Why So Many People Believe the Hierachy of Controls Is A Joke


Phil La Duke

This morning I used the restroom at my local greasy spoon, as I stood at the urinal fighting the urge to retch at the sewer smell I noticed one of those yellow “wet floor” signs. The floor was dry (at least before I got there, after all, “wet floor” is a command, not a warning.) and I thought to myself, this is why the Hierarchy of Controls is such a joke: here we have a situation where the most effective solution (elimination of the hazard) is relatively cheap and easy to implement (don’t TELL me the floor is wet, dry the damned floor). The administrative controls in our lives are absurd, from the signs in Michigan warning that the bridge might be icy in 100° weather in mid-August, to beware of dog signs on the gates of homeowners whose dog has long ago shuffled this mortal coil, to the small packet of desiccant placed in a box of electronics with “do not eat” written on it. At the risk of getting off on a tangent, who in their right mind opens up the latest gadget finds the packet and says, “I’m gonna eat this”? I have used this example many times in training sessions and every once in a while someone will point out that a pet or a child could eat this material and become gravely ill. Fair point. How many of your pets and toddlers can read? My dog is very smart, but even she moves her lips when she reads so I doubt that she fully comprehends the message and is just as likely to eat it. My other dog only reads for entertainment and would gulp down the desiccant scoof without so much as a hazy concept that might develop into an action.
The point is that in these cases and others more too numerous to mention, we are taught that many warnings are stupid, inaccurate, or just plain lies. In the workplace as in life, we are forced to determine whether the danger is real, probable, and severe enough to worry about.
If after this split second analysis we judge the warning or rule to be unnecessary we will violate it. Take for example a “Don’t Walk” signal. Many good people, including more than a couple of safety practitioners, have looked around and seeing nary a vehicle for miles in either direction, have made the bold decision to cross against the light.
My point, albeit a circumlocution, is that PPE and Administrative controls aren’t just the least effective way of controlling a hazard they are also in many cases the product of lazy safety engineering. In fact, I will go so far as to say that there are a lot of instances where using administrative controls are downright criminal. Administrative controls is safety done on the cheap. Heck, why don’t we just make a rule against getting hurt. Oh, wait, in many companies we’ve done just that. We fire or discipline people for getting hurt when in fact WE failed to control the hazard. In fact, there are some countries where people who have been injured are immediately fired so that the injury doesn’t show up in their records. I know of several workers pronounced dead in an ambulance even though their corpses were so badly mangled it took two trips to put them IN the ambulance.
If employers believe that eliminating a hazard is too cumbersome (read expensive) they will just outlaw getting hurt. And since violating a safety rule is a bulletproof way of firing someone without repercussions administrative controls is a great way of protecting the company despite putting workers at extreme risk. It’s a nice system for companies, but less so for workers who end up as the guest of honor at a closed casket funeral.
What’s worse is we can do better. We know that administrative controls (excluding training) don’t work very well and unlike an engineering control, when an administrative control fails we default to blaming the “stupid, lazy worker”. It’s a fair conclusion; a stupid, lazy worker is to blame, but the stupid, lazy worker is the person who put that control into place and thought that it would work. This kind of lazy incompetence is rife in the safety function and people get maimed and blamed because of it. I find it odd that nobody ever asks why the organization depended on such an ineffectual control to keep workers safe, and furthermore never held the person or persons responsible for their ineptitude.
The Hierarchy of Controls is one of those sacred cows of safety, and when used correctly, can be a powerful tool in creating safer work processes. But many of us don’t use them properly, we accept the excuse that eliminating the hazard is impossible, that substitution would be too expensive, and we accept that PPE and administrative tools will be enough to protect workers when all we are protecting is our own ample asses. A perfect illustration of this is a contact of mine who dismissed awareness programs by saying, “I was aware of breast cancer but I got it anyway”. Too bad getting breast cancer wasn’t against the rules, it might have saved her a lot of grief.


Doing the Right Things Wrong


by Phil La Duke

It takes a while before a concept sinks into my thick head.  For years I have been saving companies tens of millions annually by building what I call a safety infrastructure, and when I finally brought my system to a wider market and explained what I did I usually got some version of the same response[1] “were already doing that”. No amount of salesmanship could convince these people otherwise.  Of course I was beyond skeptical, after all if they were doing the same thing they would be getting the same incredible results and yet they were not.

And then one day I learned something that shook me to the core: they WERE doing those things.  This sent me into an introspective and somewhat depressed funk.  If what I had developed was already common place in industry why where people doing so poorly.  But then a company hired me, not to save money, but to change its culture around safety.  My methods clearly had set in motion profound changes in culture and I began the arduous year-long (I would always get the question, “can you do it faster?” to which I would explain that change at a faster pace would only change the climate and would only remain as long as I remained adhered, tick-like to the organization’s soft underbelly).

I was horrified to learn that this company indeed did everything I was intending to teach them until I did the first phase of the project and found that they were doing all the right things but they were doing them wrong.  They would do safety tours, but the information collected was the worst kind of pencil-whipped checklists and what made it even sadder was that all that information on hazards went directly and squarely into file cabinets without anyone even looking at it let alone interpreting it and looking for trends in the data.

They DID do weekly safety meetings, but these meetings were more like a family squabble over a holiday meal than any semblance of a meeting that looked at safety data, like how many hazards were found on a tour, how long a tour lasted, or even if the tours took place.  They didn’t seem to know or care whether or not sometimes gravely serious hazards were contained or corrected. There were no agendas or notes taken, and it was as if previous meetings had never happened.  All the members produced in these meetings were noise, carbon dioxide, and occasionally methane.  The meetings, while the right things to do, were done so poorly I saw no value in them. And yet this particular organization used “participation in safety meetings” as a leading indicator of safety! I honestly couldn’t see any correlation between a safer workplace and this miasmic circus.

Likewise they had a monthly meeting with senior leadership, but far from being a safety strategy meeting this meeting covered all the SQDCME and safety was given a scant 5 minutes on the agenda.  The meeting itself seemed more akin to an interpretive dance class with poorly prepared presenters gliding lithely around the podium while equally inept team members danced around them frantically looking for a key slide or document for distribution and immediate disposal.  It was beautiful in its own way but it didn’t do much to create a safety strategy and like most dance recitals it went on WAY too long. (Having a daughter and a half, I have been to enough dance recitals, and plays to know that nobody walks out shaking their heads complaining that the event was too short.)

Of course they ostensibly linked safety to the continuous improvement group but since the two groups hated each other and got along worse than pit bulls in a dog fighting ring this too fell flat.  The CI has its scientific approach to process improvement and many safety groups still believe in pixies, curses, and just plain hard luck.

Finally, they all did incident investigations but the inevitable but specious conclusion was always that the operator screwed up.  In this imperfect world in which we live I am continually astonished that while operators never fail do disappoint us with their half-witted screw ups, engineers, managers, team leads, supervisors—everyone EXCEPT frontline workers perform perfectly and error free. Amazing.

So in almost every case where the culture is being blamed it is really the lack of a cohesive infrastructure that connects hazard and injury information to each other. The information doesn’t flow from one activity or another and in those rare cases that it does it is seldom analyzed to the point sufficient to formulate strategies for lowering risk.

Haven’t had injuries in two years great?  Haven’t killed anyone for almost a year?…well giving credit where it’s due, better than killing two workers a year I suppose. So that’s what I do.  I teach people the right way to do the right things and when they learn that the culture changes because they see value in safety.

I also get asked, “why can’t we do this ourselves?” That’s a good question, to which I answer, “who made this mess? Do you have the skills to thinking differently? I’ve been doing this for 20 years and it’s hard as hell, but yeah, why can’t you do it yourself?” The answer is you can.  You don’t need me. Well except while people will eventually accept change they seldom forgive the person who bought it.  Oh, and I don’t report to a site manager, I am answerable to an executive, and I leave after a year.  So sure do it yourself.  I think that it will be a disaster, but then I see things through a vendor’s lens.

Just remember, when people are dying you get no points for trying.

[1] Except for  one executive who said he wanted to only be “safe enough” and another that said “the cost of safety is a drop in the bucket, nobody cares about lowering the cost” by which both responses left me stunned speechless and it takes a ton to shut me up.

There are no magic bullets

Bullets.jpegBy Phil La Duke

Forget what you think you know about me. Most of you have never met me and never will.  In the past few months I found myself more and more frustrated with my writing here and elsewhere.  Then serendipity struck.  My daughter moved out of the house and was divesting herself of many of her possessions and as she did she would ask me if I wanted this or that.  She handed me a book that I have read many times and though I have my own copy I took the copy she offered. Opened the book, On Writing Well, at random and read (and I’m paraphrasing) “Don’t write for your readers or you will find yourself pandering to the passing whims of people who don’t really matter—they can neither validate you or your writing. Don’t write for your editor or you will start to sound like every other person he or she edits.” I’m sure my paraphrasing isn’t even close to the actual excerpt, but I tried. The message concluded by saying that the only really good writing is the writing you do for yourself. So…despite having colleagues who read my work religiously looking for a reason to betray me, or the loons who threaten to kill me, or the condescending jerks who read solely to justify why they hate a stranger I am going to write for me.  If you find it enjoyable great, if it makes you think even better, but what really matters is whether or not I have written something that I can look at and be proud. Something that addresses the things in safety about which I am concerned, the things I think need saying. The gloves are off.

Several days ago I was thinking about a former employer who moved from the traditional gopher-like cubeville to a new building that was the much touted “open-environment” made famous by Google.  We were given a number of points that we could use to “purchase” coat hangers, file folder holders, mini whiteboards, etc. We were told that we would have to limit our personal possessions; it was very minimalist and unpopular.  For my part I liked it. My previous work area was an ad hoc addition to a row of existing cubes. In my short tenure there my ad-hoc cube was subdivided twice. By the time we moved to the open environment in a new building my cube was so small that I could not even fit a standard office chair in it.

What does all this have to do with safety? You be the judge.  As I thought about this standard workplace and the turmoil it created and the pushback it received, it made me think about how important a standard work area is and how hard it is to keep a workstation within the specifications for which it was designed. When it comes to safety, variation is the enemy. Variation—those things that aren’t supposed to happen, or be there, or the things that are supposed to be there but aren’t.

Variation creeps into processes; it’s a never-ending battle. As trivial as it seems, process variation is a contributor of most if not all injuries.  Given that barring some sadistic employer or a gross miscalculation from the design engineer, your process is not designed to hurt workers. If it’s true that your process isn’t supposed to hurt workers and it is a viable process with the failure modes appropriately identified and controlled, then the probability of injuring a worker is fairly remote.

So safety is as simple and complex as controlling process variation, Controlling variation is simple: just have a tightly controlled process and a concerted effort to keep the process in control. Conversely, controlling process variation is extremely difficult: saw blades dull, tools break, presses move out of tolerance, and people? Well, we all know people do stupid, reckless, and wildly unpredictable things.

The job of safety practitioners is to control the uncontrollable, to manage the unmanageable, and in some small way to figure out a way to lower the probability that someone will get hurt on the job.  It’s rare when seen in retrospect to look at a serious injury or fatality and not wonder why someone didn’t foresee the carnage that would ensue, and yet we do.  The job is made so much more difficult when we have to sift through the snake oil so many people shill.  I’m hard on people who churn out this pseudoscientific bull excrement. If you sell counterfeit medicine and people die you go to jail, but if you perpetuate anti-vaccine articles and diseases that were virtually extinct there are no consequences.  The people who peddle junk science in safety are killing people and no better than the anti-vacers or the counterfeit pharmaceutical salesmen.

There is no magic bullet for safety.  At the end of the day creating a safe workplace is about helping people to make safer choices and better decisions. It’s about educating people about the processes in which they work and the things to watch for that might indicate that the process is moving out of control. Safety is not a passive, theoretical exercise. For us to accomplish anything of any importance in safety we have to take action and remain ever vigilant.

I am beginning to think…

I am beginning to think I have lost all relevance

4 Tips For Engaging Millenials in Safety

By Phil La Duke

It can and has been said that a little of me goes a long and tedious way, and I suppose that’s true.  I just wrapped up a 2300 word beast of an article for Health & Safety International, a collaborative effort on working at height.  It’s the third article I’ve written for the publisher in just over a month and the whole ordeal has left me a bit beleaguered and not particularly interested in anything remotely connected to safety.  I want to run through a crowded shopping mall snipping scissors in both hands or swing a bag of broken glass in a crowded room of hemophiliacs; in short I need a break from writing about safety for a while.

Entrepreneur provided me a nice outlet where I could let my hair down a bit and take the leash off.  After 80 articles, over 70 of which were written in just 14 months, my editor either got tired of defending why he was publishing what could best be described as the lunatic rantings of a seriously deranged and dystopic freak or he himself just got plain sick of my articles.  I went from three a week to barely two a month, not that I didn’t put in the work—I have somewhere in the neighborhood of 10 articles in the limbo of the Entrepreneur contributors page about half unread, and all of which highly unlikely to ever see print.  Ostensibly the reason is that the water-heads and mouth breathers that read the book don’t read me in enough number to justify giving me space that earnest young writers with 5 Tips for Hiring Millenials; it’s a fair criticism.  I don’t get a bunch of indignant safety drones frothing at the mouth over my business writing and writing is a numbers game.

So it’s within in this context and against that backdrop that I give you this weak’s (sic) blog post.

  • Stop killing their family and friends and bragging about how great a job you’re doing. An alarming number of these spoiled little crybabies actually think that getting their digits torn off by poorly guarded equipment is a bad thing.  Hell when I was their ages you weren’t even considered a real worker if you could count higher than seven on both hands, and real men couldn’t count to 15 even when completely naked. Try telling these delicate porcelain dolls about how worker injuries are trending downward and your much-earned self-praise will fall on deaf ears (and not even deaf ears caused by years of exposure to high levels of industrial noise—their deafness is metaphoric.
  • Pretend that their Workers’ Comp claims are real. I know I will get push back on this, but the new hipster thing is to not fake injuries. These craft beer swilling, beard waxing, prima donnas think that their college educations mean that we don’t know that for the most part all injuries are fake.  I once witnessed a man stage his own decapitation and apply for WC claiming he was disabled because he couldn’t wear a hardhat! Does he think we’re simple?!?!? If you want to keep these delicate flowers called millenials involved in worker safety you have to bite your tongue (which, for the record you better not claim as a job-related injury) if one of them gets hurt, and play a long even if the injured youth is clever enough to actually qualify for disability.
  • Allow for injury causes that aren’t the fault of millennial behavior. We’ve known for almost 100 years that over 85% of injuries are because some jackass did something stupid.  We know this because a statistician and eugenics enthusiast said so, and he had it on good authority because he asked the injured workers’ supervisors.  We know this even though he lost his (or took no) notes. We know this despite growing evidence that he never even left his office at the insurance agency, but especially we know this because the National Safety Council reaffirmed this sometime in the 1980s and our pantheon of safety heroes and gods grew fat of profits from Behavior Based Safety; somethings you just gotta take on faith. (Not the effectiveness and relative safeness of vaccines or the moon landing, of course, but SOMETHINGS). But the voice of entitlement rings out of the mouth of babes; they greet on about mechanical failures, process failures, about lightning strikes and acts of God.  It’s as if they never even heard of Heinrich and his pyramid!
  • Do more than remind them not to die. I can’t tell you how many times my life has been saved because I saw a crayon poster slathered on the wall reminding me not to die.  The wisdom of a child’s drawing begging daddy not to die at work is all but ignored by the young whelps in the workplace today.  This spoiled, entitled, generation of special, special, snowflakes want their employers to do more to protect them than having safety BINGOs and pizza parties when they go a month without dying.  By the way at what point did pizza become the currency of safety? Is it because pizza looks so gory? That makes some sense.
  • So there you have the secret to engaging these young workers: stop hurting them, don’t treat them like liars and thieves when they do get hurt, stop funding the retirement funds of the greedy behavioralist authors who slap a different label on 100 year old junk science and sell it to another generation of the lazy and foolish.

    Is Safety A Value, A Priority, or Neither?


    Note: I don’t think anyone noticed, but I didn’t post last week.  Just too much other unpaid stuff to do for people who don’t appreciate it. Just kidding, I was lazy and the subject I wanted to talk about is one about which I feel very strongly. So here you go, not 5 days late, but 2 days early

    By Phil La Duke

    A kind reader suggested that I write a blog about the difference between safety as a value and safety as a priority, and as luck would have the alignment of a company’s values with its safety practices is one of my favorite subjects.  Too often people say something is a value when it is in fact a priority.  So what’s the difference? a lot actually.  Values are more than things we believe, they guide our every decision and how we react to issues and solve problems. Some psychologists believe that our personal values are fixed and hardwired into our brain by the time we are 7 or 8 years old. When we act in a manner that is inconsistent with our values we feel guilty and ashamed.  So if we truly value safety then safety tends to shape our decisions—we don’t need to be told to behave safely, it comes naturally to us.  While we may make mistakes (human error) that put us or others in harm’s way, we don’t take unnecessary or uncalculated risks and we don’t put up with people who do; to value safety is to have it shape your whole world view.

    Priorities on the other hand are flexible; even fluid.  What is a priority come Monday morning may fall off the list completely by Monday afternoon.  Priorities HAVE to change because life throws all sorts of things at us.  For example, for years I worked in an auto plant building seats.  When I first started our priority was production; my personal success was gauged by whether or not I could read a ticket, retrieve the correct part from dunnage, retrieve the correct screws from my tool caddy, install the part and drive five bolts every 55 seconds and keep up that pace for anywhere from 8 to 9.5 hours.  If that sounds easy you should try it.  Production was sacred and so much so that we quickly learned the exact cost of shutting down the line for a minute. They talked a good game for quality, but it we weren’t there yet, and while quality might have been a priority for the guys in the front office or at headquarters that sense of importance didn’t trickle down to shop floor.

    Not that we didn’t produce quality vehicles—I’m still proud of the work I did and when I see the cars I built on the road 32 years later (and I do see them) I feel a sense of accomplishment and will often talk to the owners about the car. But given that I was busting my hump to keep up with the line, and that no fewer than six inspectors would ensure that I put on the correct parts I didn’t value quality. Quality wasn’t my job that was the quality department’s job. Sure I would get chewed out if I put on the wrong part, but so what? They weren’t going to fire me. If I didn’t keep up with the line however, I had three chances to find a job that I could do at pace and if I didn’t I was out the door. I never saw a safety guy and to tell you the truth I’m not sure there was one.

    We had several fatalities in the short time I worked there but no one took much notice of them—not to sound cold but I didn’t know these guys so while I wasn’t glad that they were dead I wasn’t too broke up about it either.  In fact, I used to joke that we shouldn’t think of them as much as fatalities so much as job opening. I know a crappy thing to say, but I was young and had not yet come to appreciate the true importance of safety.  Then one day someone I knew died.  An electrician with whom I would have breakfast with darned near every morning was electrocuted when he failed to lock out and at shift changed the supervisor (who had no idea the electrician was in harm’s way) threw the main breaker on and killed him.  That hit home, but the reaction of the front line supervisors seemed indifferent to me; this was before my dad and brother-in-law would die from work-related illnesses so while it shook me that my friend had died it didn’t change my fundamental values.  In fact, it showed me that culturally safety was not a value nor a priority.  Production was a priority. If safety would have been a value the supervisors would have asked why the main breaker was off, he would have searched the area to see if anyone was working on electrified equipment, and he probably would have disciplined the worker for not Locking Out.  But production was the priority and it was costing a fortune not running the line so the supervisor did what he had been conditioned to do and threw the switch.

    If you want to find out what you truly value in your life see how you spend your time and money.  A good friend of mine once told me, “you always have the time and money for what’s truly important” I have had people argue against this statement but I stand by it.  If you would have me believe that your kids are the most important thing in your life and yet you spend no meaningful time with them then they aren’t something you value.  Don’t get me wrong, you probably love your kids, and it’s difficult for a parent to admit that there are more important things than time with your kids (watching football, going to work, watching television, or going out with your friends).  You SAY you value your family but you have other priorities that take you away from your family.  Saying that your family is a value isn’t quite right anyway.  Your family’s health, happiness, well-being, and security may well be a value, and you understandably will prioritize the things that enable those things, like going to work or on an important business trip during your kid’s birthday. You will know that this is a value because it’s going to feel like hell doing it even though you know it’s important to your kid, it’s more important to continue your employment and put food on the table and clothes on your kid’s back but it still sucks and you don’t like it. On the other hand if you valued time with your child enough, especially spending time with them when it’s most important to them, you would find a job that accommodates you or you would quit and find other employment.

    A priority is always a choice and always feels like a choice; we know it’s a choice, whereas values just feel like the right thing to do. Our values are so sacrosanct that if we find ourselves in a situation that does not align with our values we tend to get out of that situation.  My ex-wife and I had very different values and so we divorced. Value misalignment can not only break up marriages, but cause us to quit jobs, and threaten safety bloggers with death or violence at the merest perception that what has been said does not align with values.

    We can often excuse people who have different priorities than ourselves but it’s much harder to forgive someone (or at least see him or her as your equal) if they don’t share our values and that has created much discord in the world of safety.  If your priorities get out of whack it’s easy to recalibrate and (often with the help of your boss or close confidante) realign your priorities to your values.  In philosophical terms we all at least pretend to share the belief that everyone should go home in the same condition for which they reported to work, but too often that isn’t really a value, and sadly in many workplaces that isn’t even a priority.


    Extra: Ask Me Anything

    On Tuesday, September 26 at 10:00 a.m. I will be conducting my second Ask Me Anything session.  The first one was one of the site’s most successful.  You can post questions ahead of time but the answers won’t be published until the time of the event.  So Go to https://lnkd.in/gXPWnCB and post a question.  You may wish to read  https://lnkd.in/gi4fgvc first, however.