Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

We Need To Get Out of The Business Of Blame and Shame


blame

By Phil La Duke

Several weeks ago I began exploring safety as an outcome, as the product of well-managed business systems and not something that needs to be managed as its own element. The business systems I identified were: competency, process capability, hazard and risk management, accountability systems, and engagement. In subsequent articles I explored competency, process capability, hazard and risk management, and today I sat down to the keyboard intending to write about one of my favorite accountability topics, Just Culture. But as I ruminated on the topic I realized that what I really wanted to say transcends Just Culture.

For the uninitiated, Just Culture is a management philosophy designed to hold people appropriately accountable. According to one of the current thought leaders in Just Culture, (and author of the book Whack A Mole) there are three basic kinds of behavior: human error, at risk behavior, and recklessness (I became a certified Just Culture practitioner by studying under David Marx, and you can argue that carelessness is also a behavior, but David will argue longer until you give up and just accept these three. Trust me David is a lawyer and he is one hell of an arguer.)   So in begrudging deference to David, I stick to three. The larger message of Just Culture is that blame is a counterproductive and useless exercise that feels good but doesn’t really accomplish much except to piss off the people being blamed and make them defensive. If we take a look at the three behaviors, only recklessness deserves blame and shame. Someone, I honestly don’t know who, said, “error plus blame equals criminality” and that is the reason that Just Culture and a blame free response to foul ups is so important. Just Culture gained real traction in industries where blame was so pervasive that people would conceal their mistakes and hope for the best—no such a bad thing if you are painting a barn, but if you are administering medical treatments or flying an airplane the smallest oops can have dire consequences. If a nurse knows, for example, that she (and sorry for sounding sexist but nursing is still predominantly female and besides it’s my example so if I want to make it a female nurse or a hermaphroditic orangutan that’s my business, if it upsets you tell your therapist) has accidentally given the wrong medication to a patient and if she admits her mistake she will be fired, there is a good chance that she will at least be tempted to say nothing. (The orangutan isn’t going to say anything either but hey, someone should have thought twice before putting it in charge of administering meds). In high consequence industries where the tiniest mistake can kill people blame conceals the errors.

But I digress, as I said, I didn’t want this to be yet another column about Just Culture. It just strikes me as odd that we as a profession continue to extoll the virtues of a blame-free workplace and the wonderful opportunity we have to learn about the causes of injuries while promulgating blame-based systems out of the other side of our mouths.

Blame-Based Safety

A friend of mine is a columnist who is an outspoken critic of BBS. One of his chief criticism is that BBS systems tend to blame the worker. The BBS fanatics all try to shout him down (good luck, the guy cut his teeth at Dow, is a PhD with actual work experience, and literally has forgotten more about safety than most people (including and perhaps especially me) will ever know) but he is right: Behavior Based Safety tends to lead to a climate of blame and shame. Oh, to be sure the purveyors of snake oil will assure you that THEIR brand doesn’t blame the worker, but I have found that these systems, whatever their intent, lead to a climate of blame. If the intent is not to blame workers, when one begins with the assumption that the incident is the result of behavior on the part of someone, and in most cases that someone is the injured worker, it is impossible for the injured party to feel culpable.

Even something as simple as behavioral observations can create a climate of blame. Whenever someone stands in judgment of us it is only natural to feel defensive. But my intent is not to create another angry argument for or against BBS, because quite frankly there is a whole new trend toward blame-based safety, which holds that leaders are to blame for injuries. In there acts and decisions, in what they done and what they have failed to do. While there is no small benefit in drawing leadership’s attention to the role they play in worker safety, the time for accountability is before people get hurt.

I have said many times that everyone plays a role in safety, but too often we only hold people after someone has been harmed or property has been damaged. People need to be answerable for ensuring the workplace is free of hazards, for the decisions they make, and for managing one’s performance inhibitors (the things in one’s life that make human error and unnecessary risk-taking more common like stress, lack of sleep, drug or alcohol use, etc.).

Blame remains a pointless exercise because once we have determined who’s at fault there is no reason to look further (it’s the same reason your lost car keys are always the last place you look.) That’s not to say that people shouldn’t be held accountable, but people need to be held accountable for their actions irrespective of the outcome. This is a basic tenant of Just Culture that the extent to which one is accountable is independent from the outcome. Actions taken and decisions made in good faith are not punished no matter the outcome and recklessness is subject to discipline even if no harm occurred as a result. It’s a bitter pill for some to swallow, but swallow it they must.

Filed under: Safety

A Pyramid By Any Other Name


by Phil La Duke

Tip of the Iceberg --- Image by © Ralph A. Clevenger/CORBIS

In the past weeks I have challenged safety practitioners to view safety differently, to see beyond the fads, the snake oil, and to see safety for what it is, the product of well-managed business practices in the areas of competency, process capability, hazard and risk management, accountability systems, and engagement. I have explored competency and process capability and this week I will take a close look at hazard and risk management.

This topic is by far the most difficult to explore, not because its not well understood, but be cause it is so frequently misunderstood. So many of the basic tenants of safety—when done correctly—support this business element. Unfortunately, so few of these things are done correctly.

Take for example Heinrich’s insufferable pyramid. Safety practitioners all over the world still trot out Heinrich’s Pyramid as proof positive that if you have x number of near misses you will have y number of serious injuries and z number of fatalities. Safety practitioners cling to this concept like a tick on the soft white underbelly of business. But Heinrich’s Pyramid is a steaming pile of crap. Forget that evidence suggest that he may have made his evidence up, forget that no serious researchers (those who don’t collect checks for perpetuating this garbage) believe there is any statistical validity to the pyramid, and forget that Heinrich himself admitted that his research itself consisted of asking 1920’s front-line supervisors how injuries happened ten years or so after they actually happened. Forget all that. The greatest flaw in Heinrich’s Pyramid is that we never really know how many near misses, minor injuries, or unsafe acts there are so effectively we are missing half the information we need to make any meaningful inferences. But there I go again spoiling things for the safety professionals who: a) don’t give a rat’s testicle whether or not the pyramid is valid and b) are too lazy to replace it with something more meaningful.

Of course on the other side of the spectrum we have those who hate Heinrich with the venom and vitriol of the people who hate Heinrich Himmler. This school of thought holds that everything that Heinrich believed is wrong and damaging to the safety organization. These people, I believe, are throwing the baby out with the bathwater. While there is no value in trying to predict the expected number of injuries using Heinrich’s Pyramid, there is value to using the pyramid as an analogy to better help Operations value the benefit of correcting hazards. When forced (which is too often) to incorporate insipid pyramid into a training I am developing or presenting I explain it by saying that we know that for every injury there are numerous hazards that could have harmed us but didn’t, close calls, or minor injuries. We may not be able to use that to predict the number of future injuries but a heck of a lot of hazards represent a heck of a lot of potential for harm. That’s it, no hackneyed lectures about behavior.

Maybe the better analogy would be an iceberg. The above the waterline would be the reported injuries, recordables, DART Injuries, and fatalities and below the waterline would be the hazards, unreported minor injuries, and risk conditions. The point being that if we focus on the hazards before people get hurt we end up reducing the iceberg both above and below the waterline.

Managing hazards is pretty simple (which I’ll bet dollars to doughnuts is the reason so many safety practitioners hate it): find the hazards, contain the hazards, and track the hazard to its permanent correction. Of course implementing this simple process isn’t easy but making it more complex doesn’t make it any easier.

Managing hazards begins with identifying hazards and the best way to do that is to walk the work area and look for things that can hurt people. We don’t need to worry about whether or not the hazard is a physical condition or the result of an ancient curse, or the act of an avenging pagan god. This is not to say that we shouldn’t investigate the causes, but we need to stop obsessing and finding profundity in the ordinary.

Once we have found a hazard we must be sure that we don’t walk away from it without containing it. There is more than just the obvious reason (because someone could get hurt before we get around to it) there is legal liability issues to consider if you find and document a hazard but fail to contain (and record the containment) a hazard.

Tracking the hazard to completion adds another layer to the hazard management process and it provides real value. Meeting weekly to discuss the progress toward correcting hazards helps to build ownership among Operations, it makes the previously invisible visible and applies coercive force on the people responsible for getting things fixed (who often sweep fixing hazards aside for sexier work).

Keeping it simple is an easier sell to the organization than some complex mumbo-jumbo.

Correcting hazards tends to return more on the effort than just reducing injuries. Because we eliminate the root causes of system failures, we likely will eliminate other process bottlenecks that effect cost, quality, delivery, and morale.

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

Your Only As Good—and Safe—As Your Process


SONY DSC

by Phil La Duke

Several weeks ago I posted an article that asked you to take a new look at safety. I asked you to consider that safety isn’t something that happens to workers or that doesn’t happen to workers, rather it is an indicator of the efficiency and effectiveness of one of five basic business elements: competency, process capability, management of hazards and risk, accountability, and engagement. In that post I explored the relationship between competency and safe outcomes, and in this week’s post I would like to continue to explore safe outcomes as they pertain to process capability.

I should begin by precisely defining exactly what I mean by process capability. Process capability is the extent to which a process (i.e. an activity designed to produce a predictable desired outcome) as practiced varies from the specification. Your process is not deliberately designed to harm workers so by definition something has gone wrong when someone is injured. Process variability is seen as the principle enemy to efficiency by most process improvement; variability is deviation from the standard and this deviation means that the process is less predictable; the greater the variability the more unpredictable the results and the more hazardous the process.

There is variability in every process; even robots and the best automated equipment are incapable of returning the exact same result in every instance. Typically machine and equipment performance measured in its ability to meet specific limits. Statistical Process Control (SPC) is a discipline developed to improve process reliability (how consistently it performs within control limits) these and other tools can improve process capability and create safe outcomes.

There are obvious things that we can do to improve process capability. For starters, we can develop Standard Work Instructions (SWI). According to the Lean Institute, “Standardized work is one of the most powerful but least used lean tools.” Standard Work involves identifying and documenting the current best practice. In so doing, the organization can identify a) differences between how the work is actually performed and how it was designed, b) the safest way to do the job, and c) identify and document continuous improvements.

Once you have created SWIs you have the means to properly train new employees, evaluate the performance and skill level of existing employees and as I mentioned in the first in this series people who have the skills to do the job are better able to do it safely and correctly. What’s more SWIs allow worker input into workplace improvements. So many organizations have invested in half-baked safety systems that pay workers to watch other people work and provide feedback, why not have them do something productive instead, like…I don’t know…develop Safe Work Instructions?

Standard Work Instructions are more than merely operating instructions, but my intent here is not to give free consulting in Lean Principles. Sufficed to say that investing in standard work improves not only your process but produces safer outcomes. Standardized work isn’t just for manufacturing—it can be applied to everything from driving to dry cleaning—but it is seldom used for non-manufacturing processes even in manufacturing, which is disappointing. Too often organizations resist standardizing non-production work by claiming that it is too difficult. If that were truly the case than how do we ever train anyone to do it?

In my experience a fair amount of workers will resist the very concept of Standardized Work, once when I was teaching a workshop in standardized work one worker indignantly told me that nobody was gonna tell him where he was going to put his (expletive) toolbox. So it’s not that easy to implement standards, of course, I was able to turn it around and win him over by telling him that he was going to tell US where his toolbox should go.

Total Productive Maintenance (TPM) is another great tool for influencing safe outcomes, while the snake oil salesmen will tell you that you don’t need to invest in capital, machines wear out, technology advances, and the design, care, and appropriate maintenance of your equipment is essential. It is outright stupid to believe that you can keep workers safe using outdated, poorly functioning, and wildly unpredictable equipment and, for that matter, battered and crumbling facilities.

Another Lean tool that has a direct influence on safer outputs is 5S, but then I’ve already written ad nauseum on the relationship between workplace organization/housekeeping and its relationship to workplace safety, and given the criticisms of late that I tend to repeat myself, I won’t go into here.

All the best tools and robust processes are of little value, however, if no one follows them. The second element that you have to consider in how process capability influences safer outcomes is “process discipline”, that is, the extent to which people work within the process. We tend to construct safety controls based on what people are supposed to do, and often forget that what happens on paper isn’t necessarily what happens in the workplace. As variable as equipment can be, this variation pales in comparison to the variability of human behavior. No amount of training, hackneyed theories, or the dubious claims from soft-headed safety gurus will change the fact that human behavior is incredibly complex, unpredictable, and rife with variability. This having been said, we need to stop trying to reengineer the human brain and start building engineering controls that protect workers when they make mistakes or even deliberately take unnecessary risks or behave recklessly. We need to recognize that everyone makes mistakes, whether it be human error or poor choices, nobody should have to die because they chose poorly. I know there are people out there who feel differently (shamefully even some people within the safety practice), people who believe that some people, because of their poor decisions deserve to be injured or killed, but for me, killing workers is still bad business.

Filed under: Behavior Based Safety, culture change, Hazard Management, Mistake proofing, process improvement, Worker Safety, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

The Lie of Complacency


by Phil La Duke

complacency

In this week’s post, I was going to continue exploring the antecedent processes that organizations must manage if they hope to ensure safe outcomes, but I got distracted by a recent contention by a leading vendor of safety training that 80% of all injuries are caused by complacency. I have been hearing this more and more lately and it is driving me nuts. First of all, I question the basis for that contention. Several sources claim to have reached this conclusion based on research, but I suspect that they know about the scientific method as I do about piloting a zeppelin, which is to say zilch.

What is the Ahabesque obsession that safety people have with finding the single cause (or the most common cause) of injuries? The cynic in me wants to point out that companies whose business model depends on the perpetuation of a given hypothesis are likely to preserve it at all costs, but I think it goes deeper than that.

To begin with there is the real problem that most of these people have differentiating between qualitative and quantitative data; it’s a problem that used to be common in the quality function. Qualitative data is measured while quantitative data is counted. When we talk about the cause of injuries we need to consider qualitative data not quantitative data, in other words, it doesn’t matter what the most common cause of injuries are, what matters is what is the most serious threat to workers. Let me give you an example, the following chart represents the locations on the site that have the most injuries:

 injuries pareto

If you look at this chart it is easy to assume that your efforts should be spent at the Memphis facility, but because this is quantitative (counted) data and not qualitative (measured) data we aren’t making informed decisions. What if , for example, the injuries at the Memphis facility are predominately first aid cases, but the Charlotte facility are predominately fatalities? Does it still make sense to attack first aid cases or is it smarter to address the problems at the Charlotte facility?

So even if complacency is the cause of 80% of worker injuries (and PLEASE share with us the industry, country, time period, research methods, population, culture, etc. that these studies on which this conclusion was made), it doesn’t mean that attacking complacency alone will solve the problem, because what percent of our injuries are relatively minor and what percentage are killing people?

But specifically the idea that complacency is the primary cause of injuries is problematic. This company and those like them, would you have believe that there is one overwhelmingly widespread cause that transcends all industries, worksites, and environments is ludicrous to the extreme, and convenient if you are selling a methodology that is based on this specious argument.

Why am I so suspicious? Well let’s start with the definition of “complacency”. According to dictionary.com “complacency” is 1. a feeling of quiet pleasure or security, often while unaware of some potential danger, defect, or the like; self-satisfaction or smug satisfaction with an existing situation, condition, etc. Is this really 80% of the causes of injuries? Are people dying from exposure to poison gases because they are smugly satisfied? Are workers being maimed because they feel comfortable doing their jobs? Who thinks up this softheaded rhetoric and successfully builds a billion dollar industry around it? And what is wrong with us that we so blithely buy this snake oil? To quote Kermit the Frog, “Somebody thought of that and someone believed it and look what we’ve done so far” of course Kermit was talking about wishing on stars, but he might as well have been talking about the latest safety methodology.

Another element that works against this thinking is the assumption that our anecdotal experiences and observations are universal. Once again, this is great for companies who sell a single tool solution (or single premise) but for those of us who are on the receiving end it can be lethal or even fatal. As I pointed out in my post about Lone Gunman safety, we have to as a profession accept that there are multiple causes for injuries and the more we look for that single cause the more we delude ourselves into thinking that there is some kind of magic bullet solution.

Injuring workers is a complex problem and we have to resist the temptation to get sucked into some con game where a slick-talking salesman convinces us that we only have to…and all our problems will be solved.

Beyond all that let us suppose that complacency really is this hidden killer, what are we to do about it? Awareness campaigns? I used to work in the nuclear industry and knew plenty of people who grew complacent with the dangers of exposure to radioactivity, but they still didn’t take chances or short cuts. An awareness campaign or retraining them would have made no difference—the opposite of complacency isn’t awareness it’s anxiety. So would the people preaching that the greatest threat to worker safety is complacency really suggest that we increase the anxiety of the worker? Would they have us believe that a stressed and worried worker is safer than one who is relatively relaxed? Keep in mind that a stressed out worker is far more likely to commit errors and take unnecessary risks than the worker who is not stressed out. Add to that the stress produced by constantly reminding people to pay attention or to stay focused and you have people adding risk to the process in the name of safety.

Complacency is a danger on one way—complacent safety professionals who think they are doing a better job than they are. If complacency is responsible for 80% of injuries, maybe it’s the complacency of the safety practitioner.

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

Taking a New Look At Safety


fresh look

By Phil La Duke

 Let me begin by thanking all of you who voiced your support for me over the past week. As you may have surmised I get frustrated from time to time, mostly because so many safety practitioners still don’t get it—despite cognizant arguments (I’m not talking about what I have been saying, I’m arrogant but I’m not THAT arrogant) made by really smart people so many in the field of safety cling to shear stupidity. Arguing a point that should have been conceded long ago gets exhausting and it got to me. Add to that a moderate case of writer’s block and it’s been a rough couple of weeks.

But enough about that, some time ago I posted an article that postulated that safety in itself wasn’t something we should be managing, that safety is an outcome not a priority or a factor or…fill in the blank. Safety isn’t what happens to or doesn’t happen to workers it’s an indicator of business efficiency. We have to view safety in a radically different way and I realize going into this upset some of the delicate sensibilities of some in the safety community, but safety cannot be effective on a functional level, it needs to be managed by operations. Operations ownership of safety isn’t a new idea, and certainly not a radical change, but what I am suggesting is more than simply moving a corporate function out of administration or compliance to under Operations leadership. What I am suggesting is that Operations needs to view safety as an indicator of the health of the organization, as a criterion for judging the effectiveness of Operations management.

If safety is truly a value (and it really should be) than what is it that we are valuing? A lack of injuries? Can we really say that is a value? But let’s back up. “Value” is one of those words that simpletons bandy about without really having a clear understanding of the definition of the word. I realize that in the age of Wikipedia people feel that it is an inalienable right to assign whatever definition they want to a word; sorry imbeciles it doesn’t work that way. “Values” are your personal code of beliefs, and one of the elements of a culture is “shared values”, that is, the most deeply held belief set that guides our decisions. So if “safety” is a core value it should guide our decisions as we manage our operations in five[1] key areas: Competency, process capability, hazard management, accountability, and engagement. This week I would like to tackle competency.

I tend to boil this down to a single statement: “if people don’t have the skills to do their jobs they can’t do them safely.” I stand by this, and it makes for a great “elevator speech”[2] but there is so much more to this. Recruiters have to find the right people to do the job, people capable—physically, mentally, and emotionally—of doing the job as designed. There is a lot of cowardice in recruiting and many in Human Resources will hide behind antidiscrimination laws for not doing a thorough job of screening people for their ability of inability to do the job without hurting themselves or others. The difficulty in hiring the right people isn’t completely the fault of recruiters. In many organizations the jobs are so poorly defined that it is for all intents and purposes impossible to identify which skills and abilities are bona fide job requirements. Companies, often abetted by misguided hackneyed legal advice deliberately add competency-risk to their organization because they are afraid someone will use his or her job description as a shield. In a well-managed organization competencies are mapped so specifically that an intern can see the skills and experiences that he or she would need to master/acquire to become CEO. Before you scoff and pooh-pooh the idea as nonsense, I developed such a system for a large, tier-one Automotive supplier, not only did it help in succession planning, but it helped individuals to own their own careers, and yes, an output of a good competency management system is a safer operating environment. Competency cannot stop at the date of hire.

There is seldom, if ever, a perfect hire. Even in the best case there is at least some gap between a new-hire’s skill set and the requirements to expertly do the job. Unfortunately, in most companies the training department doesn’t do individual placement testing to ascertain a new-hire’s true competency level and tends to train to the lowest common denominator (which here again they really can’t know without testing) and over train, often with a schlocky eLearning module that is about much like actual skill building as I am like a flamenco dancer. So there is much work to be done to increase true competency in our hiring and training process.

And it doesn’t end there, once someone has been hired and appropriately trained, there is still a large degradation of skills and behavioral drift where people move away from the established process, so the organization has to have a strong performance evaluation process that focuses on performance improvement and not on pay increases or cover your assets thinking that pervades so many performance evaluation processes. At this point you’re probably seeing where there begins to be overlap between the five antecedent processes. You can probably also connect the dots between getting these basic management practices right. Not only will the organization see it’s safety increase, but in all the other business elements as well.

____________________________________________

[1] I used to have seven, I have colleagues who have identified ten, others who have as many as 35, but I’ve found that much more than five of anything confounds the organization so I simplified mine to five

[2] If someone ever gave me a little speech about what they do while I was riding in an elevator I would be tempted to smack them, but I digress.

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

No post this week


Sorry folks, suffering from a severe writer’s block this week and a fair amount of depression.  I worked on no fewer than 8 pieces that I discarded because they were rambling pieces of crap.  Better to post nothing than to waste your time.

Filed under: Safety

Discouraging Workers from Reporting Injuries Is Bad Business


Paperwork

By Phil La Duke

Under-reporting injuries is a poor business practice bordering on criminal behavior. Nowhere was this better evidence than when the U.S. government leveed a whopping $70 million fine on Honda of America for doing just that. In what The New York Times describes as a “sharp escalation of penalties against automakers that skirt safety laws” Honda Fined for Violations of Safety Law, Honda was fined for not reporting consumer injuries and deaths caused by quality defects and for not reporting the defects themselves. Last year, General Motors faced similar sanctions.

It’s worth noting that neither company has been accused (at least formally) of underreporting worker injuries, but is that such a stretch? General Motors has consistently reported one of the best safety records in industry and Honda of America hasn’t made OSHA’s radar since 1999 when one of its contractors were fined over $1 million for machine guarding issues.

All that having been said, is it a stretch to believe that companies that deliberately lie to and one branch of the government (the Department of Transportation) about public safety might not also lie to another branch of the government (OSHA) about the safety of its workers? How confidant are you that companies that do not report one set of data (in this case public deaths and defect claims) that is publicly available and can easily be discovered will willingly and openly and accurately report injuries that happen under the shroud of company secrecy? We talk a lot about indicators in this business and to me there is a strong correlation between cooking one set of books and the likelihood that another set of books is equally cooked.

Rumor has it that underreporting is an area of increasing concern among OSHA inspectors and that companies can expect stricter penalties for underreporting.

Underreporting potentially poses a much more serious threat to worker safety than injuries themselves. When a worker is injured it provides the company with irrefutable evidence that safety is not present in the workplace, assuming you define, as most persist in doing, safety as the absence of injuries. As horrible as it is to have workplace injuries the silver lining is that a heretofore-unknown hazard is revealed and can be rectified; not so if the injury goes unreported and unknown.

Companies need not hatch any insidious plot to conceal injuries in most cases thirty years or more of hackneyed incentive programs and half-baked schemes from safety pundits have created a culture where injuries are taboo and only those injuries that cannot be manipulated via case management are reported.

It’s no accident that recordable injuries are falling while fatalities are staying flat (or in some industries actually rising)—it’s tough to turn a corpse into a first aid case no matter how creative you are. Case management has become a crucial part of the safety management system and it should be. No one should be allowed to fraudulently file injury claims in an attempt to cheat the system, but then again, as loathsome as it is, the company has to balance the cost of fighting the cost of fraud against the actual cost of the fraud. This is well known in the insurance and legal communities where it is common practice to settle a dubious lawsuit rather than face a lengthy and costly legal battle. And yet companies still invest considerable sums into case management. Why? Is fraud so widespread that something has to be done or western civilization itself would collapse? No, at least according to studies cited by Lisa Cullen in her article The Myth of Workers’ Compensation Fraud only 1–2% of Worker Compensation claims are fraudulent. So why do so many companies continue to fund Case Management efforts. Is it fiscally responsible to invest money disputing claims when only 2% or less are fraudulent? Not unless disputing claims serves some other, more profitable purpose. In the instance of case management the purpose is clear (although seldom admitted): reducing recordable injuries. I know of cases where companies have sent representatives to the clinic with injured employees to instruct the medical professionals in how to treat an injuries—weighing in on everything from the type of pain reliever used to whether to suture a cut or to close it using butterfly bandages. Such practices smack of questionable ethics but are widespread nonetheless.

Some efforts that discourage injury reporting are less malignant in intent but are just as damaging to the overall efforts to reduce risk. Companies routinely sponsor incentive programs for workers to not get hurt. If that phrasing sounds odd to you it should. When you provide incentive for someone not to do something that they can’t control and aren’t doing on purpose, what message are you sending? When you provide incentive for something beyond one’s control—whether that be injuries or sales—the only true incentive is to cheat and lie. The incentive in the case of zero injury rewards is to underreport.

One can take this effort to discourage reporting injuries even further and pit worker against worker through “behavior observations” which in effect vilify the injured worker; the injured worker spoils the Safety BINGO, and may even cost coworkers their bonuses. The coercive pressure to conceal workplace injuries can be overwhelming.

We talk a lot about changing the culture and about how workers need to change how they view safety, but maybe the cultural change needs to be in who we view injury and injury reporting. If we as organizations and individuals truly value safety we have to stop pretending that condoning injuries provided that they aren’t recordable injuries is the same thing as valuing safety.

Filed under: Behavior Based Safety, Injury reporting, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Lone-Gunman Based Safety


Multiple causes

By Phil La Duke

Ever since Jack Ruby gunned down Lee Harvey Oswald while being transferred from a Dallas police station to county jail debate has raged as to whether or not Oswald acted alone or if he was part of a larger conspiracy. There’s not much satisfaction in the “Lone Gunman” theory; it lacks the panache and high drama of a conspiracy, but beyond that, the Lone Gunman theory seems too simple, too convenient, and too pat. I got thinking about the Lone Gunman theory as it pertains to safety and think the comparison is apt.

I came to realize that most safety professionals see injuries as the result of “Lone Gunman” thinking after listening to yet another argument about the nature of injures. “Injuries are caused by behaviors” “no they’re caused by process flaws” “no they’re caused by…” it sure sounds to me like the people who argue whether or not Oswald acted alone. Sound crazy? Think about it: if you believe that the majority of injuries are caused by a single thing you are essentially dismissing the possibility that worker injuries are caused by a complex situations with multiple and often inter-related cause and effects.

The lone gunman theories are attractive; they boil our problem down to a single factor that we can rigorously attack and solve it. This kind of thinking is satisfying because it means that all we need do is to solve one problem and we don’t have to be distracted by all the other things that may or may not be causing injuries.

Now some reading this will immediately hide behind the fact that they never said that ALL injuries are caused by (fill in the blank) but that MOST injuries are caused by (fill in the blank). That’s a convenient (albeit cowardly) way to stack the deck in your favor but it’s a specious and facile argument, even if we can say with credibility that 99% of injuries are caused by a single cause we have always have that 1% that aren’t and that allows us to dismiss it as an outlier.. Dismissing causes that don’t neatly fit into your view of the world as statistical aberrations or outliers is just another form of calling a fatality an unforeseeable act of God.

No One is So Dangerous as the Man with the Whole World Figured Out

When we start to see any topic with a fanatic’s singularity we become dangerous. If we believe that most injuries are caused by a single cause—whether it be leadership, or culture, or process failures, or human error, or risk taking, or pixies, faeries, and trolls—we create a world where anyone who disagrees must be heretics and heretics must die or at very least publicly mocked behind the walls of anonymity of a LinkedIn discussion thread.

Call Us Legion, For We Are Many

I am distrustful of the “one-size-fits-all” approaches to injury reduction, which let’s face it, isn’t the same as safety and yet many of the programs, snake-oils, and magic bullets our there promise safety and only sometimes deliver injury reduction. It’s dangerous to think in terms of a lone-gunman cause for injuries (even when allowing for the possibility that there could be other lone gunman working simultaneously. The opposite of lone gun thinking is conspiracy theory, which okay, I admit, makes me sound like even more of a whack-job than usual. But for our purposes think of injury causes as being somewhat, or at least potentially, benign by themselves. We interact with hazards every day and in the fast majority of those interactions we don’t get harmed. But the more hazards that are present the greater the probability of injury and the presence of some catalyst causes us to be injured. Think of the straw that broke the camel’s back: up until that last minute the camel was uninjured, but given enough objects loaded onto the camel’s back eventually the camel will exceed its capacity to hold the weight.

There are many things, often working in tandem, that cause injuries and we have to stop arguing over whether the straw broke the camel’s back or whether the man who overloaded the camel was to blame, or whether the camel made poor choices, or whether both camel and man had been poorly trained, or whether we could provide an incentive for the camel’s back not to break and realize that there is seldom only one thing going on, and in most cases hazards work together to achieve a lethal synergy that can maim, cripple, and kill.

We Need To Look for Questions Not Answers

I taught problem solving for many years. One technique we used was called Situation Analysis. This technique is used to solve problems with more than one cause, has inter-related causes and effects, and grew over time. The technique was useful for solving broad problems (like…I don’t know…injuries). What I found interesting is that this technique taught people that if you only focus on one of the causes and ignore the others you won’t really SOLVE the problems you would merely make the symptoms go away until the other causes would cross a threshold causing the problem to return even worse than it had been before. I think of the conundrum of fatalities. Injury rates seem to be going down (although many believe that this is largely the result of under-reporting or more rigorous case management) while fatalities are staying flat or in some cases rising. This is the exact pattern one would expect from methodologies that attack one cause while ignoring others─ the problem seemed to be going away until it roared back worse than ever. It has left safety professionals scratching their heads, but if we attack the lack of safety as a complex problem that has multiple causes that are interrelated we might just be able to manage things better and save some lives.

I’m Not Alone

I know I may sound like a broken record, but when you sell hammers all the world looks like a nail, and while I have heard many say “well BBS is just a tool in my toolbox” (and I use BBS as an example because I hear this more then let’s say “human performance” or “leadership improvement”) I get skeptical. I want to ask what other tools do you use? When do you use them? When is it inappropriate to use them? But I don’t; frankly I’m tired of arguing with fanatics. One bright spot is that I am meeting more and more people who are beginning to think like me. Rockwell, for example, talks about the 3Cs of safety. The 3 C’s are Capital, Compliance, and Culture. Now I’m not here to promote Rockwell but I like where their heads are at on this. I’m over simplifying their spiel here but effectively what they are saying is that you have to consider all three of these things when attacking safety issues. Capital-you have to make capital expenditures to fund projects to improve your equipment. I would expand that to include your facilities as well, but I think their point is well taken. Compliance-let’s not forget that we have to follow the law and that basic compliance is the gateway to more advanced safety solutions. And Culture-hiring qualified organizational development professionals to make substantive changes in how your organization views and values safety is important. To hear Rockwell tell it, you can’t expect great results without looking at all three; I think they are right.

Filed under: Phil La Duke, Safety, Safety Culture, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

2014 New Year’s Resolutions for Safety Professionals


by Phil LaDuke

Last year I wrote a list of New Year’s resolutions for Safety Professionals. The piece proved popular and people this time of year seem to come looking for them. I decided to write this piece without looking at the previous list and after doing so taking a look at them to see if I am capable of any sort of growth. 2014 has been a rough year for me. I lost my father-in-law and one of my few remaining uncles to work-related illness and despite by best efforts through writing and speaking and working I don’t seem to have changed anything, not a single mind. But this time of year makes the best of us reflective and after doing some soul searching and reflecting I came up with a short list of things I think we as professionals can do to be even more effective:

  1. Seek first to understand before seeking to be understood. Okay, I borrowed this one from St. Frances of Assisi but I think safety practitioners need to adopt it, especially those of us who sell safety services and solutions. We need to listen to the organization and ask probing questions—not in an attempt to lead people to our preordained solutions but so that we can understand their pain points, we cannot solve a problem that we don’t fully understand.
  2. Keep things simple. When we offer advice we need to do so because we truly want the other to benefit from our wisdom and experience not because we want to show off or demonstrate our brilliance. The best advice I have received in life was simply stated and to the point. Perhaps the absolute best advice ever given me was a single word, “stop” (my friend Ken said to me as I was about to mindlessly walk into the path of speeding Chicago traffic). We don’t need to write grand, self-serving treatises to be effective.

We have become a profession of theorists who, when proven wrong, change the rules. We need to get back to basics, as my boss if fond of saying “the best companies get the basics right and they get them right every time”. So what are the basics? Competency, Risk Management, Process Capability, Accountability and Engagement. But on an even more basic level we need to tackle the basics of hazard identification, containment, correction, and communication.

  1. Be kind. I know it may sound hypocritical of me to preach kindness but as a wise man once said to me, “make the day, don’t let the day make you”. To a large extent what we send out comes back to us and when we are kind people are more likely to be persuaded by us than when we are jerks. Besides, being the safety jerk is my job. When someone has been injured they are particularly vulnerable, “I told you so” or “you should have…” never soothed an injured worker.
  2. Serve the Organization. I spent last weekend poring over incident reports and Workers’ Compensation reports and I was struck by how often we assume the injury was intentional until proven otherwise. Are their liars and cheats who want to fake claims? Sure, but far more of the injured are victims and if we just lived our lives in service to the organization instead of standing in judgment of the injured we would see that most injuries are painful, embarrassing moments in the lives of workers. Do we have to protect the company against fraud? Absolutely, but let’s resolve to do so without treating everyone as criminals.
  3. Collaborate. We cannot be successful trying to do this alone and we have to swallow our pride and reach out to other disciplines. I have seen so many safety professionals wrestling for control with the continuous improvement group only to have both groups remain impotent in the organization. Reach out and help someone and ask for help in return; at the end of the day we’re all in this together.
  4. Teach. To be truly safe workers need to be able to do their jobs and they need to have mastered their jobs. I wrote this to a safety executive once and he wrote me back with scorn. “Why do they have to master their jobs?” he scoffed at me. I resolved right then and there never to do business with him. I don’t think he can be reached and if he can learn, he cannot learn from me.
    But in answer to his question, why do they have to master their job? Because the level of mastery of one’s job equates to the level of risk one operates under while working. Workers who don’t know how to do their jobs—or our just marginally competent—are far more likely to be injured or to injure another worker. This is most acutely evident in how companies view training temporary workers; in the minds of many better to kill a temp than to waste money training one. It’s ugly, but it’s true.
  5. The more we sharpen our skills as safety professionals the more good we can do, but I’m not talking about learning the latest safety fad. We need to learn how our businesses work, how our organizations survive, and how our companies make money. We can’t change anything unless we know how our businesses work. Instead of going to the same tired professional conferences and hearing the same tired speeches from the same tired hucksters why not attend a business seminar, or a Lean Management course? You will be a better professional for it.
  6. Safety is a tough way to make a buck, and it’s getting tougher. Hang in there, this isn’t a job for quitters.

Last year I gave you 10, but this year only eight. But I will make you a bargain. If you do these eight come see me and I’ll give you another 10.

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

Why BBS will Live Forever


By Phil La Duke

Just when you think the debate over Behavior-Based Safety has faded from the landscape something brings it crashing back into your consciousness. For me it was a recent article (and the response to it) by Dr. James Leemann. Jim asked the question “will Human and Organization Performance (HOP) finally supplant BBS” as the prevalent approach to worker safety? As one might suppose the BBS zealots and whack-jobs came crawling out of the woodwork to complain.

I’m a big proponent of HOP because it fixes system problems not the blame. HOP goes beyond the behavior and address the system-wide antecedents, the things that precede and encourage the very behaviors that influence safety. I don’t think it’s a perfect system for protecting workers but I believe that safety is the output of well-managed business systems and so HOP makes a lot of sense to my clients and me.

The backlash to Jim’s article was predictable; the usual suspects accused Jim of not understanding BBS, not having seen BBS properly deployed, etc. etc. etc.

The whole argument exhausts me. I’ve said before that arguing against BBS is like telling someone you don’t like eating fricasseed squirrel anus. The first response is always, “well you just haven’t had it cooked right; you need to try MY fricasseed squirrel anus—you’ll love it!” So you try there version and it tastes even worse that the last time. But you still don’t, in the eyes of the fricasseed squirrel anus lobby, have any real standing, how many squirrel anuses (anusi?) does a man have to eat before the nut jobs cooking it will allow that said man to refuse on the grounds that squirrel anus is unpalatable?

To speak up against BBS is, in the mind fanatics, to speak out against safety, God, apple-pie and motherhood; it doesn’t matter how much evidence you produce that BBS doesn’t work, creates bloated bureaucracies, and encourages under-reporting of injuries, you will never convince the true believers that BBS is anything less than the one true path. It’s like trying to convince Lynette “Squeaky” Fromme that Charles Manson isn’t a pure soul; talking about it is like doing a card trick for a dog.

I’m at a loss to explain why BBS lingers in the same way I’m at a loss to explain why some people still believe in the Loch Ness Monster when most of the most credible evidence has since been exposed as so much bunk, or why there are Big Foot sightings in every state of the Union (including Hawaii), or why people believe in alien autopsies while others refuse to believe that the moon landing was anything more than a government conspiracy with a Hollywood twist.

For some BBS is an important source of income and in those cases it is not inconceivable that either they unethically cling to something that they know is snake oil or they have convinced themselves to ignore information that threatens their livelihoods; either way they have the strongest possible financial incentive to refute any claim that BBS doesn’t work. It’s much like a child who begins to doubt the existence of Santa Clause but is terrified that if he or she voices this doubt the Christmas gravy train will end and there will be no more Christmas present bonanza; the pragmatist in each of us will play it safe and perpetuate the Santa Claus myth even though long after we ourselves have long stopped believing.

For others BBS is a crutch on which they lean to compensate for the lack of real competency in safety. When one doesn’t quite get it, one clings to those things that they CAN understand. If you have a safety practitioner who lacks understanding of the basic safety regulations will find BBS a comforting alternative, with it’s simplistic “just reward safe behaviors” philosophy. Many people who don’t know the hard science side of safety will gravitate toward the simple argument that “if 80% of injuries is caused by behavior then we should focus on behaviors”.

In a broader sense BBS has a wide appeal to the key players within an organization. Management likes the “let’s hold workers accountable for working safe” underpinnings of BBS. Safety professionals like the number of resources that fall under their control; they get to spend money and engage in a wide range of activities. Employees love the pizza parties and safety BINGOs and safety bonuses. And of course vendors love the revenue it brings in. There is a conspiratorial feel to all this that sets off alarm bells.

Still others, and I believe this is the largest group speak about BBS in philosophical terms. Those in this group will insist vendors have a behavior-based safety system in place as a condition of doing business; it’s a nice thought but what then constitutes a “behavior-based safety” system? Is it enough that the safety system address unsafe behaviors? If so, this is fundamentally flawed unless the definition includes some context, and because all behavior exists within a context the definition would have to be exhaustive to be of any use whatever. What’s that old saying about the road to Hell being paved with good intentions? Wikipedia, granted nobody’s vision of a credible source, defines Behavior Based Safety as “the “application of science of behavior change to real world problems”.or “(their spelling error not mine). A process that creates a safety partnership between management and employees that continually focuses people’s attentions and actions on theirs, and others, daily safety behavior.BBS (again their screw up) “focuses on what people do, analyzes why they do it, and then applies a research-supported intervention strategy to improve what people do” Let’s take that one phrase at a time:

“application of science of behavior change” according to behaviorscience.com the science of behavior change is behaviorism. And according to the American Board of Professional Psychology (people who it would seem ought to know) “behaviorism” “emphasizes an experimental-clinical approach to the application of behavioral and cognitive sciences to understand human behavior and develop interventions that enhance the human condition.” I’m pretty sure that BBS as practiced is just about as far from this as can be reasonably imagined.

“A process that creates a safety partnership between management and employees that continually focuses people’s attentions and actions on theirs, and others, daily safety behavior”. Here, while many BBS systems aspire to this none can honestly say they have achieved it, for if such a system does exist there would be no injuries, no near misses, no need for the hapless companies to frantically feed the BBS money machine.

“focuses on what people do, analyzes why they do it, and then applies a research-supported intervention strategy to improve what people do” Again, while BBS may do all these things, to what end? They haven’t and never will prove that all this focus and research changes human behavior one whit, nor does it change the ingrained tendency for people to make errors, take risks, and behave unpredictably. No, I am not condemning anyone who requires his or her vendors to have a behavior-based safety system—just using safety performance as a criteria for selection will save more lives than not doing so. I am not condemning anything really, I just want to know why merely asking the question “is it time to dump BBS and consider another approach” is seen as abject ignorance or malicious heresy. Is a world without BBS so threatening and scary?

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

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