Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

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.

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


Donner pass

By Phil La Duke 

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

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

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

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

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

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

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


Out of Focus

By Phil La Duke

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

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

Obsessed With Preventing Injuries

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

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

Obsessed With Behaviors

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

Obsessed With Finding  Root Causes

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

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

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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.

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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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