If All Injuries Are Preventable What Does It Say About Us When Someone Gets Hurt?


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Several weeks ago I posted La Duke’s 14 points for safety to a tepid response. Not that I expected to be hailed as the second coming of W. Edward Deming, but more and more I find that the nastier the message the bigger the audience.  It doesn’t speak well of the Safety trade, when the only thing that seems to draw an audience is a message that energized the puffed up and the self righteous. I’d like to think that I could draw an audience without calling strangers hypocrites and fools, but maybe I give myself too much credit.

At any rate, I thought I would expand on my 14 points, one a post until I have given each its proper attention, at least in my mind.

My first point is one that I have been preaching for almost a decade and it is also the one I get most push-back from safety professionals.

All Injuries Are Preventable

I have always been amused by scientist who pronounce things impossible just because they haven’t yet determined a way to do them.  But that isn’t even the case with preventing all injuries.  Engineers and quality professionals have long used tools to predict possible failures in a process but these tools never seem to make it to the Safety professional’s toolkit.  Perhaps the most powerful and simple of these tools is the discipline of Failure Mode Effects Analysis (FMEA).  An FMEA is a relatively simple tool used to predict all the things that could go wrong in a process and identify counter measures that can contain or minimize the risk of a process failure.

A process failure can be a machine breakdown, a quality defect, or an injury.  A secondary purpose of the FMEA is to determine the extent to which action should be taken. The FMEA calculates the probability of a failure which, in turn,  allows the organization to make educated judgments about how much effort (and money) should be spent preventing a failure that is only remotely possible and unlikely to cause a serious injury.

There are some who will argue that some injuries are completely unpredictable acts of God.  Certainly, if God is actively trying to injury your workforce there is scarce little you can do about it, but I am of the opinion that the safety professional is, in fact, blaming God for his or her own shortcomings and ineptitude.  In short, don’t blame God for hurting your workers. 

Striking a Balance

That having been said, you can’t prevent injuries you can’t predict and you can’t predict injuries without good tools.  Also, it is foolish to expect that you will be successful in predicting and preventing every injury, but that doesn’t mean its impossible.  When we conclude that something is impossible the rational response is to stop trying.  Only a lunatic continues trying to do what he or she believes to be impossible.  So we have a choice, we can either believe that all injuries are preventable and continue to create new and innovative ways to prevent injuries or we can respond to injuries by throwing up our arms and saying “oh well, shit happens”.

On the other hand, we must recognize that while preventing all injuries may be possible it may not be practical.  As safety professionals we have to recognize that we don’t have infinite resources and we have to be judicious about how and where we expend our resources.  There are some hazards that are far too costly to eliminate and a far better response is to contain the hazard and manage the risk. 

Years ago I worked with a large manufacturer who benchmarked some of the world’s safest companies.  All of these companies believed and—more importantly—acted as if, all injuries could be prevented.  These companies all had substantial procedures for identifying the hazards and conditions that could cause injuries. But more important than predicting potential injury causes, these companies placed real emphasis on mitigating risk all had formal containment strategies for hazards that could not be practically eliminated.  In one case, an aerospace manufacturer determined that removing a hazard would cost over $2 million. The hazard in question was related to a model that would be out of production in less than a year.  The company decided not to eliminate the hazard and implemented containment measures instead.

Such an action sounds dangerous and it can be.  But in this case the company realized the need to balance the exorbitant cost of correction against the risk that the hazard posed. 

Slapping A Band-Aid On the Problem

There’s a big difference between a carefully crafted containment strategy and slapping a Band-Aid on a problem.  In the case of the company that opts for containment over correction the responsible company understands that containment—even a relatively long-term solution—is a temporary fix and one that needs constant surveillance and evaluation.  In fact, in many cases, containing a problem may actually take far more effort than a permanent solution does.

Prevention Is Far Less Costly Than Correction

It takes far less effort to design a safe process than it does to reengineer an unsafe process to make it safer.  In fact, there is an old engineering adage that roughly states that in design phase one has 90% control and 10% cost but once the process is in production one only has 10% effectiveness and 90% cost. Obviously this rule isn’t hard and fast, but it is fair to say that one has a lot more control and effectiveness when making changes to a design than one does when making a change in production.

The crux of this point is that a) given enough time and information we CAN prevent all injuries and when we fail to do so, we need to be accountable for our failure.  We must continually ask ourselves why we failed to prevent an injury and continually improve our diagnostic procedures and policies.  We can’t be content with reaction as a safety management system.

To be continued in www.rockfordgreeneinternational.wordpress.com


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