrich asserted that psychology was “a fundamental of great importance in accident causation”. In other words, Heinrich saw exactly what he expected and even wanted to see. He was selling hammers and the whole world looked like a nail. It’s just like optometrists; if you go to one you will most likely get told that you need glasses.
  4. The methodology Heinrich used to generate his pyramid ratios cannot be supported. IN Manuele’s considered and expert opinion “Current causation knowledge indicates the premise to be invalid.” Manuele also pointed out that the “premise conflicts with the work of others, such as W. Edwards Deming, whose research finds root causes to derive from shortcomings in the management systems.”

Fred Manuele suffered greatly for his work. The mouth breathing behavior freaks attacked him and his work personally and professionally, and yet he persisted. In his, Reviewing Heinrich: Dislodging Two Myths From the Practice of Safety, Fred A. Manuele systematically analyzes Heinrich’s work and calls into question two of the most cherished beliefs in the safety community: 1) that most injuries are caused by unsafe acts and 2) that reducing the frequency of injuries will automatically reduce the severity of injuries.

But enough about that, flogging this dead horse will only get me hate mail and death threats from the current freak show of BBS zealots and I have neither the time nor the patience for that. Let’s just assume that you mouth-breathers and snake oil salesmen hate me and would like to see me dead. Get in line. My ex-wife has started a club you can join.

If Heinrich’s Pyramid is so deeply flawed why are so many executives so enamored of it? Simple:

  • We taught them this. There aren’t many MBA programs that teach how to manage worker safety, and the captains of industry rely on safety professionals to provide them with the basic information they need to know to be successful. So many safety pundits, snake oil salesmen and BBS fanatics have taught this dreck as Gospel that it has become accepted.
  • It makes sense. Like so many myths and urban legends the idea that reducing minor injuries and OSHA recordables will ultimately reduce severe injuries and fatalities stands to reason. But just like so many myths and urban legends this assertion ignores some key information. For the pyramid to make sense each hazard would have to have an equal potential to kill as it does to cause a minor injury and that just isn’t true. Let me give you an example. Smoking near a concentration of flammable gas is a) highly likely to cause and injury and b) that injury is highly likely to be deadly. Using a crescent wrench to complete a task that requires a pipe wrench can cause an injury but that injury is far more likely to be a minor first aid case than it is to kill someone. Unless your safety management system has a good way of distinguishing between high risk hazards capable of killing multiple workers (and perhaps members of your surrounding communities) from those that are going require a band aid and a kiss on the boo-boo from a sympathetic healthcare provider you create system where you give the same urgency and attention to a life-threatening hazard that you do to a benign condition.
  • It places the burden on workers to work more safely. How many times have you thought, “if these idiots would just be more careful they wouldn’t keep getting hurt?” Don’t beat yourself up for thinking it, heck we all do at some point or another. Blaming the injured worker makes us feel better. It absolves us of blame for not having done more to prevent the injury and protect the worker. If we emphasize on behavior and individual responsibility over finding and fixing system flaws and improving decision making skills then we can sleep better at night. But what’s more the belief that it’s all about behavior has created a cottage industry of safety incentives, based on the notion that people will take safety more seriously if there is money on the line. Incentives work, unfortunately more often than not the incentive is to commit fraud by not reporting a legitimate work injury so as not to jeopardize a reward for no injuries.

Okay fine, but is this really putting workers at risk? You betcha:

  • It creates a false sense of safety. Too many people believe that the organization working the bottom of the pyramid is actually working. They will proudly point to a significant reduction in injuries as proof that they have slain the injury dragon. Until someone dies. And then someone else dies. And so on until the company breaks out in a cold sweat as the “who’s next?” climate of fear takes hold.
  • It relies on information that you can’t effectively or completely gather. Even if we discount the criticisms of the validity of the pyramid’s ratios the bottom of the pyramid (near misses and unsafe conditions) cannot ever be accurately calculated. How many physical hazards go unnoticed? How many unsafe behaviors happen day in and day out but are never identified? And how many near misses go unreported? Furthermore the information that most companies are able to gather on first aid cases are equally dubious because many workers will treat minor injuries with a quick trip to the first aid kit.
  • It overwhelms safety systems. Many well intentioned safety practitioners actively seek to gather good information on non-recordable injuries only to quickly become immersed in a nightmare of data. Again, because attempts to collect information on hazards and near misses (working the bottom of the pyramid) often lack a means of prioritizing hazards the organization becomes a bureaucratic quagmire of useless data points instead of actionable information.
  • It isn’t equally applicable across industry segments, countries, locations, or sites. Hazards are contextual. Without both interaction and a catalyst the threat of injury from a given hazard is just potential. Welding without a hot work permit is a hazard, but the context can differ wildly and lethally. Is welding without a hot work permit on a muddy construction site the same threat to safety as welding around flammable gas or in a confined space of a mine?
  • It promotes overzealous case management. If the number of OSHA recordables is directly proportionate to the number of fatalities then it would be irresponsible (if not criminal) to not use every tool to reduce recordables. One such tool is case management. Unfortunately while case management can save organizations thousands of dollars and make its safety record seem better than what it actually is; it does nothing to reduce the risk of injuries. So IF the ratio is valid (it isn’t) good case management downplays the risks of fatalities, by seeming to reduce OSHA recordables when it isn’t doing anything of substance.

As safety professionals we have collectively created this mess and it’s our responsibility to clean it up. Here’s what we need to do:

  • Admit we were wrong. We have to suck it up and admit that we have been perpetuating nonsense.
  • Reeducate leaders. We taught the leaders to believe that these concepts would apply in every industry, site, and situation. We now need to correct this wrong-headed notion and look for better solutions for our specific situations. It will send the purveyors of snake oil and the BBS zealots into a fever pitch but we owe it to the workers to correct this mistake.
  • Shift the focus from worker behaviors to leader behaviors. Do you find yourself unwilling to let go of the “unsafe behavior as causation” doctrine? Fine, but recognize that your processes and organization plays a major role in WHY people behave as they do and that the leaders have the single greatest influence on the system and worker behavior. Place the blame for unsafe behaviors where it belongs.

I could go on and on (and in fact already have) but the bottom line is this, as long as we persist in perpetuating these myths and promulgating them across industries we increasingly endanger workers.

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Do Your Safety Management Efforts Lack A Strategy?


 

By Phil La Duke

Many of you (you know who you are) just read this headline and thought, “of course not we have a very clear strategy”. Some of you (not many in my experience) are absolutely correct, while others sadly are deluding themselves. It’s not that you don’t have great ideas or even a first-rate plan, but even some of the brightest and most forward-thinking organizations (and their safety practitioners) routinely mistake a series of seeming related tactics for a strategy. In my experience there are scarce few who understand the difference between strategy and tactics.

Is a strategy all that important? Well…yes. A strategy is the means by which one achieves one’s goals. In safety our goal should be the reduction of risk to the lowest practicable level. The word practicable sends shudders down the spines of good safety professionals everywhere because there is a tendency for organizations to cop out on safety. When we say “practicable” or “practical” it gives organizations a way out. If a problem is perceived to be too expensive or impractical to fix leaders can dismiss it as such and move on with a clear conscious. Of course in the real world we have to recognize that there are limits to what we can or should do in the name of safety, but we have to balance that against the “that piece of PPE is too expensive” excuse making. We as a profession are often rightly accused of going overboard with safety and we need to combat this perception, first and foremost by knocking it off.

We certainly need a strategy, and if we think we already have one how do we know if we don’t? Wow, you’re really asking good questions this week. So let me break it down.

Vision

A good strategy (heck even a crummy one) will clearly articulate where you want to go in quantifiable terms, and that’s where a lot of us safety folks stumble. We tend to speak in the vagaries of trade. Instead of talking about a zero-injury utopia, our strategy should be more solid and tangible. For example, instead of a strategy for reducing injuries (which let’s face it, while this is certainly our goal, effectively we’re just saying we want to fail less than we did last year. What other business function could get away with such a vision?) we might try a strategy for shifting the ownership and management of safety to operations (the people who have the most concrete control over safety).

Value

For a strategy to be successful it must win supporters within the organization and for that to happen the strategy must provide a demonstrable value proposition. People need to understand why accomplishing the strategy is good for them, the organization, or society; in short, people need to know why they should support the strategy.

Values

The ends seldom justify the means, especially in safety and your strategy should clearly outline the guiding behaviors and criteria for success in pursuing the strategy. People must understand what is acceptable and what is unacceptable. Consider the dubious strategy of lowering a company’s injury rate. Is it okay for the people to deliberately under report? Can healthcare providers intentionally downplay the severity of an injury to keep it from being a recordable? Or can case management workers disallow legitimate work injuries by claiming they happened off the clock? In most organizations these tactics would be considered unethical, but for workers to be engaged the organization has to identify the lines before anyone crosses them.

Validation

Throughout the execution of a strategy those involved have to stop and check their progress. Without a criteria for validating whether or not a strategy is still on track things can quickly meander off track and devolve into chaos. Validation can be built into a strategy in the form of milestone and can be managed using metrics that are identified in the strategy.

Victory

A strategy has to do more than just provide a philosophical vision it has to provide a line of sight from the kickoff of the project until the strategy can be seen as a complete victory. The strategy must, in no uncertain terms identify the victory conditions and had best deliver on the value it promised when it was first approved.

So given these criteria do you have a strategy, or do you have a collection of related tactics? It may not sound important, but when you are asked what your safety strategy is you had better have more than a stupid look on your face.

If you do have a strategy and you want to understand how effective it is ask yourself these questions:

  1. How does this activity specifically support the strategy? In a lot of cases I see organizations spending a lot of time and money doing things in the name of safety that have little to do with accomplishing this goal.
  2. How are all of my activities connected? If you can’t draw a clean line of sight between all of your safety activities you should ask yourself why on Earth you are continuing to do them.
  3. Do your metrics align with your strategy? Too often we find ourselves collecting data for the sake of collecting it. We decide what information to collect first and then we struggle with what the information is telling us. The only metrics you need concern yourself with are those that support the strategy or that are required by statute.
  4. Does the activity return commensurate value? In many cases safety practitioners fill their days with things that cost more than any benefit they could ever hope to provide.

Strategy is an area where many safety organizations are weak and without a strong strategy we put our jobs and people’s lives in jeopardy.

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The Leader’s Role in Safety


By Phil La Duke

 

There are a lot quixotic efforts out there to find the one key to making the workplace safety. This search for the safety equivalent of the city of Cibola has led to a lot of flakey methodologies and given rise to the age of zealots in the safety function—people so unwilling to even consider a hint at a new idea that they not only are unable to learn, but who also sour the rest of the organization on sound safety practices.

Much as it would make our lives easier there is no panacea for safety, no golden key that will unlock all the mysteries surrounding injuries, no magic bullet. But insomuch as there is no one thing that we can do that will solve all our problems in worker safety, there is one element of safety that stands above the rest: leadership.

I don’t talk much about leadership in the context of safety. Frankly, the reason I don’t explore the role of the leader in worker safety that often is because it invites a cacophony of whining from the safety practitioners who endlessly bleat about how they suffer in vain because leaders don’t listen to them. I’ve said it before and I’ll say it again: Leaders don’t listen to whiney; “the sky is falling” prattling. They want evidence, cost estimates, and return on investment (not effort, changing the name to “return on effort” is a recipe for disaster).

That having been said, leaders play the most crucial role in safety than any single group. How? Simple:

  • Expect Excellence. To a large extent you get what you put up with. If leaders are happy with a workplace that is “safe enough” they will get the bare minimal. Accepting mediocrity creates a low functioning operation rife with risk. When someone ultimately dies in the workplace the leaders shouldn’t be surprised. The death isn’t just bad luck, but the product of inept leadership that accepts unsafe conditions and behaviors simply as the cost of doing business. In every (and I am loathe to use an absolute, but here it is accurate and appropriate) high functioning and highly effective organization safety is a priority, it’s a deeply embedded value. You can fake a priority, but your values dictate who you are both as a person and as an organization. A leader who doesn’t accept unsafe behavior and conditions will find that more often than not, the organization will rise to his or her expectations.
  • Invest In Competency. Incompetent workers are rarely able to work safe. If one cannot perform the task one is required to do, or if one has not been properly trained in how to do the task one’s job requires, one will likely end up doing it incorrectly greatly increasing the risk of injury and the severity of any injury that does occur. (We tend to focus on preventing injuries and lowering severity of injuries by looking at the process; on how things are supposed to happen, rather than on how they actually happen.) Simply investing in building the core skills of the workforce is one of the best investments an organization can make. Skilled workers miss less time, are more engaged, produce faster and at higher quality. An investment in competency isn’t just an investment in safety it’s an investment in success.
  • Hone the Process. Much as some would have you believe, safety isn’t all about behavior. Machines wear out, tools break, vehicles break down, and facilities deteriorate. (And yes, you can ultimately track all of these things back to some form of behavior, but ultimately this serves only to frame a hypothetical masturbatory intellectual debate that serves no good purpose except to make me want to smack someone.) Leaders, and I am referring to leaders at ALL levels, should look for ways to increase the reliability of the process and to leverage continuous improvement to make the workplace more efficient (and thus safer, there is no such thing as productivity without safety). The relentless pursuit of process variation is characteristic of great leaders.
  • Encourage Sound Judgment. Workers, who stop work to double check the safety of the work, discuss some confusion in the plan or otherwise stop and think before rushing into action should be encouraged for working smart, not punished for slowing operations.
  • Exhibit Consistency. Workers have to know what to expect from leaders. By consistently reinforcing the value of safety and the positive business effects of a safe workplace, leaders create shared values for safety.
  • Sell Safety. Leaders sell safety by believing in it, by cutting through all the malarkey and platitudes and doing the job the right way every time. Only when workers believe that safety is a core value of their leaders will they begin to act truly value it themselves. And by value it, I mean truly internalize it and hard wire it in their work; value not only their own safety but the safety of others as well.
  • Demand Performance. Once the leaders have created the clear and consistent expectation of safety, have ensured that people are able to work safe, created robust processes that produce predictable outcomes, encourage sound judgment and decision making on a consistent basis, then, and only then, he or she needs to ruthlessly demand performance. Demanding performance means holding people accountable for keeping the workplace a safe an efficient place to do our jobs.

Leaders play a pivotal role in worker safety, but that doesn’t get the whiny “but the leaders don’t listen to me” safety practitioners. Safety practitioners ARE leaders, and it is their job to build competence in other operation leaders. The safety practitioners are essential in educating other operation leaders in the discipline of safety. Most operations folks have no formal education in safety methodologies and those who have some idea of safety have often been sold snake oil. If your organization is going to be successful safety practitioners need to step up their efforts to build better leaders. Easier said than done, but whining about it won’t change anything.

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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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