Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

Want to Make things Safer? Take More Risks.


By Phil LaDuke

I don’t write for a living; in fact, all the writing I do I do for free. That has more to do with me retaining my rights to the intellectual property than it is to with any sort of altruistic intent. I mention this, because after over 50 published articles and around 250 blog posts I have created the impression that I am primarily a writer; someone who watches the industry and spouts largely academic opinions about work that I don’t really do, that I somehow l lack standing.

As surprising as it is to some, I actually DO work in the field. My particular niche lies in organizational change relative to worker safety and helping companies build a robust safety infrastructure (what point is there in implementing a safety change intervention if there is no means to sustain it long-term?) I begin the process of a safety change intervention (or infrastructure build) by talking to business leaders about their visions—what do they want to accomplish with their worker safety management system. Recently I have noticed a trend: business leaders tend to say they want to be the best, to be world class; and then they are almost obsessive about what “everyone else is doing”.

You Can’t Make an Omelet without Breaking Some Eggs

Becoming the best involves innovating, and innovation involves risk; a great deal of risk. But unless you take the plunge and move outside your comfort zone you will always be following the leader, and nobody ever won a race—or became the best at anything—by watching the leader and doing your best to match his or her every move. The people and companies that become the best do so not by following the leader but by experimenting with things that have never been done. Years ago I was working with a large international company who was at the forefront of culture change relative to safety. My working contact was something of a perfectionist who continually fiddled with the process in an attempt to get things exactly right. The executives above him grew impatient and wanted to implement what my contact considered a half-baked (and by that I mean mostly done, but not quite “there” yet) solution. When my contact protested that the solution wasn’t ready to be implemented, the executive responded by saying that we are operating in uncharted waters and even if we were to wait until the solution was perfect in our minds we couldn’t really know with any certainty if it would work. He said we needed to go with what we had and if it didn’t work we would try something different. My contact saw implementing too early as undermining the solution, essentially an opportunity to fail, but the executive saw failure as an opportunity to learn, and reasoned that the sooner we learned these lessons the better. I learned a lot from that executive.

Benchmarking Isn’t Copying

Years ago I taught classes in benchmarking, and I can assure you that benchmarking is one of the most misunderstood business concepts out there. True benchmarking involves taking a concept from outside your industry and applying it in a new and innovative way to what you do. People often mistake competitive analysis (the practice of evaluating the things you in comparison to the practices of others in your industry). The difference may not seem to be a big deal, but it really is. Benchmarking involves putting a new and different twist on a practice outside your industry or discipline but competitive analysis is another gradation of follow the leader. Benchmarking gets the creative juices flowing and spurs new ideas and breakthroughs.

The Journey is Sometimes More Important than the Destination

The trial and error of innovation can hone an organization’s problem solving skills, investigative abilities, and transform the culture from one asks “what is it?” to one that asks “what could be?” Learning from failure is becomes a habit in organizations that embrace risk taking and innovation and in safety we must learn from our failures to ensure that we don’t repeat tragedy after tragedy.

The Blind Leading the Fearful

So what does this mean for safety? I understand how ridiculous it is to expect safety professionals, who—not to stereotype, but let’s face it—tend to be a risk averse group to take more risks. But as Dr. Robert Long says, “risk makes sense”, and when it comes to safety we really need to stop reswizzling the same old tired snake oil and take real risks. We need to see what we can learn from management systems, lean principles, quality operating systems, and a host of other functions. We need to benchmark, and experiment, and generally turn safety on its ear. We will fail, and in failure we will learn a better way to keep our workers safe in our specific environments. Safety has plateaued in many respects and if we don’t shake things up we run the risk of losing ground.


Filed under: Risk, Safety, , , , , , , , , , , , , , , , , , , , , , , , , , ,

Six Simple Ways to Change Your Life

by Phil La Duke

Years ago I worked in talent development for one of the largest faith-based healthcare systems in the United States. I left it to pursue other career goals but it never left me, at least not completely. The system was founded when two religious orders merged after discovering that the youngest among the two orders was 78 years old. They came together to preserve a way of life that had existed over 500 years. Sure it ran hospitals, but more important was the spiritual community that it had created. Faced with extinction it set about an elaborate plan for turning over its legacy to the laity. I always took that very seriously. For me it wasn’t about organizational development or training, although these were certainly a big part of my job, rather it was about preserving a way of life.
Some time ago I shared the podium at the Canadian Society of Safety Engineers with an anthropologist and National Geographic photographer who talked about cultural extinction (which interestingly enough, he attributed to the growth of the written word). According to him, cultures are going extinct at a far faster rate than animals; it’s scary really, thousands of years of knowledge lost as cultures die daily. I was determined that I would do everything in my power to save this one culture to which I had been entrusted.
I wasn’t the only one so entrusted; there were scores of professionals whose primary jobs were to preserve the mission, culture, and vision of the consolidated order. One of the tools they had for preserving the culture was the Guiding Behaviors (note to the grammar vigilantes: I know this sounds like number disagreement but the Guiding Behaviors is considered one tool). As I reflected this morning, as I do every morning, on these behaviors it occurred to me that these would serve the safety professionals as much as anyone else. I have changed the wording of some of these to make them less specific to healthcare, but I doubt the surviving members of the orders will mind too much.

“We support each other in service”
The first of the behaviors is “we support each other in service” what better way for a safety professional to sum up his or her job? We don’t really save lives—not the way doctors or nurses do anyway—but we can always support people in making better decisions and while not directly saving lives influencing people to save their own lives or the lives of a coworker.

“We communicate openly and honestly, respectfully, and directly”
I’ve written volumes about the importance of open and honest communication. I still believe that the only path for safety professionals to get respect is by truly respecting the people and organizations they serve. It’s disappointing how many safety professionals disparage the people they are charged with protecting. People who feel respected tend to respond respectfully. We must always strive, not only to be truthful, but truly honest and not just with the people we serve but with ourselves as well. And let us never confuse hurtful speech with honesty. Before speaking we should ask ourselves, “is what I want to say true? Is it helpful? Is it intended to help someone or merely to make ourselves feel better? And finally, is it necessary?” if all of these things aren’t true then maybe we should just keep it to ourselves.

“We are fully present”
Perhaps the behavior I struggle with the most is “we are fully present”. Being fully present means that you keep your mind on the job—no multitasking, no distractions, no dreaming about the weekend. While it’s easy to see how staying fully present on the job would greatly benefit most workers—distraction on the job can be deadly—we also need to be fully present as safety professionals. This means really participating in meetings and really listening (not just waiting to talk) and working with others to accomplish things. Keeping your head in the game every minute of every day is really tough and if you try to do it you will come home exhausted.
“We are all accountable”
“We are all accountable” means more than holding others accountable, although that is certainly a part of it. We also must strive to hold ourselves accountable. Each day we must ask ourselves if we earned our pay. Did we make a positive impact in people’s lives, not just in the context of safety, but did we make the workplace (and the world) a more pleasant place? Did we really bring our “A” game or did we merely phone it in? We must also remember that we have a duty to be just in holding others accountable. We do not stand in judgment above those we serve, but we owe it to the organization and to the entire population to hold people answerable—both positively and negatively,
“We trust and assume goodness in intentions”
People screw with our work, our day, and our heads on a daily basis. But trusting and assuming goodness in intentions has taught me one of the most powerful lessons of my life: we screw with our own work, our own day, and our own heads far more often than anyone else ever could. They say that forgiveness is a gift we give ourselves and it begins by never taking slight in the first place. Instead of assuming that the Operations leadership is throwing us under the bus we should ask the person some questions. Most often we will find that because we assume that the person meant us no harm and was probably completely unaware of the issues he or she was creating for us. Assuming goodness in intentions brings a person real peace and strengthens relationships. There is a saying that if you keep meeting jerks all day long the jerk is you. I say that if you assume goodness of intention in all you meet you will live in a world like you could never imagine. Send out good stimuli and you receive good responses.
“We are continuous learners”
Too often we strive to teach. We are, after all, the experts in safety and what good is that expertise unless we share it with the organization? We get sad and frustrated when people don’t want to listen to what we have to say. But when we are continuous learners, when we focus not on what we can teach others, but what we can learn from them, we find that we end up teaching other so much more of value than if we were to just spout facts at them. Continuous learning involves a lot of introspection—we have to examine our mistakes and try hard to understand why things went wrong and what we can do to fix things them.
The World Loves a Hypocrite
While I try to live by these simple six statements I don’t always succeed; in fact I fail a lot. But the beauty of these guiding behaviors is that they are things to which I aspire. So now I charge you to share these aspirations with me. Try doing these six things for a week. You may fail, but remember in some cases success comes, not in the outcome, but in the attempt.

Filed under: Behavior Based Safety, Hazard Management, Just Culture, Performance Improvement, Phil La Duke, Worker Safety, , , , , , , , , , , , , , , , , , , , , ,

What Can The Executive Suite Expect From Safety Professionals

By Phil La Duke

About a year ago, one of my Facebook friends, a nurse, posted a frothy meme about nurses.  “we’re not maids, we’re not you’re kids baby-sitters…” and it went on from there;  a post filled with vitriol and resentment for the patients and their families for which they serve.  I commented that if she felt such bitterness at her constituency perhaps she should choose a different profession instead of whining about it on social media.  I observed that the nobility of any deed is lost when one complains that one does not get one’s proper recognition, appreciation, and accolades.  She responded by “defriending” me; good riddance. I’ve seen similar posts from policemen, fireman, and teachers and the common thread—besides being whining malcontents—is the intense lack of judgment shown by people who publicly deride their constituency. I have never trusted people who define themselves in terms of what they aren’t; me thinks the lady doth protest too much.

While I haven’t seen anything posted on Facebook where a safety professional bellyaches about the lack of appreciation shown to him or her, LinkedIn threads are rife  with complaints from long suffering safety professionals about those that lead their organizations.  From the vague lack of support to accusations of ethics just south of Heinrich Himmler, safety professionals have a lot to say about the executives of their companies and most of it is bad.  One common complaint is that even the best-intentioned executive is a slobbering oaf when it comes to safety.  Safety professionals say they want more educated leaders but scarce little is done in terms of what the executives should be able to expect from their safety professionals.  So what should the executives be able to expect? What are the baseline things that business leaders should be able to count on from any competent safety professional?


At a most foundational level an executive should be able to count on the safety professional to have mastery level knowledge of safety regulations and compliance.  The safety professional should be expected to know and understand what must be reported, how basic regulatory metrics are calculated, how safety data should be interpreted, and where to find more in-depth explanations of the most common safety questions relative to the appropriate industry.  There are limits to what the safety professional should know, of course, after all they aren’t lawyers, but the safety professional should be keenly aware of his or her limits and be open with the executive as to where the safety professional’s skill set ends.

Honesty & Integrity

Safety professionals should always be honest with the executives—if it is a good idea to do something then that’s different from it being a legal requirement.  Safety professionals who use a liberal interpretation of regulatory requirements to push through a pet project are not to be trusted.  It’s this sort of moral flexibility that gets some safety professionals in trouble.  Executives need safety professionals to keep them on the right side of the law, not just compliant.  In some cases, the performance of the safety professional can be the difference between an executive being charged with a homicide.  The honesty and integrity of the safety professional must be above reproach.  Conversely, if a safety professional falsifies data, deliberately underreports, or otherwise subverts the law, then the executive may fined him or herself in legal hot water because of what the executive knew or should have known. Executives have the right to expect the safety professional will assertively point out when the executive is dangerously close to a legal or ethical breach.


Safety professionals should be dispassionately reporting the facts.  Executives should expect safety data to be free of commentary, sermons, melodrama, or pontifications.  The safety professional should be reporting facts, assessing risks, and professionally interpreting trends.  The safety professional should then be presenting recommendations that are free from personal agendas and editorializing. An executive needs a recommendation that clearly articulates the expected benefits, risks and rewards, and likelihood of success, not a lot of campaigning for a pet project.

An Informed Opinion

Executives count on experts to guide their decision-making and for that to happen they need the safety professional to distill, often complex data and safety trends into meaningful and useful chunks of information.  Too often the executive is given jargon-filled gobbledygook that he or she finds of little use. Most of all, the executive has the right to expect that the safety professional will always understand that no matter how informed the opinion it remains just that: an opinion. Asking one’s opinion is not allowing one the power to make a decision for you.


Professionalism must extend beyond the normal niceties of office etiquette and assertiveness and move into the realm of true professionalism; the safety professional has a specialized skill set that must be brought to bear in situations with a lot of unknowns and ambiguity.  Executives need skilled experts in worker safety not zealots and martyrs who believe that their job is more of a spiritual calling than a job.  Executives neither want nor can afford a softheaded boob at the helm of the safety function.

Business Savvy

Calvin Coolidge once said, ““the chief business of…people is business” but he’s often misquoted, as “the business of business is business”. However you interpret the quote one must agree that the primary goal of any business (heck any organization) is its own propagation.  The executive’s first directive is always to ensure that the business continues to exist.  Safety people often lose sight of this.  Hiding behind the self-righteous indignation and pronouncement that safety is more important than anything in all cases alienates executives.  And while nobody wants to risk people’s lives in favor of the immortal buck, executives have the right to expect that safety professionals will understand that within ethical and moral boundaries safety isn’t always the most important consideration and even in cases where safety may be the most important consideration it may not be the most urgent.


Often the executive will make decisions that aren’t especially popular with the safety professional.  It is not incumbent on the executive to explain his or her rational for making a tough call, in fact, the executive may not be able to legally or ethically disclose the “hows” and “whys” of a decision.  Executives have the right to make these decisions without the safety professional bad mouthing him or her behind his or her back.  Safety professionals who get sarcastic, rude, or pouty because the executive made a decision that was not to their liking lack the respect that the executive is owed and should not be surprised by the consequences.

A Clear Definition of “Support”

The biggest complaint I hear from safety professionals is that the executives don’t support them (or that the executive don’t “back them up”) but when I ask for details I seldom get them.  When I talk to senior leaders they tell me “I give the safety professionals whatever support they tell me they need”; clearly there’s a disconnect between the two worlds.  Executives tend to be reluctant to buy the proverbial “pig in a poke” and may actually believe they are supporting the safety function even though the safety professionals feel very differently. Clearly leadership is essential to a robust safety effort, but unless all parties can pinpoint exactly what “support” means one side or the other (or both) are likely to be disappointed.

Filed under: Safety, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Maybe You Weren’t Fired For Sticking To Your Principles

By Phil La Duke

“I was sad because I had no shoes, until I met a man who had no feet; so I took his shoes.”

hung over mandrill

In case you were wondering, this is what I imagine a hung-over mandrill looking like

The other day I met a man who lost his job. His tale of woe may ring true for some of you; he squared off with a company leader over a safety issue. Things got heated and when things cooled down he found himself sacked…again. You might suspect that I would devote this week’s post to all the injustice associated with people, particularly safety professionals, who lose their jobs because they are forced to choose between their principles and their livelihoods, but alas, sadly you would, yet again be wrong. The person in question is a known hot head who, apart from being euphemistically described as “rough around the edges” has a penchant for going on rabid attacks. He is disliked by many and respected by few. I’d like to assume the best about people, but when you’ve lost your job several times because you’ve lost your cool…well at some point I’ve got my doubts.

If You Can’t Tell Who The Mark Is, It’s You

There’s a saying going around that says, in effect, and I will clean this up for those of you of delicate sensibility, that if you keep meeting “jerks” all day, than you’re the “jerk”. Speaking as a “jerk” of note I can attest to the truth of this saying. As it happens, I’ve also heard a lot of safety professionals bitterly complain about being fired, admonished, disciplined or otherwise pimp-slapped by their employers simply because they were trying to do their jobs. These, the wretched refuse of the safety profession, commiserate with each other, their shoulders sagging, spirits broken, kept upright only through the inflation of self-righteous indignation, decrying the injustice of it all. But is it really unjust? Or is it as likely that these buffoons were served their just desserts and found the taste unpalatable? Of course it’s true that there are safety professionals who have been unceremoniously relieved of their positions for no greater offense than advocating for safety. I only say this because I can here the murmuring of the pain-in-the ass contrarians that will inevitably throw up statistical outliers as proof that I don’t have standing to speak out on a subject. So while I make no claim of the universality of situation I will say this: a lot of safety professionals who believe they have been fired, censured, or otherwise have suffered unpleasant consequences have actually been fired because they have the interpersonal skills of a hung-over mandrill.

I’m Only Doing My Job

A lot of malcontented safety professionals will loudly protest that they got into hot water when they were only doing their job when in fact they were doing their job poorly. Maybe they did; history will judge them. The point being that, from the guards at Auschwitz to the surly safety manager, many people try to excuse some pretty reprehensible workplace behavior as merely doing your job. The more noble the calling the more likely one is to excuse dysfunction as a necessary, if not admirable part of the job. Safety professionals often believe that the fact that they are “trying to keep people safe” excuse some pretty awful “bedside manners”. It becomes more a matter of HOW the job is done than whether or not the job is done at all. It’s like the policeman who writes you a citation and throws the book at you while adding a little sermonette as he hands you the ticket. Even though you know you are in the wrong and that the officer is under no obligation to give you a break, you may still prefer that he keep the commentary to himself. And many policeman will be jerks to you when you get a ticket and—despite being jerks about it—puff out their chest and steadfastly refuse to apologize for “doing their jobs”. Now, suppose you are in a position to influence that officer’s career advancement? Are you going to be able to overlook the fact that he does his job while acting like a jerk? If so, you are a better man than I. If not you can probably understand where I’m coming from.

Life Without Consequences

It seems to me that there are many people—not just safety professionals, but workers of all stripes—who believe that they can treat others in the workplace (coworkers and even customers) however they see fit in the name of being plain-spoken, tough, or “keeping it real”; these people believe they can live a life without consequences. This idea is typically reinforced throughout their careers because their technical expertise makes them seem invaluable to the company. Some are legitimately bent—either functionally mentally ill or simply social maladroit—while others simply behave like bullies, fussing and fuming their way through life. Add to that the mistaken believe that some safety professionals have that they are the policemen of the workplace.

It’s Not Always The Jerk’s Fault

Loud-mouthed jerks typically remain loud-mouthed jerks because they are rewarded for it. They snarl at waitresses and get refills of hot coffee, they yell at coworkers and things get pushed through; special exceptions are made just for them. They come to see themselves as perfectionists, tough-but-fair, and no-nonsense. Meanwhile the bar tender is slipping a few drops of Visine in their meticulously specked Old Fashion. I’ve long thought that society in general would be more polite and generally more civil if more people had been beaten within an inch of their lives after some of the stunts they’ve pulled, but alas folks have just got too civilized I guess. What’s more, most of the biggest workplace jerks I’ve ever known—the type of people who throw tantrums the envy of a silver-spoon 4-year old, put like felt up prom dates, and generally act in ways that make you shake your head—have had numerous warnings and “one last chances”. If the behavior works why not stick with it?

The Things We Don’t Remember And the Things We Can’t Forget

I can already hear the murmurings from people who will accuse me of suggesting that safety professionals need to sell out if they want to keep their jobs. Nothing could be farther from the truth. In fact, even a cursory read of my body of work will demonstrate my deep belief that safety professionals who remain passive in the face of gross violations, ethics abuses, or other attempts by employers to subvert their legal or moral obligations are cowards and thieves ; shirking one’s responsibilities to avoid conflict and even to save one’s job is tantamount to malpractice.

That having been said, today’s safety professional has to be persuasive and understand that his or her opinion, professionally informed not withstanding, just that: opinion. If people can’t hear past the dysfunction we cannot be effective in our roles . Maya Angelou said, “At the end of the day people won’t remember what you said or did, they will remember how you made them feel.” I think this quote is the essence of what I’m trying to say. People will forgive us for being incompetent screw-ups who don’t know beans when the bag is open, but if we’re jerks, they will lie in wait for us to screw up. You don’t have to be popular to be an effective safety professional but it sure helps.

Filed under: Just Culture, Safety, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Creating a Culture of Safety Excellence

by Phil La Duke

There’s been a lot of yapping in the safety community about creating a safety culture and some of it has merit and some of it is just yapping.  In fact, there are a lot of people working in the safety profession who know as much about changing a corporate culture as they do about building an aircraft carrier.

A note about the photos in this week’s blog, I took these photos at the Detroit Institute of Arts, they are images from the mural painted in the courtyard by Diego Rivera.  A masterpiece you can only see in Detroit.


Contrary to what many will tell you, a culture is more than just “how we do things around here” it’s the codified set of behaviors that keep us from killing each other.  People who study corporate culture and change talk about culture in terms of:

  • Norms. Norms are the accepted practices and methods of a population.  Norms determine what the population judges as “normal” and what is “abnormal”.  Norms form the foundation for etiquette and identifies what is polite or impolite.  To a large extent, norms determine an individual’s success.  When new people join a population there are strong incentives to learn and adopt the norms.  One does not feel comfortable until one is completely operating within organizational norms.
  • Habits. The secret to change lies in understanding how our habits to a very large extent determine how we live our lives and whether we become morbidly obese, change-smoking, degenerate gamblers. In his 2012 book “The Power of Habit: Why We Do What We Do In Life and Business” Charles Duhigg explores how, despite free will, most of us live our lives doing things that are self-destructive, unpleasant, and that inhibit our success merely out of habit. Duhigg believes that organizations, like individuals, operate largely out of habit, and while it may seem that people at the top of organizations are geniuses or imbeciles, much of a organization’s performance is rooted in habit.
    Habits can be helpful or harmful. Some habits, like getting up early to exercise, carry with them significant benefits, while others, like eating when you’re not hungry, can cause serious, long-term health problems; its no different with organizations and those of you who are looking to change the “safety culture” of your organization should pay very close attention to those habits that are having the greatest influence over the relative safety of the organization.
  • Shared Values & Taboos. Every culture is marked by a collective sense of what is important (values) and the things that are, without exception, unacceptable (taboos).  Shared values not only shape the key decisions made by leaders in an organization, but also make the actions of leaders more predictable which in turn reduces stress and uncertainty in the population.  Taboos make it easy for the entire population to know where the line is and to expect certain and uncompromising reprisals for those who violate a taboo. Shared values and taboos are often informal and unwritten and may well conflict (typically in dysfunctional organizations) with the expressed values or official policies.

Culture versus Climate


A culture is a deeply embedded and codified set of expectations; its largely unconscious—people may aspire to change or direct a culture, but they are seldom successful except when those trying to change.  Cultures are how companies survive and thrive and, as such, it is deeply imbedded in the collective psyche of the population.  Climate, on the other hand, refers to the largely transitive state of the environment.  Climate change is most often driven by an intense outside force that is generally short in duration. The resulting change is typically rapid but it is rarely lasting and things quickly revert back to the old state once the outside force is removed or even lessened.

The term “safety culture” has become muddled by years of misuse and hype by safety vendors who purportedly bring culture change but bring climate change instead.  James Reason, the father of Just Culture, believed that before a company could move to a culture of safety it had to first create a culture of justice.  Throughout the years, a mixture of a confusion over Reason’s teachings and out and out misleading branding created the idea that somehow some companies had a “safety culture” while others did not.

All companies have a safety subculture, in that all companies have norms, habits, values, and taboos related to safety.  So essentially, “safety culture” is a subset of the overall corporate culture and is characterized by:

  • Safety Norms. The things that are accepted practice within safety.  Safety norms can be as simple as the example set by a veteran worker and emulated by new workers or as complex as the ways that workers interact with leadership and the safety function.  Norms are typically the unspoken and even subliminal acceptable ways we do things.  Organizations tend to reward those who follow the norms in safety and punish those who don’t, often without even being conscious of doing so.
  • Work Habits.  All organizations have a slightly different risk tolerance and one company’s killer job is another’s routine work. Risk tolerance is highly influenced by national culture as well as by safety norms and other subcultures.
  • Shared Values & Taboos about Safety. Every organization has an imaginary line when it comes to safety.  Once that line is crossed the individual who crosses it is judged to be reckless and to have taken an unreasonable risk.
  • Something Every Organization Already Has. As I mentioned, every organization has a safety culture, but every organization’s  is unique. Understanding how your culture views the safety of the workforce takes research and an open mind.  It is often extremely useful to have an outside set of eyes (not necessarily a vendor, it could be a customer, or someone from another location) to view your culture and identify the value it places on worker safety.


The leader plays a pivotal role in worker safety and in shaping the culture.  Ideally, the leader’s behaviors are in alignment with the desired, norms, taboos, and habits of the organization, but when they are not, these leaders tend to be pressured out of the organization (although too often they create a great deal of dysfunction before they go).  There are two ways in which leaders influence the corporate culture: how they behave and how they manage.

The Shadow of the Leader

Strong leaders create such a powerful influence that their personalities can be seen in the attitudes and behaviors or those who work for them.  Bellicose tyrannical leaders tend to produce departments where individuals scream and bully other departments to get their own way, where leaders who exhibit a strong ethical sense and who reinforce the values tend to produce people who act likewise; it’s not magic, people have a very strong drive to conform.  So in a very real sense, leaders shape how the organization behaves and make decisions.


Dysfunctional Management Breeds Dysfunctional Operations

It should surprise no one that organizations with poor systems tend to produce a great deal of chaos and a periodic review of policies and procedures is necessary to get better results.

Ultimately, the leader determines whether the workplace will be dysfunctional or productive, and whether or not people will make good decisions or take reckless chances.


Mao said, “all change comes from the barrel of a gun” and I think there’s something to that.  Before people will even consider changing they will explore every option that allows them to keep doing what they’re doing. People will resist change even if they believe it will likely benefit them, why? Because of fear of the unknown. Why do we tell our children not to take candy from strangers when everyone knows that strangers have the best candy? Simple, subconsciously we play out a really simple and pragmatic decision making process: we must assume the unknown will harm us to survive. To foment change we must convince the population that it cannot survive and thrive if we continue to operate in the way we have been. We must make taking the candy from strangers the most attractive, or at least the least loathsome option, and that takes some doing.


One of the best ways to foment change is the financial argument.  Injuring workers costs a LOT of money, and the bulk of the population is either convinced that all management cares about is money or is open to the possibility that operations that aren’t financially successful will be closed, sold, or face pressure to make brutal cuts in benefits and even pay.  Also, tapping into whatever your organization finds most important—whether that be productivity, tonnage shipped, or whatever—and expressing the costs in those terms (we would have to ship an additional hundred tons of cargo to recoup that cost.  It makes an impression.


To some extent, there is, or should be, intrinsic dissatisfaction of the status quo if anyone is getting hurt on the job.  But in cases where there is a fair amount of organizational inertia, fomenting dissatisfaction can be tricky.  Even organizations that ostensibly are dissatisfied with some element of its performances may be fiercely resistant to change.  Dissatisfaction with the end result doesn’t always mean dissatisfaction with the status quo, and many organizations perish because, despite a deep and abiding dissatisfaction with its performance it is not particularly dissatisfied with its current tactics.

Why Does The Organization Have To Change


Dissatisfiers must be compelling and easy for the average person to understand.  True dissatisfaction comes from the answer to the question, “why do we have to change?”  When it comes to worker safety the answers tend to be pretty simple:

  • Changes in Our Business Environment. Applying static solutions to dynamic problems lead to disaster and clinging to those static solutions until it is too late has driven many companies out of business.  The speed at which our business environment changes dictates the speed at which our culture must change to address the outside forces. In safety, the cost of worker injuries (both direct and indirect) are driving changes in our safety strategies and tactics.
  • Changes In Society’s View of Workplace Deaths and Injuries. Both my grandfathers died from workplace injuries. My father and brother-in-law both died of work-related illnesses. I lost a great uncle to a workplace injury, and I’ve lost count of how many friends I’ve lost to workplace injuries.  In many of these cases, people looked at what happened and said, “that’s a shame”. Today, these deaths may well have been prosecuted as homicides! The point is that while there was a time when workplace deaths were seen as unfortunate incidents, society now views them as completely unacceptable.Rising Insurance and Medical Costs.  Rising insurance and medical costs are big news.  For years these costs have sky-rocketed and now are at the point where companies with poor safety performance are finding it difficult to compete.
  • Growth. The business strategies for running a small company aren’t the same as those for running a midsized company which aren’t the same as for running a large company.  Organizations that understand the need to upgrade accounting, IT, and sales systems to accommodate growth often miss the very real need to upgrade safety management systems as well.

Making the Case For Change

IMG_0209_1 When creating dissatisfaction, you have to make the business case for change.  Often, leaders will adopt a “if it aint broke don’t fix it” approach to organizational change; this approach is often dangerous and irresponsible.  When making the case for change you should be able to articulate the answers to these questions:

  • What is it about the current state that is unacceptable?
  • Where would you like to take your organization?
  • What is the difference between where you are and where you would like to be?

The Cost Of Safety

The cost of safety (both direct and indirect) must be calculated and shared in a way that is meaningful to the organization.  Expressing the cost of safety in ways that reflect the corporate culture are key to making safety a priority.  For example, if your corporate culture places a high value on sales, then expressing the costs of safety in terms of the added sales required to replace the money spent on worker injuries is a great way for the organization’s leadership to connect the dots between sales and worker injuries.


Also, it is important that you use actual cost figures and avoid averages, formulas, or other ways to calculate the “true cost of injuries.” These injury calculators use averages derived from figures across all injuries.  Unfortunately, the spectrum of injury costs vary widely and where your particular industry falls on this continuum (or where your company falls on the continuum within your industry) will rarely represent your actual costs.  It’s a lot of work to research and calculate these injury costs but the alternative is for an executive to (rightly) dismiss your figures as conjecture.  In many cases, your figures will be significantly higher than those calculated by formulas any way.  And if you’re figures aren’t particularly compelling (some companies don’t spend much on worker injuries, and may in fact not hurt many workers at all, until they have a catastrophic system breakdown that causes a fatality) you shouldn’t be focusing on cost and shift your attention to something more appropriate to your situation.


Dissatisfaction with a compelling vision for success leads to frustration and dysfunction.

Why Create A Compelling Vision For Success?

Beyond the need for a vision for a better workplace you have to create a vision that makes sense to your organization and to do that you have to create a vision that details precisely what the desired behaviors look like.  In many cases, the desired behaviors are simply a reiteration of your expressed values; getting people to “walk the talk”. Creating a vision for appropriate behaviors should also address norms and confront norms that don’t match the corporate values (“we say we want “’X’ but we do ‘Y’  instead).  The vision should always be crafted such that it remains in the context of the dissatisfaction (“we are doing this because we don’t want “Y” any more”).  You can’t achieve change without changing your organization’s habits and norms.


Creating a Compelling Vision of Success

A compelling vision of success answers the question,  “What do we want our culture to look like?”  While this may sound like an easy question, it can be difficult to answer.  In fact, you need to ask yourself what you need to do not only to create of vision of success, but also to make it reasonable, practical, and achievable? I  can’t answer that question for you; in fact, no one outside your organization can.  While outsiders can facilitate sessions that lead you to answers to these questions, no outsider will ever know your organization better than you do; beware and avoid those who think they know your world better than you do.


Culture And Habit

Many of are norms are really just organizational habits.  In his 2012 book, The Power Of Habit  Charles Duhigg explores how institutional habits effect populations.  According to Duhigg, habits essentially burn a path in our brains which allows for automatic behavior.  This path allows our brain to have a sort of a subroutine that helps to automate behavior.  Duhigg believes that once a habit is truly formed it can never be erased.  The key, Duhigg says, is to overwrite a new, acceptable behavior over the existing undesired one.  Duhigg also believes that there is little difference between personal habits and institutional, or cultural habits.  Habits, according to Duhigg, form a loop.  They begin with a cue, for example boredom, followed by a routine, buying a snack from the vending machine and visiting with coworkers, which leads to a reward, in this case social interaction.  If an individual wants to lose weight and stop ingesting unhealthy calories will have greatest success by keeping the cue and reward the same, but substituting the routine for something healthy, for example walking around the block, while keeping the same reward (that is, social interaction after the routine).


Of course to make these kinds of changes (in your personal life or in your organization) you need to become very aware of the cues and rewards associated with the habit, and this in itself can be very challenging. In my experience an organization’s bad habits around safety tend to manifest most frequently in what I call the Seven Pillars of Safety Excellence.

Focusing On Getting It Right

In safety, it’s easy to focus on the negatives.  Organizations tend to address worker safety in a series of “thou shalt not…” statements.  It’s easy, for example, to create policies that forbid working on energized equipment without first locking out. But these kinds of fiats aren’t all that effective.  People tend to pick and choose which rules they follow and which ones they ignore.  (in fact, I wrote an article on this subject Why We Violate The Rules ).


A better way of effecting lasting change is to work to instill values.  Many companies have their golden rules, or safety commandments, but in a few rare cases there are companies that have created an atmosphere where people behave in a way that truly supports worker safety and a brother’s keeper mentality.  So what’s the difference between the companies who have slogans hanging on the walls and those whose values are manifest in the workplace?   The successful companies make decisions from the top of the organization to the grass roots based on deeply embedded values that model the “right thing to do”.

To mimic these companies’ successes, you should:

  • Plan for Success. This may sound trite, but success is impossible without active planning and a whole lot of work.  No pun intended, but success in worker safety doesn’t happen accidentally, rather, it is the product of hard work on the part of dedicated and talented people.
  • Create a Compelling Vision of Success. I mentioned creating a compelling vision of success before, but it is important enough to repeat it.  A compelling vision of success isn’t a safety slogan or a lofty bit of prose hanging in the corporate headquarters lobby.  A compelling vision of success is a simple statement that clearly illustrates how the organization is going to approach keeping workers out of harm’s way; it’s the things people must do to keep themselves and their coworkers alive and unharmed.
  • Defining desired habits.  It’s not enough to write a list of things people need to do to stay alive, you must also tackle the habits that typically prevent people from doing these things. Using our lockout example, one might include a statement like “we always ensure that energy has been isolated and controlled before attempting maintenance” but unless you also seriously consider the reasons people might  NOT always do this your vision of success doesn’t ring true.  It becomes a platitude instead of a guiding value or governing behavior.  When defining the desired habits you need to take a hard look at “what about when…” statements or “except for…” conditions.  If you don’t address the cues and rewards that lead to dangerous behaviors your vision will fall on deaf ears.

Crafting Next Steps

Schein’s final element of change is next steps.  A dissatisfied population with a compelling vision for success is powerless and rudderless without clear and practical next steps.

I mentioned a moment ago that I would explain what I see as the Seven Pillars of Safety Excellence.

safety house

Early in my career I was fortunate enough to participate in benchmarking the world’s safest companies and in so doing I discovered seven elements essential to achieving safety excellence:


Training isn’t limited to safety training, in fact, the most important training for keeping workers safe is in their core competencies; workers who don’t have mastery of their basic jobs can’t do their jobs safely.

Process Capability

If your process isn’t robust and stable you subject your workers to risk of injuries

Hazard and Risk Management

Removing hazards before people get hurt is the key to a sound safety management system.

Incident Investigation

When we understand and correct the causes of injuries we can prevent them from recurring in other areas.

Strategy Deployment

Too few organizations have any real strategy for safety. Safety strategy involves taking a big-picture look at the safety of the workplace. Safety strategy development should establish periodic reviews of policy to ensure that anachronistic rules, policies, and procedures do not jeopardize worker safety.


Accountability is different than blame.  Safety excellence depends on good systems of accountability that hold employees answerable for the risks they take.


Workers at all levels must be empowered to make sound decisions and to take action to make the workplace safer, but beyond mere empowerment workers must be engaged. Empowered workers are entrusted with the right to make decisions but engaged workers intuitively know the right decisions to make.

These seven elements are typically where a company picks up bad habits.  It’s not that companies don’t do these seven things, rather, it’s HOW they do them that can make or break their efforts at making the workplace safer.

Create a Cultural Infrastructure: Embed Safety Into Your Operational Practices


One of the Pillars of Safety Excellence that stands out for me is engagement.  Engagement at all levels is essential to maintaining a safe and productive workplace.  Engaged workers do things just because it’s the right thing to do. A motivated worker will work to get a reward or safety incentive, but an engaged worker will continually look for ways to make the workplace safer because making the workplace safer is the right thing to do.  It’s in his or her best interest to work safely; it’s in his or her coworker’s best interest to work safely; and it’s in the company’s best interest to work safely.

Never Underestimate the Importance of Empowerment

Creating a common-sense infrastructure around the Seven Pillars of Safety Excellence is the key to creating a safety management system that is not only sustainable, but can morph and grow as your business needs change.  I have helped companies create safety management systems almost ten years ago and not only are these systems still in place, but they are thriving.  In each case, these systems (built around changes to their approach to each of the Seven Pillars) look very different than the ones that I helped these companies design and build.  These systems grew and changed in response to (or in anticipation of) changes in the business climate.

The secret to the success of these systems lie not in what was done, but also what wasn’t done. Essentially, the approach was to sandwich new behaviors between existing, familiar behaviors. By maintaining as much of the existing infrastructure I was able to retain the cues and the rewards, and successfully replace the poorly performing routines with highly effective ones. Even so, the credit goes to my customers who took the time, committed the right people, and spent the resources necessary to identify the cues and rewards and trust in the coaching that they were provided. I learned on those projects that change is more palatable when it is surrounded by things that won’t change.

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The Madness Of Measuring Nothing


By Phil La Duke

These days’ organizations live and die by measurements. It seems that no matter where we work we are confronted with the dreaded balanced score card and so we are tasked with measuring “safety”. I’ve said for a long time, “the absence of injuries does not denote the presence of safety” and zero injuries doesn’t tell us a heck of a lot about the risk of injuries within a given population.

The traditional measures of safety, i.e. injuries or days away or restricted time, don’t help us predict the likelihood of future performance, and yet that is the best we seem able to come up with. We play at leading indicators like near miss reporting (as somehow indicating the level of participation of workers in safety) but even these measurements are fraught with statistical noise that can lead us to conclusions not in evidence; so many of our indicators mislead us that one has to wonder if there is any value in them at all.

Recently I was asked to address a meeting of the senior leaders of a multi-national manufacturer and I was asked what some good predictive measures would be for safety. I was pressed for time and I’m afraid I didn’t have the luxury of a prolonged discussion on metrics (my topic was Creating A Culture Of Safety Excellence). So given the fervor set in motion from my last three posts I thought I would add a bit of metaphorical fuel to the fire and lay out for professional debate, what I see as some good ways for correlating business measures to future performance in safety.

Risk Factor #1: Worker Stress and Distraction

Worker stress has a profound impact not only on human error, but on risk taking, and worker’s health as well.  Highly stressed workers are distracted and distraction leads to mistakes which lead to injuries.  Some measures that I think directly correlate to worker stress are:

  • Worker absenteeism.  Absenteeism rates are indicators of both worker stress and worker competence. Research has shown that stressed workers tend to miss more work, and when a worker misses work, his or her job is done by someone less skilled, less practiced at the job, and therefore more likely to deviate from the standard.  In other words, the worker stuck doing the job is at greater risk of injury than the worker whose muscle memory is completing many of the tasks by rote.  Of course this isn’t universally the case, but it is true often enough to correlate, and when it comes to prediction, correlation is the best we’ve got.
  • Number of calls to employee assistance programs.  When we talk about worker distraction, we tend to think in terms of distractions borne in the workplace.  Workers who are worried about financial problems, divorce, or other “off-hours” problems while working face the same dangers as those distracted by work issues.  The number of calls to EAP lines can provide a good idea of how much distraction is in the workplace which correlates to human error, behavioral drift, lapses in judgement and ultimately  workplace injuries.
  • Worker turnover.  Employee turn over creates risk in much the same way absenteeism does: it introduces greater variation into our work processes which in increases the risk of injuries.  The greater the worker turnover rates the higher the risk of injuries as newer, less competent and skilled workers replace higher performing, more experienced workers.
  • Engagement survey scores. Engaged workers tend to do things because these things are the right thing to do.  The lower the level of employee engagement the higher the risk of worker injuries.

In all these cases we have to remember that we seldom have a perfect correlation (a case where everytime factor A is true factor B is also true) and even in those rare cases where there is a perfect correlation such a condition does not mean that there is a cause and effect relationship between two factors.  But since we are looking at the measurement’s predictive value there is always a margin for error, statistical anomolies and statistical outliers.  If we had a perfect way of predicting exactly where and when an injury would occur we would be using it. 

Risk Factor #2: Worker Incompetence

When we talk about worker incompetence, we’re not talking about the nincompoop  who doesn’t seem able to do even the most rudimentary task without screwing things up, rather, we are talking about the skill level at which a worker is able to perform his or her job.

There is a strong correlation between level of mastery at which a worker performs the tasks associated with his or her job and the risk of injuries.  To that end these measurements are appropriate and predictive:

  • Required training % complete. Assuming that we require training because it is necessary to do one’s job, the lack of this training would indicate process variability.  Tracking the percentage of training provides us with a glimpse of how much risk a worker faces of being injured because he or she performed a task improperly.  The greater the percentage of people who have completed training the lower the risk of injury because of a gap in essential skills.
  • % of licenses and certificate expired. Just as the percentage of required training that is complete provides us with an understanding of approximately how many people are likely working out of process (it’s tough to do the job right simply by guessing) so too does the percentage of workers who are working despite having expired licenses and certificates.
  • Time to complete required training.  The longer it takes to complete required training the longer a worker is exposed to workplace risk associated with a skills gape.
  • Worker performance appraisal scores. This particular measure is tricky—it assumes that the worker appraisals are fair assessments of the worker’s ability to accurately complete tasks and do the job. Assuming that there is a robust worker performance appraisal assessment the lower scored individuals should be at greater risk that those who are peforming at higher levels. 

Risk Factor #3: Leader Incompetence.

Workers generally perform in ways for which they are rewarded and eschew behaviors for which they are punished. Low-performing leaders often exacerbate safety issues by behaving inappropriately in their interactions with workers. Some measures that I think directly correlate to leadership competency are:

  • 360 Reviews. 360 Reviews, that is, reviews where a leader’s team members, boss, and peers all contribute to the review, are often excellent indicators of how well a leader interacts with his or her team. The weaker the leader the higher the risk of process variation and hence a rise in the risk of injuries.
  • Leader performance review.  Leaders who perform poorly are generally allowing more variation into the work area the higher the performance of the leader the less likely workers will be harmed on his or her watch. It’s important to note that the leader’s performance review will most likely include things like the productivity of his or her team, general performance in things like cost, quality, and efficiency, in other words, things that will either directly or indirectly impact the risk of injuries.
  • Worker morale.  Of course worker morale can be effected by a host of things unrelated to the leader, but worker morale is heavily influenced by the performance of the leader.  Workers suffering from poor morale generally perform at lower levels which fall outside the processes control limits.  The worse the morale the higher the risk of variation and ultimately injuries.
  • % of safety reviews completed on time. I am not a fan of “behavioral observations”; I’ve always felt the time watching someone work could be better spent taking a more holistic view of worker safety by reviewing the risk conditions (procedural, physical, or behavioral).  That having been said, it is important that leaders conduct routine and repeated inspections of the workplace to identify hazards.  The percent of safety reviews/tours/inspections/observations completed on time is a, at least ostensibly, an indicator of the time to which workers are exposed to hazards.
  • % or performance reviews completed on time.  Completing performance reviews on time isn’t just about making employees feel good, it is also about assessing competency.  The more reviews that are completed on time, the more skills and performance gaps are identified in a timely manner.
  • % Attendance at safety meetings.  The percentage of safety meetings that a leader attends provides a good insight into the level of priority on which the leader places on safety. 

Risk Factor #5: Process Capability

Process variability creates risk; to the product, to the equipment, and to the workers.  The frequency and duration of non-standard or out of process work is a good predictive indicator of risk of injury.  Good measures of process capability (relative to safety) are:

  • % of nonstandard work.  Statistically speaking nonstandard work tends to be more dangerous and the injuries associated with nonstandard work tend to be more lethal than its standard counterpart.  The percentage of work that is nonstandard can indicate a substantial bump in risk associated with any operation.
  • % of jobs with completed JSAs.  A complete and current Job Safety Analysis (JSA) is crucial for the safe execution of work, yet I don’t know any company that has 100% of it’s jobs with JSAs, and many companies don’t have a good track record of keeping the JSA’s current with the standard operating procedure. Understanding the percentage of your tasks have good and current JSAs is a good predictor of future risk (the higher the percentage the lower the risk).
  • % of jobs with Standard Work Instructions. Personally, I prefer Standard Work Instructions (SWI) to JSAs (a good SWI should address all the safety concerns of a job), but SWIs suffer from the same problems that I discussed regarding JSAs above.
  • % behind in production.  I still have nightmares about my days working an assembly line and falling “in the hole” screams of “man in the hole” booming above the cacophony of hand tools, presses, and industrial vehicles still give me chills.  Whenever ever workers are struggling to catch up because they are behind in production the risk of injuries rises.
  • % parts shortages.  When there are part shortages (or tools shortages, or materials shortages, or labor shortages for those of you who work outside manufacturing) workers are forced to work outside the standard process.  This is incredibly dangerous because the standard process is designed with protections against injuries embedded in the tasks.  When a worker is working outside the process the organization is relying on luck to protect them.

Risk Factor #6: Worker Engagement In Safety

We’ve discussed worker engagement in a broad sense, but I think it is important enough to look at worker engagement specific to safety.  Engaged workers will work safely for no more reward than because working safely is the right thing to do.  Worker engagement in safety can be measured by:

  • Number of reported near misses.  Some will argue, correctly, that near misses are lagging indicators, but whether or not a worker choses to report a near miss correlates to the level of worker engagement in the safety process. This meaurement, admittedly, is difficult to get accurately.  Since we don’t know the total actual number of near misses we can’t say with certainty whether the current level of reporting is a high or low percentage.  Even so, the number of workers who report, even more so than the raw numbers of near misses, can provide a good glimpse into the level of importance workers place on safety.
  • Number improvement suggestions.  Workers who take an interest in improving the organization are generally interested in finding and eliminating failure modes, which will include those failure modes that will ultimately place workers at risk of injury.  The greater the number of suggestions the lower the risk.
  • Participation in continuous improvement workshops.  Elimanating variation, risk, and hazards are part and parcel of the continous improvement process so it should surprise no one that the level of participation in these activities correlate to the level of risk.
  • Number of worker grievances.  Worker grievances shed valuable light in to many of the other risk factors identified here and generally the greater the number of grievances the higher the level of risk of injuries.
  • Number of disciplinary actions for safety violations. The number of disciplinary actions for safet violations are indicative of two things: the number of unsafe acts being committed and the extent to which these incidents are taken serioiusly.

Of course one has to be careful in designing and managing these measurements to avoid unintended consequences (for example, one could easily reduce the number of disciplinary actions by not applying appropriate discipline, or one could raise worker performance evaluation simply through “score inflation” but the risk of these unintended consequences can be reduced by solid management practices and random sampling audits.

The Imperfection Of Predictive Measures

To some extent we can never have a perfect set of measures.  In many ways it’s like predicting the weather, since we are talking about probability there is always a chance that the organization will beat the odds.  In fact, there isn’t one of these measures that I couldn’t construct a convincing argument against.  What’s important is to use those of these measures that make sense and use them in conjunction with each other.  One correlation does not a pattern make, but when we look at multiple areas of risk and analyze them in a holistic context we can find a more useful way to measure safety than counting bodies and broken bones.



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Forget Injuries—They Have Nothing to Do With Safety




By Phil La Duke

Last week I posted an article defending (to some extent) Zero-Injury goals that touched off a powder-keg of on-line debate.  I have gone back and forth on the idea (on one hand zero-injury (or zero-harm, or zero-anything) goals don’t work very well (for a variety of reasons that I don’t feel like getting into right now) and on the other hand if our goal isn’t zero than how many people can we kill in the workplace and still call it a job well done?) until I finally landed on a position with which I can live: who cares?

Now before you start rounding up pitchforks and lighting torches to drive me from the village, hear me out. We as a society have been using injuries as proof of an unsafe workplace and the absence of injuries as proof of safety and nothing could be further from the truth.  Is it safe to leave a toddler home alone? Is it safe to walk around an unfamiliar and bad neighborhood at night? Why? After all most toddlers wouldn’t be harmed and most people don’t get mugged, and yet most people I’ve talked to agree that many practices like this (or using tools with the guards removed) aren’t safe.

So if we can agree that there are many, many activities that aren’t safe irrespective of the outcome, why do we persist in using injuries as the chief criteria for determining what is safe and what is unsafe? In some organizations safety professionals claim credit for saving lives simply because they reminded people not to die. In other organizations safety professionals are hammered by leaders for injuries that they didn’t cause, but failed to prevent.  Nobody much likes the system, and nobody wants injuries and fatalities. And yet we persist in chasing numbers that don’t matter and juking stats that tell us nothing about the safety of the workplace.

The Measurement Craze

Industries’ fierce desire to measure every element of the business is a by-product of the quality revolution, and in many people’s eyes, if you can’t measure it, it doesn’t exist. Unfortunately, the Safety function directly copied the Quality function’s approach to measurement.  In some respects this makes sense, because an injury is not unlike a defect; both are the outgrowth of a process defect (and no I won’t be baited into an argument over whether or not the cause is procedural, behavioral, or systemic. I’m sorry to disappoint but it really doesn’t matter to a meaningful degree—unless, of course you are selling some new whiz bang approach and you have to differentiate it from the pack). In other respects it makes no sense whatsoever, since, as we’ve already established while there is a quantifiable relationship between the absence of a defect (the part either is within the tolerance limits of its standard or it is not) there is no such quantifiable relationship between a worker’s safety and injuries.  Let me put that another way: we have a good understanding of what constitutes a defect (since we also have a clear understanding of the specifics criteria for an acceptable product) but we don’t have a clear understanding of the specifics of safety, that is, we don’t really have a clue how much risk a worker faces at any given moment so it’s tough to measure safety in any meaningful way. Many organizations have become so obsessed with measurement that they are losing site of the real purpose of the safety function: to help both the organization and the individual to make better choices when it comes to safety.

It’s About Risk

When we talk about safety we’re really talking about risk, that is, how probable is it that our workers will be injured in the normal course of their work days?  The gross misunderstanding of basic statistics in general, and probability in specific, lies at the heart of the trouble so many organizations have in tackling worker safety.  I know it sounds like heresy but in a real sense injuries have little to do with safety and in fact often distract the organization from the real task of lowering operational risk.  Individuals who would never gamble with company funds blithely roll the dice when it comes to the safe execution of work. If we continue to concentrate on injuries at the exclusion of risk we lull ourselves into the false sense of security and when we achieve a year with no injuries we throw a big party and pat ourselves on the back for a job well done, despite the very real risks that lurk unseen in our midst.

More and more companies are celebrating the hard work that seems to have paid off, when in reality, they don’t have a clue whether or not the results they are getting are a product of hard work, voodoo, divine intervention, or blind luck. As a friend of mine recently said to me, we don’t understand the real problem (process variation) so we invent a problem we can solve and call ourselves heroes.  Since we’ve solved the problem that we do understand (worker injuries) we no longer work to solve the real problem (process variation, i.e. risk of injury). The processes (and for the purposes of this post I am including both behaviors and systems in the word “processes”) continue to drift away from the standard and soon exceed the control limits.  Before too long we are operating completely on luck while congratulating ourselves for slaying the dragon of injuries.  By the way, it’s a myth that sooner or later our luck will run out; we’d like to believe it, and statistics support the belief that in most cases risk will catch up to us, but probability being what it is there is always a chance that the organization will keep humming along on a wing and a prayer and never have risk come up and bite it on the ass. It’s theoretically possible that an organization will survive on luck alone, but more often organizations who fight the injury battle continue to win (there is a lot of overlap between the efforts to end injuries and the efforts to reduce process variation) because of good luck will ultimately have a catastrophe that corresponds to some change in the workplace.  Those who understand risk know that given enough risk the probability of injury becomes so likely that for all intents and purposes a serious injury is certain, but the self-congratulatory organizations who trumpet their zero-injury achievements tend to ascribe causation to some external force that has nothing but timing to do with the spike in injuries.

Whose Job Is It Anyway?

Some argue it that the problem is that safety professionals don’t spend enough time “on the floor” or “on the site”. While certainly out of touch safety professionals that don’t understand the nature of the business can’t be effective, I doubt that’s the real issue.  Safety professionals need to be agents of change and continuous improvement, not safety know-it-alls who scurry through the worksite trying to “catch someone doing something safe”.  The front-line supervisor owns safety, which is not to say that that worker don’t have a role, in fact a central role, in safety. After all, it is their fitness to work, decisions, competence, commitment, and judgment that collectively create what we call “safety”.

But when speaking operationally, when everyone is responsible for safety (and that responsibility is not clearly delineated) effectively no one is responsible for it. Certainly the worker must be responsible for his or her safety, not just at work but everywhere. But the individual’s responsibility for safety does not obviate the supervisor’s responsibilities. As a former automotive production worker, trainer in healthcare, construction laborer, consultant, security guard, food service worker and more, I can honestly say that I had a tendency to focus on the rigors of my job and tried to do it as safely as possible. I took it for granted that other workers were doing their job safely, that my boss was ensuring that the equipment and facilities were safe to operate and work in and yes, that my boss was ensuring that my coworkers weren’t doing something that would get us all killed.

My bosses had the decision rights to intervene in unsafe situations that I flat out didn’t have (short of losing my job). I depended on my bosses to keep me safe from the things over which I had no direct control. Too many people believe that safety is the responsibility of the individual alone. Leaders play a key role in all of this and owning the safety of the area is far different from individual ownership of safety.

Consider this: Every day we as individuals go through life responsible for our own safety, and yet we take for granted that someone is acting on our behalf. Don’t believe me? I’m willing to bet that within the last month you (while firmly responsible for your own safety) ate a meal where: a stranger harvested the ingredients, another stranger delivered them to a restaurant, where they were accepted by a person we’ve never met who also decided that the ingredients were safe to use, another stranger prepped the ingredients for cooking, still another stranger cooked you a meal using utensils washed by another stranger who then placed the food on a plate (also washed by a stranger), it was then delivered to you by a stranger, and you ate it using silverware washed, yet again, by a stranger. If at some point you were to die (or merely get really sick) because there was some breakdown in the supply chain, would society have the right to say, “well you never should have trusted so many strangers so you deserve what you get”? of course not, and yet many people bemoan the worker’s lack of ownership of safety.

My point is that we often assume, as workers, that someone else has inspected the tools, made sure the machines are in good shape, checked to ensure my coworkers are fit to work, and in general has looked out for my safety, at least those things that I cannot practically do for myself.

I believe this is the role (primarily) of the first line supervisor. While everyone should have the right to stop work if they feel it is unsafe the front line supervisor often makes the choices that directly affect the safety of dozens of people.

Filed under: Safety, , , ,

Mouthing Off About Safety


By Phil La Duke

There’s a lot of talk about safety.  Safety talks, reflections on safety, safety reviews, safety observations, LinkedIn discussions, forums, blogs and…well the list goes on and on.  There doesn’t seem to be any shortage of talk about safety, but does talking about safety change anything?

In 2011, Harold D. Stolovitch published the book, Telling Aint Training a book that I confess to having not read—no judgment here, I read voraciously but just haven’t gotten around to reading this particular book. Why mention a book I haven’t read? Simple: the title intrigues me (apparently not enough to shell out $17.50 for the book, or even enough to drive the approximately one mile to the public library and at least ask about checking out a copy, but that’s neither here nor there.) I’ve known for years that people, at least adults, don’t learn from having things told to them, rather the deepest learning comes from drawing from their own experiences and adapting things they have learned from experience and applying these skills to new circumstances and situations. So what good are safety talks where we find a 6956th way to say “be careful” in broad and ambiguous terms.

Adults need to draw from their own experiences and want to learn things according to their own timetable and in a style that they prefer. In 1956, a team led by Benjamin Bloom, created “Bloom’s Taxonomy of Learning”.  Bloom, et el, postulated that there were three “learning domains”:

  1. Cognitive: mental skills (Knowledge)
  2. Affective: growth in feelings or emotional areas (Attitude or self)
  3. Psychomotor: manual or physical skills (Skills)

Blooms taxonomy

According to Bloom, and several generations of researchers since, adults learn by building higher-level skills by building on the things they have learned at lower levels.  Too often in safety we ignore a wealth of research and knowledge of how people learn and pursue behavior modification techniques instead.

So what are we hoping to accomplish through these safety pleasantries? Awareness? What adult isn’t aware of the connection between unsafe behavior and injuries? So why do we devote so much of our safety messages to the lowest domain (knowledge)? Do we really believe, for example, that workers are injured in slip and fall accidents don’t know the connection between trip hazards and falls? Or that by removing those hazards likely to cause a worker to trip they can significantly lower the risk of a slip, trip, and fall injury?

Take the well known but growing problem of texting while driving (or walking for that matter).  The dangers of texting while moving are well known by just about everyone, and yet, a significant number of people continue to engage in this reckless activity; why?  Texting provides immediate gratification—we get an endorphin rush from receiving text and you have to send them to get them. Diverting our attention away from a routine and fairly boring task like driving to a task we find of interest (whether it be texting, changing a radio station, or composing an opera in our head) seems like a rational thing to do, given the presumption that our attention will only be diverted for a microsecond.  Except the facts as I have stated them aren’t exactly accurate.  Texting doesn’t just take a microsecond, in fact, it takes enough time to create a real traffic hazard; but people already know this.

The problem is that texting (as with most safety issues) isn’t rooted in a lack of knowledge or skills; people know very well that it’s a dangerous activity but choose to do it otherwise.  People perceive the risk as no big deal.  Similarly, the problem isn’t psychomotor—the danger isn’t rooted in a driver’s lack of manual dexterity; it’s not dangerous because the driver lacks typing skills.  The danger of texting while driving is that while drivers know that the behavior is unsafe, they simply don’t care. No amount of safety talks will change the fact that most unsafe behaviors begin with poor choices, and these poor choices are rooted in an undesirable attitude about safety.  This undesirable attitude toward safety lies at the heart of the so-called safety culture.

How many psychiatrists does it take to change a light bulb?

Changing an attitude is more difficult than it seems.  For starters, you can’t change an attitude by telling someone that they have a bad attitude and need to change…or else. Attitudinal change comes from within, and as answer to the old joke says, “only one, but it has to want to be changed?” It keeps coming back to the Edgar Schein model for change, where dissatisfaction + vision + next steps must be greater than the resistance to change. I’ve written enough about that already so I won’t waste any more precious space on it here.  Sufficed to say, if someone believes that his or her current state is serving them well they have no incentive to change; and before anyone goes out and starts buying gift cards and throwing pizza parties that’s not the kind of incentive I’m talking about.  People need a strong, WIIFM (What’s In It For Me?).  If an adult doesn’t believe there is sufficient WIIFM, or that the supposed WIIFM isn’t worth the effort they will continue to resist the change.  Change is personal, and as a Organizational Change practitioner for many years, I have learned at great pains that unless you understand that change will only happen when enough individuals feel that the pain of not changing is greater than the pain of changing.

Shame And Blame Doesn’t Change Anything

Some people try to shame and blame people into changing, and it doesn’t work.  Whether it be children’s safety poster contests (which if you’ve read much of my work, you know I hate…what kind of sociopath introduces the possibility that a parent might die at work to a seven or eight year old?) or “It happened to me videos” or out and out, “you monster, don’t you care about safety…” lectures, these ham-fisted external attempts to force change don’t work.  People start to dislike you for blaming and trying to manipulate them and you become less effective as a safety professional, so perhaps I should say, nothing positive changes.

Building the Inner Driver for Change

Ultimately the way to change is a) get people to want to change, b) give them tools to change and c) support and encourage their efforts to change.

I could write another 1,000 words on building the case for change, but I’m not going to, at least not today.  Besides, if I told you everything I know, who would hire me to consult with them?

Filed under: Safety, , , , ,

Working In the Line of Fire


By Phil La Duke

When someone dies in the workforce through no fault of his or her own it’s undeniably a tragedy.  But in many people’s minds, line of fire injuries—those injuries that result when a worker places his or her body in the direct path of  a serious hazard—the injured worker must bear at least some culpability for his or her injury. It’s especially easy to dismiss a line of fire injury as the worker’s “own damned fault”, but is it?

Before I continue I should disclose something about myself that could bias me on this topic: my grandfather died on the job from a line of fire injury.  In the case of my grandfather, he was driving a tractor (he was a farmer in the 1950’s having left a lucrative career installing conveyor belts—a job that required extensive travel—so that he could spend more time at home with his family.  He was struck by a speeding locomotive (witnesses said the train was going upward of 80 mph) at a poorly marked crossing.  His view was at least partially obscured by overgrown bushes near the tracks and he was either legally deaf or close to it.  He left behind a widow and four daughters (one of whom was developmentally disabled) who would eke out a hardscrabble living, financially and emotionally crippled by his death; a family laid waste by a single moment.

While there were many things that factored into my grandfather’s untimely demise, the fact remains that in the last moments of his life he made a decision to place himself in the line of fire.  My grandfather isn’t alone; the Bureau of Labor Statistics reports that 17% of workplace fatalities (in the U.S.) are the result of line-of-fire injuries.

As you might expect, I spent a lot of time thinking about the circumstances of my grandfather’s death, I don’t attribute it to shaping my view of worker safety, but I suppose that’s inevitable.  Sufficed to say line-of-fire injuries raise a lot of questions; questions, sadly, to which we will most likely never get satisfactory answers.

What were they thinking?

I have always believed in two simple truths about worker injuries: 1) nobody wants to get hurt and 2) the process isn’t designed to hurt them. If these things really are true then why would anybody ever knowingly put themselves in the line of fire? Simple:

  • They don’t believe they are placing themselves in real danger.  No one in his or her right mind (let’s face it: the primary role of our central nervous system is to keep us alive, and as long as that is functioning properly we generally aren’t looking to kill ourselves) expects to be killed when they place themselves in the line of fire. Too often workers who place themselves in the line of fire are making a decision based on imperfect information—they either assume that something is true when it is not, or they assume something is not true when it is.  Take the case of my grandfather, we can only speculate, of course, but for the sake of argument let’s say that he knowingly and deliberately put himself in the line of fire and crossed the railroad tracks without looking or stopping long enough.  Since there is no evidence that he was suicidal—by all accounts he was good-natured, popular, and happy in life—we can infer that he didn’t deliberately place himself in the line of fire thinking that he would most likely be killed—we can speculate that he believed that the likelihood that a train would approach unseen, in fact, undetected were infinitesimally small.  Had he believed that there was a strong possibility that a train would strike him he never would have taken the chance.
  • They believe the time of exposure is small enough to protect them.  How many line of fire injuries are the result of  “I’m only going to be in there for a second” thinking? It’s a big temptation to risk it when you believe that your probability of injury is directly proportionate to the length of exposure to the hazard.  Unfortunately, probability doesn’t work that way and too few workers truly comprehend the dangers that some line of fire hazards pose irrespective of the length of exposure. If a worker makes contact with a piece of energized equipment of sufficient power he or she will be electrocuted even if he or she touches the equipment just for a second.
  • Familiarity breeds content. For most of us, the longer we work around a hazard (or in this case the more we place ourselves in the line of fire) and suffer no negative consequences the less we respect a hazard’s ability to harm us.  We teach ourselves that an activity is safer than it is; as we become more comfortable working around a hazard we convince ourselves that we will not get hurt “as long as we’re careful” when in fact, we are not.
  • The job is too difficult to get done without placing workers in the line of fire. Much as we would love to place the blame squarely on the shoulders of the injured worker, some jobs are so poorly designed or safety procedures are so onerous that no reasonable worker will work within process.  In fact, I know of many companies that continue to have standard operating procedures that place the workers in the line of fire.  These cases are the most troubling because in general workers believe that if they follow the standard operating procedures they will not be injured, even though some processes are grossly unprotected.
  • They aren’t thinking. Research has shown that the average worker makes 8 mistakes an hour (this number falls to around 5 for workers in “high consequence industries—healthcare, aviation, oil & gas, energy, etc.). These are human errors; unintended foul-ups.  Five mistakes an hour, eight hours a shift, five shifts a week amounts to mistakes in the neighborhood of 10,400 mistakes in the course of a work year. Obviously this number is much higher for workers who work longer shifts, six- or seven-day workweeks or any number of a host of other factors that would extend the worker’s work year from the traditional 2,080 hours in a typical year.  Inevitably, some of these mistakes will place the worker in the line of fire.
    The incidence of human error increases when a person is sleep deprived, under stress, using drugs or alcohol or is otherwise preoccupied.  Something as simple as bright lights can dramatically increase a person’s tendency to take risks.

Line of fire injuries may always remain an enigma and as one safety veteran once told me (after learning of the death of veteran worker caused by several line of fire violations). “I don’t know how to save worker’s from themselves.”  I don’t know either, and in truth nobody really does.  We try engineering controls and people remove guards and by-pass interlocks. We put administrative controls in place and workers ignore them, and we require PPE only to have worker’s grouse about wearing it. But one thing is certain, if workers continue to put themselves into the line of fire they will continue dying on the job.

Filed under: Behavior Based Safety, line of fire, ,

Should We Be Applying “Ethical Buying” To Safety?

Ethics scale

By Phil La Duke 

Recently I was introduced to the concept of “ethical eating”; for those of you who are, as I was, ignorant of the concept, ethical eating is the practice of avoiding certain foods because you believe the animals were treated unethically (presumably swindled out of their life’s savings, I’m guessing.)  Actually, it turns out that “ethical eating” is just the latest pretension that has been around for decades—call it vegetarianism, veganism, or whatever the hipster-come-lately superiority complex.  As someone who was raised on a farm and an animal lover, I both eat meat and believe that animals should be treated humanely. I reject the idea that someone is morally superior simply because of his or her diet (who picks the aphids off the broccoli they eat?) It is, as my daughter is fond of saying, “a first world problem”—people who struggle to get enough to eat rarely wrestle with the moral conundrums associated with the rare meal they manage to acquire.  But the idea got me thinking.  Why are so many people ready to apply economic and political pressure in defense of animals while ignoring the very real plight of the people who grow and harvest our food, make our clothes and computer goods, deliver our mail, and generally provide the goods and services that make our lives possible?

Let me be clear, I’m not advocating a course of action here. Rather, I am merely asking a question: “Should we be using our considerable economic power to influence how organizations feel about safety?”  Is it right to continue to buy goods and services from companies that have shown a wanton disregard for the safety of their workers?

Economic boycotts are hardly a new idea, and even boycotts designed to pressure companies to provide better lives for their workers have been around for many decades (I date myself in doing so, but I would point to the Caesar Chavez call to boycott grapes as an example of such an action).  But as effective as economic boycotts can be, they are seldom—if ever—directed at a company because of its safety record.  Some would argue that if we truly care about worker safety we should avoid doing business with companies that hurt workers at all costs.  Are they correct? Before you answer, consider:

  • It isn’t easy to get a good picture of a company’s safety record.  It’s fine to say that you aren’t going to do business with a company because they have a poor safety record, but unless the company is embroiled in a public scandal regarding its safety it can be all but impossible to determine the kind of job a company does in protecting its workers.
  • Just because a company doesn’t injure a lot of workers doesn’t mean it does a good job in worker safety.  Safety is about lowering the risk of worker injuries, a company that doesn’t hurt a lot of workers doesn’t necessarily mean that it does a good job managing and lowering risk, in fact, it may not have a lot to do with good safety management and a lot to do with good old fashioned luck.
  • Just because a company hurts a lot of workers doesn’t mean it is guilty of depraved indifference.  I make my living teaching organizations how to change their corporate cultures and the customers I have dealt with over the years have run the gamut—from organizations that hurt many workers but don’t know how to stop the trend to organizations that take huge risks and are lucking enough to avoid catastrophe to organizations that do a good job but that want to do a great job. I’ve learned that it is wrong to assume that just because an organization hurts a lot of workers that they don’t care.  Sure there are companies that honestly don’t care whether or not they hurt workers—they see workers as a consumable commodity that get used up and replaced—but these companies are relatively few and far between.
  • Punishing a poor safety record really doesn’t do much but make you feel better.  In many respects, boycotting a company that has a bad safety record is much like “ethical eating”; it makes you feel morally superior but it really doesn’t change anything.

Should We Just Give Up?

If things are going change they have to change at the business-to-business level and fortunately things are changing.  Many companies use prospective vendors’ safety records as a criterion for selection in the bid process. This trend is encouraging but it’s only a start.  If you’re serious about using your economic power to affect change in workplaces you can get involved.  First, talk to your company’s purchasing department and ask to what extent the safety performance of potential vendors is used in the selection process.

Make The Case For Safety

If your company doesn’t use safety as a criterion for doing business suggest that it start.  Safety is more than a moral issue; it’s also a business issue. Organizations that ignore safety tend to fail at other things as well; things like quality, customer services, reliability, and cost. In short, companies that don’t care about safety tend to cut corners or are just so unsophisticated that they can’t function as reliable business partners.

It’s fine to give lip service to caring about worker safety, but until we get personally involved we really aren’t doing anything praiseworthy. On the other hand, most of us haven’t quiet removed the splinter from our own eye, so maybe we needn’t worry, just yet about the plank in the eye of our vendors.

Filed under: Safety, , , , ,



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