Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

Changing The Safety Culture: You Got To Want It

By Phil LaDuke


To some extent the world is driven by desire, and I have said (quoting a long-time friend) that you always have the time and money for what is truly important to you.  As I continue battling to sell safety systems to companies who truly do need to change their cultures I am continually beset by companies who are quick to say all the right things but when it comes to making a commitment they just plain lack the political will to get things done.

Of course no one will ever admit that they don’t want a safe workplace; to do so would brand them a villain worse than any war criminal.  So why is it so difficult to sell companies who employ large staffs dedicated to making the workplace safer? And why is it harder still to maintain the momentum it takes to drive lasting and sustainable change in an organization?  Will.  So many companies are so fixated on finding a magic bullet for safety that anything that is of any magnitude is quickly disregarded.  But it’s not really the difficulty in selling safety solutions that is troubling, rather, it’s the lack of commitment to sticking with change when things get tough, or scary, or chaotic.

In my many years as a corporate culture change agent I have found that the strongest driver of change is the desire for success—and that applies not just to safety, but success at everything.  I am reminded at the biblical story (and forgive me folks by I am by far no theologian or biblical scholar although I did get ordained on the internet but given that the entire ordination consisted of me filling out a form and having Reverend credentials emailed to me I don’t think it qualifies me as a religious scholar) where a man approached Jesus and asked him what he had to do to gain salvation.  Jesus told him that he must sell all his possessions and give the money to the poor and come follow him, AND THE MAN WENT AWAY SAD.  Wow.  And I thought I made poor life choices (and for the record I have) but what a whopper that guy made.  It doesn’t matter your religious persuasion (or lack thereof) what is important is that this guy believed that Jesus could deliver the goods and when he heard what it would take he decided that it was too high a price to pay for eternal life.  And he went away sad.  Was he disappointed that the solution was so life changing or was he expecting Jesus to say something like, “don’t sweat it, I can get you in, I know people.  When you get to the gates of heaven just tell them you’re with me”?

I think there are strong parallels between this biblical story and the state of safety.  People come to the providers of culture change solutions and expect the answer to “the key to culture change is taking this course, or having your employees read this book,” or “all you need to do is…”  I think when they realize that culture change is a laborious process that involves engaging outside experts and changing the way the organization operates and a foundational level they go away sad.  Or they buy snake oil and hope it will work.

Of course some try the longer term, more holistic approaches, and many of them are successful (I have a pretty good track record of helping companies be successful if I do say so myself) but so many others give up, and having given up refuse to be “fooled again”.  I am partnering with a company who is really excited about my approach to culture change, but there is one snag.  The one person within the company who has the most power and influences to get me in front of his customers doesn’t believe that sustainable culture change is possible.  I have provided him with case studies of customers I have successfully served 10 years ago who are still sustaining the gains that I helped them achieve.  I have provided references so that he could hear testimonials from the proverbial horse’s mouth all to no avail.  The lessons he learned from the snake oil salesmen will not be easily unlearned and in fairness to him, I would meet anything that promises safety salvation with a sharp dose of skepticism.

Why do so many change initiatives fail? Too often it’s because the organization wants to take components of the solution and expects that implementing a “lite” version of the solution.  In the 1980’s the Japanese Management was all the rage.  Many companies tried to emulate the results that the Japanese companies achieved, but when they looked at all the components that the Japanese style of management required they quickly started eliminating practices. The resulting watered-down solution was completely unrecognizable as an effective management system.  We see the same thing today as companies try to imitate Google or Yahoo, taking ingredients of the recipe only to be surprised that the effort completely fails.

But in the final analysis, it’s not a lack of time, money, resources, or solutions that get in the way of safety; it’s a lack of desire.  If leadership continues to value productivity over people, the bottom line over the front line worker, tactics over strategy, the immediate business needs over the long-term solid business decisions, all efforts to improve safety will be transitory at best.  You can’t change anything and expect it to remain the same.

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Porn Safety

porn safety

By Phil La Duke

Two days ago I visited the porn capital of the world; no I wasn’t making a pornographic film. The fact that my business in the area seemed lost on friends and colleagues, who saw fit to ask with a smirk if I was going to provide safety services to the porn industry.

The matter got me thinking if, ethically speaking, it is right to turn down business because of one’s personal beliefs. Naturally there has to be a moral line one needs of which one must be cognizant when doing business, but can one politely decline saving lives just because one finds an industry distasteful? I understand that many of you have already made up your mind and are ready to quit reading before really asking the really hard (no pun intended) questions.

Over the course of my career I have worked with clients who have run the spectrum from those who want me to take their already exemplary safety programs to the next frontier to those who want to do the bear minimum to be compliant without the quietest whisper of concern for the safety of their workers. If I turned down every client because of my politics, moral indignation, or personal preferences I would be derelict in my duties.

Who is the moral reprobate? The professional fornicator or the safety professional who refuses an industry in need because they find the product morally objectionable.

“Conscious Do Have a Cost”—Bunk Moreland to Omar, The Wire

Perhaps it’s easy to shy away from porn—it’s not like most of us have an off-the-shelf course in fluffer safety —but where is the line? Can we shun the porn industry on one hand and accept jobs in other industries that are guilty of worse sins? To be sure pornography is obscene, but how much more obscene is war? If it is okay for us to provide safety services to companies that build missiles, land mines, and bullets how is it not all right for us to provide safety services for the adult entertainment industry?

The Slippery Slope Argument

Some would argue that providing safety services to the porn industry starts us down a slippery slope. If, they ask, we provide services to the porn industry, then where does it end? Should we provide safety services to prostitutes and pimps? Should we sell safety to drug cartels and contract killers? Well for starters the production of porn is legal, and no one can ethically provide professional services to criminal enterprises without aiding and abetting a crime, so I think this argument is moot. Again we come back to is it okay for us to refuse to provide services to individuals and industries simply because we find them distasteful. The other side of the other side of the slippery slope argument is this: can you refuse to provide safety services to a company because of their gay friendly policies? How about refusing to provide services to hospitals that perform abortions? Conversely, can you in good conscious refuse to provide safety services to companies who discriminate against gays, blacks, midgets, albinos, or women?

The Hypocrite’s Oath

While it’s true no one (at least no one I know) in safety has taken an oath to provide services to any and all that need them, I feel an ethical responsibility to not refuse work on ethical grounds. Perhaps I sound like a morally vacuous whore, but it’s often the worst of companies that need me the most. I often work with companies who don’t really see an issue with killing workers provided that they don’t kill too many. Many more companies just don’t understand safety and how to manage it so they need me to help them mature as an organization. It seems like everybody and the neighbor’s monkey is out their preaching “change the culture” and “we have to change the way we think about safety” mantras. Who better to serve than the rogue’s gallery of companies who are making the news for gory butchery of their employees? If we say that every worker has a right to go home unharmed, how then can we pick and chose which workers won’t get the benefit of our services simply because of the job they do? Is a bull semen collector (an actual job at breeding ranches) that far off from porn? Is the manufacturer of the gun of choice to street gain killers that different from the sociopath who pulled the trigger?

If We Don’t Have a Moral Code Who are We?

I am not suggesting that each one of us doesn’t have the right to refuse work if said work is so at odds with one’s value system that to agree would deeply conflict with one’s value set. I am suggesting that we as safety professionals routinely turn a blind eye to the ugly realities of our business. We can’t make manufacturing weapons of war more effective and not acknowledge that we blood on our hands, so in that respect if we oppose a company’s business (or politics) and we still provide services one could justifiably brand us hypocrites.

For my part I see myself as akin to a criminal lawyer who believes that even the worst of society deserves competent representation and that defending loathsome criminals does not abet the crime, rather it is in furtherance of justice and results in the betterment of society. I will work with anyone who will have me, not because I believe in their products, purpose, or politics, but because I believe that everyone has a human right to be safe on the job and if that means that I have to do business with organizations that others (or even I) loathe (all though I have found that it’s tough to loathe anyone writing you checks) so be it. My job is to help companies protect their workers, their profits, and their very existence; a noble calling to be sure, even if there is nothing noble about customers that I serve.

Quick disclaimer: My existing client base is in no way engaged in politics or practices that I find objectionable but that doesn’t mean I won’t sometime soon.

Filed under: Safety

The Zero-Injury Witch Hunt


By Phil La Duke

Sometime ago I wrote, almost in passing, about the rift that James Reason first identified in the safety community between those who believe that injuries are primarily the result of individual choices or systemic causes. As deep and destructive as this riff, another deeply divisive issue threatens the safety community the argument over the possibility of Zero-Injury goals.

On one side of the argument zealots argue that the only acceptable goal in safety is “Zero-Injuries”. After all, if our goal isn’t the complete elimination of injuries that what our goal? How many people can we kill a year and still consider ourselves successful at providing a safe work environment?

Critics of this thinking counter that the belief that zero injuries can be deliberately achieved and sustained is naïve, even simple-minded. These critics argue that zero injuries can only consistently be achieved when an organization achieves zero risks and that is impossible, at least in any sort of sustainable state.

Most critics of zero injury goals are increasingly reticent to voice their criticism for fear of loss of their livelihoods. This fear is far from unfounded; many Fortune 500 companies have so institutionalized the religious fervor around zero injuries that to question the wisdom of zero-injuries as a goal is to be branded a heretic and to become a pariah. Many of these same companies make “Zero Injuries” a condition of providing services to them.

For my part I believe that zero injuries CAN be achieved, but in most cases most of the most ardent supporters will never achieve it. The reasons are simple:

  1. For an injury to be prevented it must be foreseeable. Anyone who has ever been injured will likely attest to the fact that they “should have seen that coming”, but there are always those bolt-from-the-blue injury causes that we never could have seen coming.
  2. Foresight can only prevent injuries if there is time to act on this foresight. Consider this: you are walking through a store and you notice that the stock on the top of the aisle is stacked too high and before you have time to react it begins to shift. You can foresee that you will be injured but you don’t have time to react; foresight provides you no advantage.
  3. Any foresight must have perfect information. A colleague of mine likes to tell people he is training in hazard recognition that whenever an injury occurs it is because someone either did something they shouldn’t have or didn’t do something they should have. This may sound simplistic but it makes profound sense. What I have found is that in many cases is that the reason people make the choices that they make because they lack perfect information. In other words, people who make decisions erroneously believing that something is true (“I thought it was locked out”) when it was not (yes I realize the redundancy but it reads better that way) or that something wasn’t true (“I didn’t know the gun was loaded”) when it was. That having been said, how often do we truly have perfect information?
  4. Zero-Injuries depends on an extremely low tolerance for risk. Organizations and cultures that reward the risk takers for their bold decision making and “save-the-day” approach to life open themselves up for increased risk and increased risk correlates to increased injuries. You’ll notice I used the word “correlates” rather than causes; some of these companies go years without an injury just because of dumb luck. They operate at a higher risk level and thus a higher probability, but probabilities are just that; not certainties.
  5. Some industries lend themselves to zero-injuries more readily than others. It’s a dirty little secret that some injuries are just plain more dangerous than others. Okay so maybe it’s not all that secret but it isn’t talked about all that openly either. This isn’t to say that all industries can aspire to be safer, but some industries are going to face an uphill battle. Of course all work carries with it some chance of injuries, but a greeter at Walmart is statistically less likely to be gored by a bull than a bullfighter or a rodeo clown. I won’t open the whole can of works that comes with saying that this or that industry is safe, but a quick glance at the U.S. Bureau of Labor Statistics website will prove my point: some industries are intrinsically more dangerous than others.
  6. ZeroInjuries depends on workers accepting onerous controls put on them. While I ardently believe that no one in his or her right mind wants to get hurt, I also believe that we all have our own idea of when the quest for safety becomes ridiculous, intrusive, and downright simple minded. People fight for the right to ride motorcycles despite evidence that suggests that one is much safer in a car. Some of those same people fight for their right to ride motorcycles without a helmet despite evidence that wearing a helmet significantly reduces the chance of head injuries. We all have different tolerances for risk and as long as we do we will have different probabilities of injury.
    Who among us hasn’t violated a safety rule for no better reason than because we thought the rule was stupid, over protective, or otherwise shouldn’t apply to us. Deep down we all harbor a “you’re not the boss of me” or “I don’t want to and you can’t make me” attitude (some of us have it buried deeper than others) that makes us want to passive aggressively resist the safety rules?

So let’s avoid the Zero-Injury witch-hunt. Let’s recognize that we all want the same thing—to hurt fewer workers in the workplace. Let’s acknowledge that whether or not we believe it’s achievable zero-injuries, at least conceptually is a noble pursuit. If you don’t believe it’s possible then at least recognize that you probably believe dozens of crazy, ridiculously implausible things that they don’t buy. And to all of you who would deprive others of their livelihoods and run people out of the business simply because they don’t believe in one of your most cherished beliefs, lighten up; there are lots of right answers and you don’t have a monopoly on the truth.

Filed under: Safety

Safety Never Sleeps: Creating A Culture of Vigilance


By Phil La Duke

Creating a safety culture is all the rage today, and whether you are a snake oil shyster or an organizational psychologist working in safety everyone seems to agree that we need to create cultures of safety to be successful in reducing injuries.  I don’t know about you, but I get a more than a bit nervous when everyone agrees on a single course of action.

The concept of a “safety culture” in itself is both widely known and impossibly vague.  In broad strokes a safety culture is a state where “safety” is a shared value.[1]  I put the word “safety” in quotes because it is the most basic definition of our profession and the most poorly defined.  I have had people define it as the absence of injuries, but that doesn’t necessarily make one safe.  I have been in plenty of unsafe situations where I never even came close to being injured.  Some say that safety is the absence of risk, but since such a thing can never be true defining safety as such is to admit that safety is an impossibility. There are even some that will say that safety is a state of mind, that we either feel safe or we don’t, but if that’s the case pursuit of safety is the pursuit of complacency (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.[2]) and since one of the major players in the safety community now openly claims that complacency is the cause of something like 60% of all injuries this creates a circular logic—we can only be safe if we feel safe and if we feel safe we are complacent and if we are complacent we can never be safe.

Safety is too broad a concept, too philosophical on which to build a culture.  So if not safety what then?  A couple weeks ago I began toying with the concept of a culture of vigilance.  What, I asked myself, if we decided to pursue a culture of vigilance instead of a culture of safety? Could it work? What would it look like?

I envisioned a culture where people valued the approach more than the result, where risk taking wasn’t a sign of bravery and ingenuity but of recklessness and irresponsibility, I asked myself what might that look like.  It’s tough in a world where the “cowboy culture” is no longer a uniquely American thing the world loves an action hero and the ubiquitous rogue anti-hero pervades pop culture from Australia to Greenland, from Hollywood to Bollywood, from Argentina to Japan.

Arsonist Are the Best Firefighters

There is nothing like the feeling of sweeping into a mess and saving the day.  Unfortunately, too often we idealize people  for cleaning up their own messes.  We rarely praise someone for planning and executing a task with such precision that nothing even comes close to going wrong; it’s boring, and as my daughter (and Chris Rock) are fond of saying, “you don’t get credit for doing the things you are supposed to do”.  But maybe we should give credit for the people who get it right, and that’s what I think lies at the center of a culture of vigilance.

Rewarding someone for putting out the fire he or she set is a bit like the puzzling practice of having far less harsh penalties for attempted murder than for actual murder, I mean, in so doing aren’t we just rewarding failure? Not to make light of murder, but if we adopted a culture of vigilance the penalty for TRYING to commit murder (the intent or the action) would be the same as it would be for SUCCEEDING in killing someone (the outcome).  We need to focus on what we can control and stop focusing on those things beyond our control.

The Values Of A Culture Of Vigilance

If such a thing as a Culture of Vigilance can be said to exist there must be shared values associated with it.  I would like to submit the following for your consideration:

  1. Success is borne of planning. Solid planning is required for Operations to run smoothly with minimal variation and lowest possible risk; the better we plan the safer we are.
  2. We Cannot Prevent What We Cannot Foresee.  One of the first things we should be asking ourselves when someone is injured is not “what could the injured person have done to have avoided being harmed” (not that this question isn’t worth asking, but it shouldn’t be the FIRST question), rather we should be asking “was this foreseeable?” and if so, “why did we fail to foresee this?” and then “if we did foresee this, what did we do to mitigate our risk?”
  3. An Ounce of Prevention Is Worth a Pound of Cure.  It is always smarter and more effective to prevent injuries than to react to them and we need to build safety systems that spend far more effort preventing injuries than in treating them and preventing recurrence.
  4. Safety Never Sleeps. A culture of vigilance means that we are relentlessly pursuing the prevention of injuries and that we can never be fooled into thinking that nothing can go wrong; we are piloting The Titanic , a ship that once regarded as the safest ocean going vessel, right up until it sank.
  5. Vigilance is Exhausting So It Takes Everyone Working Together.  Constant vigilance creates a state of chronic unease that leads to stress and injuries so we have to get as many people involved as possible; many hands make for light lifting.
  6. Knowledge is Power.  We won’t be perfect, but as long as we learn from our mistakes we can continue to improve, and continual, incremental improvement will make the workplace safer.
  7. Every Injury Is A Big Deal.  We may never achieve zero-injury, and zero-harm may remain an ever elusive goal, most certainly we can never achieve zero risk,  but its never okay to hurt workers.  People can argue whether or not the idea of zero injuries is a faerie tale or the only acceptable goal, but both sides should agree that hurting workers is never okay and that anytime  a worker is harmed we have failed at our jobs.


[1] Before anyone runs off at the mouth about how this isn’t how he or she defines safety culture please read and then kindly keep your definition to yourself; I don’t care Daniel Webster you don’t get to just make up definitions to suit your purpose although I guess that’s essentially what I’m doing, but hey, it’s my blog; such is my right


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The Rise of the Safety Theocracy


By Phil La Duke

“You’d be surprised at how many companies don’t care about losing money”—A colleague when I showed him my presentation and case studies demonstrating my ability to lower companies’ injury costs by millions of dollars.

A few years back I figured out a way to automatically notify companies of lockout violations as they were happening; I was understandably excited…think of the implications! Think of the lives that will be saved! Think of the money I will make! I soon realized that nobody cared.  Fast forward and you find me shilling a safety solution that had a proven track record of lowering the cost of injuries by an average of $2.5 million a year only to find myself summarily dismissed because of a lack of sales—again because nobody seemed that interested in saving money by lowering the cost of injuries.

I was telling these stories to a colleague of mine who responded with the opening quote.  To some improving safety performance to save money is seen as crass, as tacky, and as well…immoral.  To be sure improving safety so that no one gets hurt and everyone gets to go home and to continue to enjoy life (well at least as much as they did before going to work.  I was married  to a nagging shrew of a woman and frankly going home after work wasn’t the height of fine living, but after 26 years of blissful post-divorce bachelorhood I can honestly say that even life with her—such as it was—was better than dying at work or living with her as a cripple (the Bette Davies/Joan Crawford classic Whatever Happened To Baby Jane immediately springs to mind, but as so often the case, I digress) is a laudable goal, but to some it runs deeper.

Some people seem to believe that equating safety with business costs somehow cheapens the goal of keeping people safe, as if saving money lessens the nobility of reducing workplace injuries.  This proselytizing of safety frankly, is getting out of hand.  Why can’t we do the right thing and also make a buck doing so? What is it about quantifying the savings associated with reduced injuries that is, in so many people’s minds, vulgar, distasteful, and wrong?

Until we manage safety like a business element it will remain a quasi-religious movement where decisions are made based on philosophical platitudes versus basic management techniques. Approaching safety on moral grounds is doomed; creating the cult of safety where we perpetuate superstition simply because we want to believe it rather than based on research and facts means we create a sort of safety theocracy where charlatans and gurus dictate how we run our businesses.

This is not to say that good business practices and an ethical and moral approach to our work need be mutually exclusive, quite the contrary. Many companies have shown that they can engage in highly ethical and moral business practices and still make considerable profits. These companies serve as role models for all of us; they represent what can be achieved and to what we should all aspire.

Tracking the cost of injuries allows us to keep score; we use it to gauge the severity of injuries and it helps us to understand the difference between safety improvements caused by picking the proverbial low hanging fruit and those caused by solving deeper systemic issues.

Opponents of tracking the costs of injuries do make some good points.  For example, some worry that if we focus too closely on the costs of injuries we run the risk of losing site of the fact that even if spending money in pursuit of a safer workplace need not return on investment to be a good business decision─since we can never really know what may have happened if we had ignored the risk.  Money spent reducing the chance that someone will be seriously injured or killed is typically money well spent.  If we quantify the cost of injuries do we risk returning to the days when financial professionals calculated the cost of worker deaths as a cost of doing business? Maybe, but I think we are looking at a continuum here.  At one end of this continuum we have businesses who are averse to calculating the cost of injuries and at the other end we have businesses who won’t spend money on safety unless a compelling business case for doing so can be made.  I believe this is a bell-shaped curve where most companies are somewhere very close to the mean and the ones at the extremes represent a very small portion of the population.

Beyond all this there are some practical and sensible reasons for tracking the cost of injuries.  Unless we track the cost of injuries─and track them completely, not with multipliers or estimates but with hard and real measurements─these cost remain an invisible onus that cling barnacle-like to Operations impeding our progress, sapping our productivity, and consuming resources that could be put to more important and valuable efforts.  In other words, our overall performance suffers and we are never truly cognizant of the reasons why.  What other business issue costs us money, and we accept the fact that we don’t know how much it costs? In what other function can we spend money without knowing or caring how much.

So should we calculate the costs or does doing so make us less committed to doing what is right just because it’s right? The essence of engagement IS doing what is right, not out of self-interest or for an external reward, but for no other reason than because it is right.  Like so many issues I have taken something simple and made it complicated.

When my colleague said to me, “you would be surprised at how many companies don’t carry about losing money” I thought, “how could these companies be so short-sighted?” But  having interacted with some companies who honestly don’t care what the cost of safety is, not because they are short sighted but so adamant about safety, I have to say that I was probably being too harsh, but the most successful companies don’t shy away from quantifying their injury costs, and proudly stand at the intersection of morality and fiscal enlightenment.

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When It Comes To Injuries, the Simplest Answer Often Isn’t the Correct Answer


By Phil La Duke

Occam’s Razor is one of those things that a lot of people cite, more have heard of it, and in safety, many more use it to jump to conclusions. Perhaps the most often cited simplification of Occam’s Razor is “when looking for an explanation as to why something happened, the simplest explanation is usually the correct explanation.” Before the army of pedantic boobs mobilize and reign down a flurry of insults at my oversimplification of Occam’s work (which, for the record, experts don’t believe he actually invented) I should say that I fully and whole-heartedly admit that a) this is indeed an oversimplification but it’s not my oversimplification, and b) this oversimplification really belies a misunderstanding of what Occam’s Razor really says. La Duke’s Razor would be “The easy solution to worker injuries is generally the most popular, irrespective of its effectiveness.”

That having been said, too often, incident investigations assume that the simplest cause is the correct root cause and that conclusion, while comforting, is irresponsible ─ even dangerous. Take the all too common root cause of “operator error”. The conclusion that a worker was harmed because he or she erred is satisfying; if an investigator asks “why?” the answer is the variation on Murphy’s Law that says, “shit happens”, or for those of you scandalized by my scatological idiom, “nobody’s perfect”. The contention that everyone makes mistakes is a facile but deeply satisfying conclusion. When investigators conclude that a plane went down killing all aboard because of “pilot” error, we sigh a collective “thank God it wasn’t terrorists” sigh of relief, slap each other on the back and it’s “Miller Time”. Occam’s Razor and Murphy’s Law support the errant worker as proximate injury cause and who are we to argue with a dead guy and a fictitious guy? Certainly a fair number of injuries result immediately or soon after a worker errs, but until we understand exactly why a worker erred we will never have a complete understanding of the circumstances that led up to the injury and without that understanding avoiding future injuries caused by these unknown elements are complete luck. (I am fond of pointing out that in general lucky people win lotteries; I’m not sure I would categorize someone who narrowly escapes serious injury as lucky; they just aren’t fatally unlucky.)

Some injuries are tough for us to see beyond the obvious and the easy. Take for example the time I was walking on a sidewalk abreast of a colleague and a customer. As the three of us walked side by side we approached a temporary sandwich board and instinctively moved to the left to avoid the sign. As we did so, I stepped partially off the sidewalk and fell striking my knee against the sidewalk. My pants were torn and I skinned my knee. The most severe injury was too my dignity. If we use the standard 5 Whys it goes something like this:

Problem Statement: Worker tripped because he stepped off a sidewalk which caused him to lose his balance and fall and strike his knee against the side of the pavement.

Why? Worker moved to avoid a temporary sign but failed to verify that the area to which he was moving provided sufficient space to safely walk on the surface.

Why? Worker was distracted by a conversation he was having with his companions and committed an error.

Why? The worker was distracted because he was discussing a safety issue with his colleague and customer.

Why? The group was on its way to a lunch meeting.

Why? Because there was no other time to have the meeting and also have lunch.

Why? etc.

Such facile, linear logic sure feels good, particularly because (whether we admit it or not) it leaves the injured party holding the bag, sprinkle in some creative case management and garnish liberally with administrative pressures to achieve zero injuries and you can substantially improve your safety performance without reducing your risk one wit.

Truth be told, the simplest explanation doesn’t scratch the surface of the factors in play in this example. Off the top of my head here are some of the key contributors to the incident:

  • A sandwich board sign was placed on a crowded sidewalk that impeded pedestrian traffic.
  • The height between the sidewalk and the parking lot was slightly higher than usual.
  • The sidewalk was uneven
  • There was heavy pedestrian traffic
  • The sidewalk was adjacent to parking (the front of the come cars were parked against the sidewalk and in some cases cars were hanging over the sidewalk.)

The simplest explanation is that I wasn’t watching where I was walking and I fell. In other words: I screwed up and I got hurt, and to some extent I would have to agree. My first instinct is to admit that I needed to be more careful and watch what I am doing. But as pat an answer as that is, it doesn’t begin to tell the whole story. I WAS watching where I was walking, however, the sudden shift of the pedestrian traffic forced me to decide to move off the sidewalk (which would have meant walking into parked cars), collide with my colleagues (which would have forced them back into the sandwich board) stop until the path was clear (which would have risked having the people behind me collide with me), or step on the edge of the sidewalk and take care to maintain my balance). People take risks like this every day, heck I’m sure I’ve taken risks like that many times in the past and not been harmed. My assessment of the risks associated with my actions are that I probably won’t get hurt and if I do get hurt it probably won’t be serious; it’s easy to waive off any precautions as overly cautious.

It’s tempting to see simplest possible cause as the proximate cause because if we do it absolves us of having to do anything meaningful in the way of prevention. If the proximate cause of the injury is my carelessness the organization need only tell me to be more careful. If complacency is to blame for an injury the organization only has to tell people to stop being complacent. But if the problem is complex the prevention is likely to be difficult if not impossible. Let’s look at the example of my fall. What could we do to prevent this convergence of hazards? A quick look at the hierarchy of controls is pretty disheartening.   Realistically eliminating the hazards (heavy pedestrian traffic, cars parked adjacent to the sidewalk, a sandwich board blocking the flow) while possible isn’t feasible. We all know how hard it is to engineer out hazards once the bricks have been laid and mortar poured. Substitution is equally unfeasible, realistically the only thing we can substitute would be the sandwich board which the shopkeeper would likely resist any substitution, having selecting the sandwich board for its effectiveness and relatively low-cost. That leaves us with administrative controls ─ the police could ticket drivers for parking too close and blocking the sidewalk, outlaw sidewalk sandwich boards, or even establish rules requiring pedestrians to walk single file down the side-walk ─ and I think we can all imagine how effective these would be. I suppose we could require everyone to wear knee pads but count me out.

So we are left with two choices here equally loathsome: either we can take the easy route and decide that my injury was the result of my own carelessness and remind me to be more careful, or we can decide that the injury was the result of many interrelated factors that combined to raise the risk of injury to a level where someone was bound to be injured, and make corrective action difficult if not impossible.

It amounts to this, philosophically I believe as many do, that all injuries are preventable, but I also believe that sometimes preventing some specific injuries just isn’t feasible so individuals and companies decide it’s just better to live with the risk.

Filed under: Hazard Management

Dispelling the Complacency Myth


By Phil La Duke 

The latest scape goat for injuries seems to be complacency. The latest in conventional By Phil La Dukewisdom holds that people get hurt because…well…they just need to be more careful. In fact, complacency is such a convenient villain that a major safety management system provider has built a business around it. The only problem is that many of the conditions described as worker complacency is anything but the case.

The dictionary definition of complacency, “1: self-satisfaction especially when accompanied by unawareness of actual dangers or deficiencies or 2: an instance of usually unaware or uninformed self-satisfaction”[1] which would imply that those who blame complacency for worker injuries believe that workers become over confident and therefore indifferent to the dangers around them. But according to an article on “complacency happens because workers, supervisors and management perform many functions on a continuous basis. Almost all jobs are repetitive in nature, and the more we repeat what we are doing, the better the chance at becoming complacent without even realizing it. Therein lays the potential danger”. It would appear that in the author’s view, complacency in the workplace is more akin to over confidence than true complacency.

Finding complacency as a root cause, in my opinion, is just another in a long line of “blame-the-injured” cop outs. If we accept the explanation offered by the article on Westfield Insurance’s website (no author is credited) complacency develops as people become indifferent to the dangers after doing repetitive tasks for hours. The answer, therefore, is to find a way to force people to pay closer attention to the tasks at hand. Unfortunately, such an approach is not necessarily supported by science.

I am not prepared to say that overconfidence and a corresponding desensitization to dangers as one spends more time in close proximity with at risk conditions isn’t a key factor in workplace injuries, but I am always a bit suspicious when safety professionals “discover” the next big injury cause. Certainly people will get complacent and over confident, but there are also other factors at play.

Mental Fatigue

If people are getting harmed because they are overconfident and take short cuts it makes sense that keeping the workers mind on task would make the most sense, but research in the physiology of the human brain[2][3] shows that intense concentration on a repetitive task causes mental fatigue, and the longer the period of time one spends intensely concentrating the greater the fatigue, and the greater the fatigue the higher the likelihood of human error[4] and the corresponding increase in the risk of worker injury.

This creates a quandary for the safety professional─ not enough focus on the task at hand and workers put their safety at risk, but too much concentration on a task also puts them at risk. What’s worse is that in the middle is behavioral drift (the practice of slowly and subconsciously moving away from the standard operating procedure.[5]

How Much Concentration Is Too Much?

Boksem, et el, found that mental fatigue was evident within one hour of intense concentration and other studies have found that moderate mental fatigue can impair judgement[6] . Mental fatigue (or sleep deprivation) leads to:

  • Impeded judgment. Fatigue impedes the worker’s judgment and reasoning ability so attempts to get workers to concentrate may actually be increasing poor decision making.
  • Lack of manual dexterity.  A loss of mental acuity because of fatigue has been shown to decrease people’s manual dexterity; assuming that the job requires some level of manual dexterity fatigue leads to greater risk of everything from slips trips and falls to the proper use of tools and even PPE.
  • Lack of alertness. Invariably, the brain will fight any efforts to maintain prolonged concentration on a task and fatigued workers may become groggy and absent-minded.
  • Diminished ability to focus on details. A fatigued worker is far more likely to miss critical steps in a process, and when a worker is working out of process he or she is far more likely to be injured.

Multiple sources list fatigue as one of the top five causal factors in workplace incidents[7] so while experts may attribute upward of 90% of workplace injuries to unsafe behaviour, most fail to answer the question of why a worker behaved unsafely. Increasingly, that answer is linked to a fatigue.

If one hour of concentration on a task is enough to increase the risk of worker injuries that how much more risk is there to workers who are working longer hours. Research has found[8] an 88% increased risk of an incident for individuals working more than 64 hours a week.

Damned If You Do, Damned If You Don’t

So it boils down to this: workers who don’t pay enough attention to the task at hand are at far greater risk of injury, but workers who pay too much attention to the task at hand are at even greater risk. It would be easy to either suggest unworkable solutions (a ten minute break every ten minutes, for example) but even if these techniques were enough (and research has shown that returning to a non-fatigued state where performance returned to normal are difficult and time consuming[9]). In effect, there is no practical solution to eliminating the risk of complacency, behavioral drift, or mental fatigue. We can’t ─ no matter how hard we try ─ eliminate human error and risk taking so we should instead focus our efforts on mistake proofing. We need to channel more of our energy into protecting people from their mistakes instead of trying to reengineer the human animal.

[1] Merriam Webster On-line Dictionary

[2] Effects of mental fatigue on attention: An ERP study, Maarten A.S. Boksem, Theo F. Meijman,Monicque M. Lorist

[3] Mental fatigue, motivation and action monitoring Maarten A.S. Boksema, Theo F. Meijmana, Monicque M. Lorista,

[4] Whack A Mole Marx, David

[5] For more interesting facts about behavioral drift, see Behavioral Drift’ Threatens the Safety of Flight Operations

[6] For more information on the effects of fatigue on workplace safety see my article, Asleep on the Job Published: 19th Mar 2014 in Health and Safety International

[7] Chan, 2010

[8] Vegso et al (2007)

[9] Environmental Influences on Psychological Restoration, Scandinavian Journal of Psychology, 1996, Hartig, Terry, Gook, Ands, Garvill, Jorgen, Olsson, Tommy, and Garling, Tommy

Filed under: Behavior Based Safety, Risk

Safety In the Age of Wikipidiots


By Phil La Duke

“It is better to keep your mouth closed and let people think you are a fool than to open it and remove all doubt”—Mark Twain

I haven’t posted an original post in over a month. I decided a while back that posting for the sake of posting served no good purpose. Not that I haven’t had anything new original to write, it’s just that I have started no fewer than six pieces that degraded into lengthy meandering pieces with which I was never quite satisfied; those of you who are long time readers must know that my bar for satisfactory work is set pretty low and can conclude that while the pieces have had some kernels of truth and fresh perspectives they weren’t worth the paper on which they were printed. I have been working on an original published piece for the Michigan Manufacturers Association which will be out in the organization’s digital June issue, a follow up piece for the same magazine for June, three pieces for Entrepreneur which are far and away more of a pain in the ass than they effort could ever be worth, and my monthly column for Fabricating & Metalworking which inexplicably haven’t even been read by my editor let alone seen print (do me a favor and drop him an email and ask him why I’m more than a bit curious myself.) But most of my in the last two weeks has been spent sparring (both publicly and privately) with one of my many detractors; the particulars of said feud aren’t really important, but what IS important is that all of the back and forth has inspired four different posts (the first one being the one you are reading).

The argument devolved into a “is so, is not” where the detractor did nothing but heap condescension and abuse on anyone who dared question his interpretation of what I found to be specious conclusions to dubious research. I quit the exchange early, as it was, as I am so found of saying “like trying to do a card trick for a dog—no matter how hard I tried, how slowly and patiently I explained my point, or what I said, he just wasn’t going to get it.”

One of the other participants in the public quarrel quoted something that James Reason said of the safety profession in the early 70’s (those of you who simmer in pedantic rage at my lack of citation can look it up, I have neither the desire not the ambition for such an undertaking). The quote had to do with the great schism in the safety community over whether or not injuries were the outgrowth of individual error or system flaws. I’ve spent the better part of two years reading scientific and behavioral science research on why we make mistakes and I am somewhere in the middle of this debate. But the concept resonated with me (and I use the word “resonated” in the truest, purest form) I found the concept of this most basic philosophical disagreement echoing through my thoughts, coming to me at odd moments, and nagging at me. I realized that my work in safety is probably a waste of time, that I might as well be standing on my balcony addressing an army of ceramic lawn gnomes; in other words I am not likely to change anyone’s mind about safety.

Who Needs Facts? I Got Me An Opinion!

When future historians trace the origins of the demise of Western Civilization my guess is that the Wikipedification of society will be seen as a key factor. People today are quick to believe what they want to believe, seek out other opinions disguised as facts that support their largely untenable positions. It’s not just Wikipedia that has created this “if enough people believe it then it must be fact” mentality. A few years back Google modified its search algorithm to steer people to web pages that were aligned with their beliefs. It seems that people don’t want to have their beliefs challenged and learn; rather they want to be reassured that whatever stupid dreck they’ve come to believe isn’t nonsense after all. We have created a world where facts, logic, research, and even scientific findings are subject to a vote; while Lot looked for ten just men, today all one need do is find one delusional crackpot with a message we find reassuring and we can discount science, history, and…well just about everything. It doesn’t matter if we have a smoking gun definitively and indisputably disproving a methodology or belief, the people who derive a living from spewing their soft-headed pabulum will simply shout it down whilst speaking to rapt audiences eager to believe in their hog wash.

So What’s the Point?

Ostensibly, this doesn’t seem to have much to do with safety, but it does. If we continue to give equal credence to charlatan and visionary alike people will die. Innocent people are being killed in our workplaces every day. And when people over simplify safety with their magic bullet solutions—which are lucrative and easy to sell—they have blood of innocents on their hands. I know of a company that invested heavily in a well-known snake oil solution and had a fatality. I am still haunted by the blood-splattered poster and I wonder if the victim was able to see the irony in his gore festooning a poster reminding him to work safe. I wonder as he lay dying if he was able to think of anything beyond what must have been incredible pain, and if he was able to think, if he would care that so many people around the world bought the snake oil worked, drank the Kool-Aid, or simply agreed that reminding people to work safe would save his life. Or did he think of his widow and his children, if the dead could edit Wikipedia what would he have to say on the subject?

The Attention Spans of a Fruit Fly

I write for a lot of outlets, and when I am given my first assignment I always get the same spiel: No more than 500 words. Why? “my reader’s don’t have time to read anything more than that, and frankly 500 words is too much”. We aren’t just getting dumber as a society we are demanding that people dumb it down. I gave a speech recently where the second of two was cancelled because my message was “too sophisticated for workers” (my speech was on what it meant to have safety as a value) I was literally replaced by a guy who set fire to stuffed squirrels to demonstrate the dangers of arc flash.

Stupid Is As Stupid Does

I have never wanted to be stupid. I have had a strong thirst for knowledge and seek out opinions diametrically opposed to my own. It can be scary to read books by experts that artfully lay out an argument that makes such perfect sense that it shakes your beliefs to the core, but it’s necessary to grow as a person. I don’t think I’m in the minority but you will never go broke selling stupidity to the stupid. I spend my spare time reading non-fiction books on safety, just culture, mistake making, the physiology of the human brain and how our emotions shape our decisions. It doesn’t make for fun weekends or scintillating dinner conversation. (You might be surprised at the level of uninterest (apparently this is not a word, but I don’t mean “disinterest” which means not really caring one way of the other, but of the absolute dearth of interest) in how synapsis work, or what part of the brain we use to make decisions, or why biologically making mistakes is not only unavoidable but necessary for survival.)

Is There No Hope?

I realize, I confess, that I print a pretty bleak picture. But when we stop listening to experts in favor of money-grubbing mouth-breathing safety profiteers we risk more than our own careers we risk the lives of others. I should note, for the record, I don’t really think of myself as an expert on worker safety, rather I think of myself as a guy who reads all the articles, books, and opinions of true experts and translates their work into simple truths that I share with a handful of safety professionals who by and large are just looking for solutions to problems that are beyond their ability. They’re looking for fast answers and quick fixes—in safety time isn’t money time it’s blood—and I do my best to find and share them.

I started this post with a quote (at 1388 words I wonder if anyone is still reading this) about staying silent and being thought a fool (I guess we’ll know by the number of people who post comments correcting me on the source. I checked my sources (as I generally do) and found that this Mark Twain quote had been attributed to no fewer than 8 sources. I thought it appropriate to start the article with something so easy to verify (who said what) on which know one seems to be able to agree. For the record, Abraham Lincoln said something similar (“Better to remain silent and be thought a fool than to speak out and remove all doubt”) but both he and Mark Twain were both quoting (or more accurately paraphrasing) Proverbs 17:28, or Proverbs 18:28, or A Farewell To Arms, or Curious George Goes To The Beach let’s put it to a vote; what difference does it make?

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

“Safety Manager Charged in Worker’s Oven Death”

Phil La Duke:

Think you are immune to prosecution…think again

Originally posted on EHS Safety News America:

The former safety manager at a Santa Fe Springs, Calif., tuna-processing plant faces a maximum sentence of three years in prison and/or a $250,000 fine if convicted on felony criminal charges related to the 2012 oven death of an employee.

The rare charges against a safety professional were brought by Los Angeles County District Attorney Jackie Lacey, who alleges that Bumble Bee Foods, the company’s former safety manager Saul Florez and the company’s plant director Angel Rodriguez willfully violated worker safety rules.

According to Lacey, 62-year-old Jose Melena, a six-year employee of the plant, entered a 35-foot-long oven in October 2012 to make a minor repair. Co-workers were unaware that he was in the back of the oven as they loaded it with cans of tuna, closed the door and turned it on. During the two-hour heat-sterilization process, the oven’s internal temperature rose to about 270 degrees. Melena’s severely burned…

View original 187 more words

Filed under: Safety

Superstition-Based Safety?

safety ritual

by Phil La Duke

Does this sound familiar: You do what all the experts say, you read articles on how the world’s safest companies, or you come back from a conference ready to implement the hot safety tool? But instead of creating your safety Utopia your efforts fall flat. You end up doing all the right things but—far from getting the remarkable improvements you’ve been expecting—your efforts fall flat. You end up trying idea after idea but nothing seems to make a difference.

I have been on far too many sales calls where I was stopped cold be the same objection: “we’re already doing that”. I would always get frustrated, because I in my arrogance I reasoned that given that I had invented this process there is no way on God’s green Earth that someone else was “already doing that”; except that they were. It really messed with my head when I first realized that what I thought was this profound and innovative approach was being doing done by numerous other companies around the globe. I shouldn’t have been surprised, my approach is based on the practices and values of the world’s safest companies and since many of these practices were widely known and used it was reasonable for these people to believe that I had nothing new to offer. Except there was one important difference: my approach rapidly improved safety performance and drove down the monies companies spent on worker injuries—both the frequency and severity of injuries fell exponentially, so if these folks were doing the same thing, why weren’t they getting the same results?

I’ve spent a fair amount of time pondering how two so very similar approaches can produce such dramatically different results and I have reached several conclusions:

  1. Requirements without Context. When people are given an assignment without a clear explanation of why they are doing it the behaviors become ritualistic. After a time these behaviors become deeply imbedded into the culture and since the population has no understanding of what these events are supposed to accomplish they just keep doing them often complaining bitterly that they are getting nothing out of the activity. Think of your safety meeting, what exactly are the expected, tangible outcomes? Do these meeting achieve these outcomes? Are achieving these outcomes worth the time and effort spent to achieve them. It’s important to recognize that people don’t always recognize ritualistic behavior (I’m not talking about drawing pentagrams on the floor after all).

Perhaps the most common ritual is the safety metrics review. Why do we review our metrics? If all we do is trot out our latest performance without asking ourselves what these figures are telling us than the safety metric review (no matter how wonderful our leading and lagging indicators are) then we are wasting our time and the company’s money.

  1. A colleague of mine used to describe most companies’ safety efforts as “administrivia”. I like the term. For me it conjures up images of people dutifully going about their business without any expectation of change. In many organizations, safety is filled with administrivia; things that we do because our policies say we must or things that we do because someone other organization says we should, or things we do because it’s a safety tradition. There are many things that we do in safety that may have added value at a time but don’t any more. There are still others than add value but not enough to justify their continuation. All of these things attach themselves barnacle-like to the organization and slow us down, make is less nimble, and unproductive.
  2. Compliance Without Understanding. In some organizations the corporate office has laid out a strategy or a plan and the sites have dutifully implemented its elements. All is right with the world. Unfortunately, those at the site don’t really understand what the purpose of what they are doing. Because they don’t understand why they are doing what they are doing they don’t ascribe the same importance to getting it write, doing it on a regular basis, or even be able to ascertain whether or not it has been done correctly. The lack of understanding leads again to ritualistic behaviors and superstition-based safety, but in this case, the ritualistic behavior will never be questioned or even seen as anything improper.
  3. Absence of Connection. Companies with world-class safety performance connect everything they do to improve safety into a performance improvement system. Many organizations miss this and instead create independent and discreet activities that limit the effectiveness of the safety efforts. Without a flow of clean data that can be interpreted by the people with the power to act on the data these activities simply produce data that is inaccessible to those who need it. Furthermore, without a connection between the activities it is impossible to get an accurate read on the effectiveness of the safety efforts; trends get more difficult to see and accurately interpret which leads to misinterpretation of the data. In some cases the organizations start to see trends where there are none and are misled into thinking that a course of action is working (or not working) when the opposite is true.
  4. Organizational Inertia. Sometimes the organization gets so caught up in tactics and activities that it loses sight of the fact that in the end results are all that matters; we get no points for trying hard if we fail. Organizational Inertia is akin to the worker who is disengaged; the man or the woman who is just punching the clock caring neither about success of failure. Inert organizations will continue doing things in the name of safety because they are afraid that if they cease these activities someone will accuse them of not caring about worker safety, far better to continue ineffective activities than to be branded as antagonistic or indifferent to worker safety.

All of these factors make the difference between high-performance safety infrastructures and safety pomp and pageantry, between safety systems that work and those that don’t, and in some cases they make the difference between life and death.

Filed under: Safety



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