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.

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