Often while training people how to identify, contain, and correct hazards , I find that people often miss obvious hazards because they are looking for something on a mental checklist; instead of viewing the work place holistically the look for one hazard at a time. Inspecting a work area for potential hazard is hard—in many instances the hazards are contextual and given the right conditions virtually anything can increase the risk of injuries. And as our familiarity with the workplace increases our respect for workplace hazards diminish until we become blind to the risks in a given area. If forced to find hazards in the area, people will indeed find hazards, but typically these will be obvious hazards that pose no serious risk to workers.
To prevent this dynamic one should begin by asking a couple of questions:
What happens here?
If you ask someone what they do they will tend to tell answer in broad, general terms (“this is a deburring station”) so one will have to probe further. Ask the worker to describe in detail the tasks—lifting, walking, material flow, handling parts, attaching fasteners.
This detailed description of the basic elements of the process forces you to move away from the checklist and really think about the forces and inputs that go on in the area.
What could go wrong? What injuries have I seen in this area in the past?
Typically whoever who is inspecting a work area is intimate with every possible problem one is likely to encounter in the work area and can tick off a list of process failure modes complete with a list of triggers, from there it’s easy to scan the area for these triggers.
What doesn’t belong here/what is out of place or out of process?
By targeting the sources of process variation we teach ourselves to focus on the critical few hazards that are most likely to seriously injure workers. This technique is also useful for eliminating the tendency to “pick the low-hanging fruit” and ignore those issues that tend to be more difficult to anticipate or readily observe.
What has changed since the last time you toured this area?
Variation creates problems in the workplace. And provided the system is stable, once the root causes of process hazards have been identified and corrected the one need only focus on things that have changed. On a side note, I start every incident investigation with the question, “what was different in this case than in the way this operations is usually done?” I typically get a resolute “nothing” to which I respond, “if that was that true either the worker would never get hurt or would get hurt every time. And since neither condition is true, there must have been SOMETHING different in this case.” Differences represent process variation and where there is process variation there is heightened risk.
Holistic versus Category Based
Viewing the work area holistically, that is, as a complete system versus as discrete elements can be difficult if one doesn’t truly understand the process. And while this is easier in manufacturing than in non-production environments like a hospital ward or a warehouse, viewing a manufacturing operations as a system can be very challenging. When we look for things that have the potential to harm someone the shear magnitude of the hazards can be overwhelming, and a checklist is a logical tool for keeping one organized and for ensuring one doesn’t miss anything. Unfortunately, because we are typically moving around when we are inspecting an area for hazards we tend to inspect as we go and we move down the list as we move geographically through the area. For a checklist to work one would have to walk the entire area for each checklist item and that’s just not sensible. But holistic inspection means that the inspector must have an in-depth knowledge of not only of the systems active in his or her work area, but ergonomics, human factors, and more specifically each subset within an operation. Such knowledge is useful not only for improving safety, but all of the SQDCME. Unfortunately, this kind of sophisticated knowledge of the work being performed is exceedingly rare in the modern workplace.
The Human Behavior Wildcard
The biggest source of process variability is differences in human behavior. People do stupid things, do things subconsciously, or just vary the way they do things. This variation can combine with other process variation to create injury triggers. It is no secret that the majority of all injuries have some behavioral component to the cause. Unfortunately, variation in human behavior is also the most difficult variable to control. Organizations, acting on the dubious advise of Behavior Based Safety advocates have spent millions trying (largely in vain) to manipulate human behavior such that the workplace is substantially safer. Most of this money was wasted, or resulted in organizations that significantly increased overhead and costs preventing injuries. Instead, these companies would have been better served investing in mistake proofing their processes or investing in contingent measures to reduce the likely severity of an incident and or protecting workers.
Striking an Acceptable Balance
Ending the checklist mentality completely is neither possible nor desirable—the categorization and trending of hazards and injury root causes is beneficial and useful—but there are better ways than working from a checklist. When looking for hazards one should take a page from Stephen Covey’s playbook and seek first to understand and THEN work the checklist. In other words, take a failure modes effects analysis look at the area before pulling out your checklist. Use the checklist to confirm that the absence of hazards after you have walked the area instead of using it to prompt you to look for a hazard. This may sound like a trifling distinction, but it may well mean the difference between identifying and correcting dozens of hazards and finding one or two.