The Power of Pyramids: How Using Outmoded Thinking about Hazards Can Be Deadly

LaDukes Pyramid

 

By Phil LaDuke

 Gallons of virtual ink have been used in writings condemning Heinrich’s Pyramid. But even though a significant population in the safety industry question its validity not only does the malarkey still persist, it thrives. What’s more, people believe accept it as a universal truth in industries where Heinrich had no standing. Throughout my storied career as an organizational change agent and safety strategy consultant I’ve met with resistance in the form of “that won’t work here, we’re not…” fill in the blank. Whether it be mining, Oil & Gas, Chemicals, Aerospace, Heavy truck, the entertainment industry, construction, or logistics the first time I worked in those industries (and yes, I have actually WORKED in those industries) I was met by this objection. Early on I believed that the objection was absolute hogwash but eventually came around to a way of thinking that caused me to stop hawking my one-size-fits-all solution in favor of co-designed and co-developed, shaped interventions that consider the challenges of a given client culture, geographic location, industry, and even site. The solutions tailored to the specific needs of a customer are universally better (or at least as good) as something that the safety conglomerates and mom-and-pop snake oil salesmen have been successfully selling for decades. I even defend this in another blog post In Defense Of Not-Invented-Here-Thinking.

 

If executives in Oil & Gas, Mining, Energy, and Construction et al, rightfully believe that other safety tools and methodologies are not necessarily applicable to their worlds why are they so quick to drink the Heinrich Kool-Aid? Before I answer that, I guess I should provide a bit of background information.

 

For the uninitiated, Herbert William Heinrich was an American statistician who in the late 1920’s and early 1930s studied worker safety in an industrial setting (specifically manufacturing) He created a pyramid based on his “law” that for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injuries. He arranged it in a neat little pyramid and claimed that because many accidents share common root causes, addressing more commonplace accidents that cause no injuries can prevent accidents that cause injuries. He also found that more than 80% of all injuries were caused by unsafe behaviors. It makes sense which is what makes it so dangerous.

 

Heinrich’s Pyramid became a mainstay of safety theory and was largely unquestioned for 80 years or so until Fred A. Manuele reviewed Heinrich’s “research” and found real problems with it. Like Heinrich, Manuele retired from the insurance industry albeit many years later. In his book, Heinrich Revisited: Truisms or Myths, Manuele openly called much of Heinrich’s work into question, specifically:

  1. No one seems able to find Heinrich’s files on his original research making it impossible to peer review (and is accepted practice in scientific research today) impossible. This doesn’t necessarily mean that Heinrich wasn’t spot on, but it does mean that we can never know how he came up with his conclusions and ultimately if there is any scientific or statistical validity to his work. We would never accept these conclusions
  2. Heinrich’s studied accidents that happened in the 1920s, in a manufacturing environment that bears little to no resemblance to the workplace of today.
  3. Heinrich placed a disproportionate emphasis on psychology which impeded his ability to remain impartial. Heinrich asserted that psychology was “a fundamental of great importance in accident causation”. In other words, Heinrich saw exactly what he expected and even wanted to see. He was selling hammers and the whole world looked like a nail. It’s just like optometrists; if you go to one you will most likely get told that you need glasses.
  4. The methodology Heinrich used to generate his pyramid ratios cannot be supported. IN Manuele’s considered and expert opinion “Current causation knowledge indicates the premise to be invalid.” Manuele also pointed out that the “premise conflicts with the work of others, such as W. Edwards Deming, whose research finds root causes to derive from shortcomings in the management systems.”

Fred Manuele suffered greatly for his work. The mouth breathing behavior freaks attacked him and his work personally and professionally, and yet he persisted. In his, Reviewing Heinrich: Dislodging Two Myths From the Practice of Safety, Fred A. Manuele systematically analyzes Heinrich’s work and calls into question two of the most cherished beliefs in the safety community: 1) that most injuries are caused by unsafe acts and 2) that reducing the frequency of injuries will automatically reduce the severity of injuries.

But enough about that, flogging this dead horse will only get me hate mail and death threats from the current freak show of BBS zealots and I have neither the time nor the patience for that. Let’s just assume that you mouth-breathers and snake oil salesmen hate me and would like to see me dead. Get in line. My ex-wife has started a club you can join.

If Heinrich’s Pyramid is so deeply flawed why are so many executives so enamored of it? Simple:

  • We taught them this. There aren’t many MBA programs that teach how to manage worker safety, and the captains of industry rely on safety professionals to provide them with the basic information they need to know to be successful. So many safety pundits, snake oil salesmen and BBS fanatics have taught this dreck as Gospel that it has become accepted.
  • It makes sense. Like so many myths and urban legends the idea that reducing minor injuries and OSHA recordables will ultimately reduce severe injuries and fatalities stands to reason. But just like so many myths and urban legends this assertion ignores some key information. For the pyramid to make sense each hazard would have to have an equal potential to kill as it does to cause a minor injury and that just isn’t true. Let me give you an example. Smoking near a concentration of flammable gas is a) highly likely to cause and injury and b) that injury is highly likely to be deadly. Using a crescent wrench to complete a task that requires a pipe wrench can cause an injury but that injury is far more likely to be a minor first aid case than it is to kill someone. Unless your safety management system has a good way of distinguishing between high risk hazards capable of killing multiple workers (and perhaps members of your surrounding communities) from those that are going require a band aid and a kiss on the boo-boo from a sympathetic healthcare provider you create system where you give the same urgency and attention to a life-threatening hazard that you do to a benign condition.
  • It places the burden on workers to work more safely. How many times have you thought, “if these idiots would just be more careful they wouldn’t keep getting hurt?” Don’t beat yourself up for thinking it, heck we all do at some point or another. Blaming the injured worker makes us feel better. It absolves us of blame for not having done more to prevent the injury and protect the worker. If we emphasize on behavior and individual responsibility over finding and fixing system flaws and improving decision making skills then we can sleep better at night. But what’s more the belief that it’s all about behavior has created a cottage industry of safety incentives, based on the notion that people will take safety more seriously if there is money on the line. Incentives work, unfortunately more often than not the incentive is to commit fraud by not reporting a legitimate work injury so as not to jeopardize a reward for no injuries.

Okay fine, but is this really putting workers at risk? You betcha:

  • It creates a false sense of safety. Too many people believe that the organization working the bottom of the pyramid is actually working. They will proudly point to a significant reduction in injuries as proof that they have slain the injury dragon. Until someone dies. And then someone else dies. And so on until the company breaks out in a cold sweat as the “who’s next?” climate of fear takes hold.
  • It relies on information that you can’t effectively or completely gather. Even if we discount the criticisms of the validity of the pyramid’s ratios the bottom of the pyramid (near misses and unsafe conditions) cannot ever be accurately calculated. How many physical hazards go unnoticed? How many unsafe behaviors happen day in and day out but are never identified? And how many near misses go unreported? Furthermore the information that most companies are able to gather on first aid cases are equally dubious because many workers will treat minor injuries with a quick trip to the first aid kit.
  • It overwhelms safety systems. Many well intentioned safety practitioners actively seek to gather good information on non-recordable injuries only to quickly become immersed in a nightmare of data. Again, because attempts to collect information on hazards and near misses (working the bottom of the pyramid) often lack a means of prioritizing hazards the organization becomes a bureaucratic quagmire of useless data points instead of actionable information.
  • It isn’t equally applicable across industry segments, countries, locations, or sites. Hazards are contextual. Without both interaction and a catalyst the threat of injury from a given hazard is just potential. Welding without a hot work permit is a hazard, but the context can differ wildly and lethally. Is welding without a hot work permit on a muddy construction site the same threat to safety as welding around flammable gas or in a confined space of a mine?
  • It promotes overzealous case management. If the number of OSHA recordables is directly proportionate to the number of fatalities then it would be irresponsible (if not criminal) to not use every tool to reduce recordables. One such tool is case management. Unfortunately while case management can save organizations thousands of dollars and make its safety record seem better than what it actually is; it does nothing to reduce the risk of injuries. So IF the ratio is valid (it isn’t) good case management downplays the risks of fatalities, by seeming to reduce OSHA recordables when it isn’t doing anything of substance.

As safety professionals we have collectively created this mess and it’s our responsibility to clean it up. Here’s what we need to do:

  • Admit we were wrong. We have to suck it up and admit that we have been perpetuating nonsense.
  • Reeducate leaders. We taught the leaders to believe that these concepts would apply in every industry, site, and situation. We now need to correct this wrong-headed notion and look for better solutions for our specific situations. It will send the purveyors of snake oil and the BBS zealots into a fever pitch but we owe it to the workers to correct this mistake.
  • Shift the focus from worker behaviors to leader behaviors. Do you find yourself unwilling to let go of the “unsafe behavior as causation” doctrine? Fine, but recognize that your processes and organization plays a major role in WHY people behave as they do and that the leaders have the single greatest influence on the system and worker behavior. Place the blame for unsafe behaviors where it belongs.

I could go on and on (and in fact already have) but the bottom line is this, as long as we persist in perpetuating these myths and promulgating them across industries we increasingly endanger workers.

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