By Phil La Duke
This blog started as an exercise in intellectual pursuit. A purely academic pursuit. You see I discovered that (as I’m sure that most of you have) that there are different categories of hazards and these different categories of hazards represented a distance from an injury. I’m not talking about probability or even severity, more like proximity to an injury. I realized quickly that there may be no practical use to these categories, but just couldn’t get the idea out of my head. Some hazards are in the immediate vicinity of an injury. You reach too far for a tool and fall to your death. The hazard isn’t that you weren’t wearing your fall protection; the hazard is that you are working at height and given the right catalyst could fall. Then we have hazards that are one step removed, in this case not wearing fall protection. As I write this I am not wearing fall protection and since I am not working at heights am not at risk of falling a from a distance that fall protection would do anything of value, in fact WEARING fall protection might actually pose a threat. The further you move from the injury the less the risk of an injury. Think about the hazard of “fire extinguisher inspection out of date”. Is it a hazard? Yes. Is it likely to kill someone? Well to do so we first need a fire, a person who is authorized and trained to use the fire extinguisher, the fire extinguisher needs to be the proper type for the fire at hand, the path to the fire extinguisher must be unblocked, and even then, just because the fire extinguisher’s inspection isn’t up-to-date doesn’t mean the extinguisher isn’t completely capable of extinguishing the fire. The hazard in this case is so far away from the possible injury it’s almost pointless to consider. Then it occurred to me that Root Cause analysis does just that; it takes us to a single cause (relax Taproot and other systems I know there’s more to it than that) and eliminating that root cause hazard is meaningless. Did the lack of inspection CAUSE the fire? No. So why then do we chase hazards so far removed from an injury?
The secret to eliminating injuries lies in removing hazards (whether behavioral, system, or procedural). This is in my mind an absolute; I’m not going to argue the point. But in too many workplaces we find two or three hazards and we pat ourselves on the back for a job well done. Heck we may even achieve zero injuries for a time, and then disaster strikes leaving workers dead or gravely injured. It leaves us scratching our heads in disbelief. How could this have happened when we did everything right? Simple: we didn’t do everything right.
Any safety management process worth its sand begins by picking the low hanging fruit. Given that the average safety practitioner literally doesn’t have time to take a restroom break or a lunch unless he or she elects to do the two at the same time, it’s not surprising that they do one of two things: 1) Pick low hanging fruit, or 2) Slaying dragons. For those of you perhaps new to the terms, let me explain. Picking low hanging fruit is the practice of addressing the hazards that are easy to spot, easy to correct, and easy to get people to agree to fix (housekeeping comes to mind). Over the years we’ve done an excellent job of picking low-hanging fruit and it shows: relatively minor injuries are down. Unfortunately, fatalities remain flat and in some sectors are trending upwards. Why? Simple, poor housekeeping (in and of itself) rarely harms people. To be sure it can, I for example live in squalor and may stub my toe on a box that I should have put away, cut myself on a knife left to soak in dishwater, or tripped over some peace of clutter. I have rarely injured myself to the degree that—were it in the workplace—the injury would have risen to a recordable injury. Again, the defenders of the face are likely to argue for the value of picking low hanging fruit, but I won’t be baited. You can’t tell me that you don’t have a minute to breath and then argue that you need to go pick more fruit and convince me that you are doing much to lower the risk of fatalities and life-changing injuries; I just don’t buy it.
The second term, “chasing dragons” is where a safety practitioner hears of a serious injury and springs superhero-like into action doing everything in his or her power to ensure the barn door is firmly and securely locked once the cattle have left the barn. Don’t get me wrong, when there is a serious injury we have a lot to do—-from ministering to the injured, to making sure the regulatory paperwork is done, through case management—but the cows are already gone and all we can do is design a better barn door to ensure that the new cows never escape in the same way.
Both these activities have value and are to some degree necessary, but are we giving them too great a priority. The only way to make the workplace safer is to predict and reduce risks, but not all risks. The risk of slipping and falling on an oil leak is substantial and important that we get it corrected, but is that as risky as a person smoking a cigarette around explosive vapors (yes, I have seen this; right below a sign that said “No smoking. Highly flammable materials in the area”. When I approached with the site safety manager the smoker hastily through the lit cigarette in a trashcan full of flammable solvent-soaked rags.)?
Isn’t it better to calculate our most critical risks first? Of course, but this can be tricky because low hanging fruit can conceal much greater risks and so we definitely have to address them. Sadly I have seen too many organizations who stop there; too many safety practitioners who measure their value because no one has died recently. In fact, there are still too many of us who think of safety as the absence of injuries. They count the bodies and when the body count goes down they look at their bosses and ask, “do you see what a great job I’ve done here?” Conversely, if the carnage continues they dodge any culpability by claiming the injury was an act of God, or the victim’s stupidity, or a voodoo course, or…well you get the picture.
In too many environments we are hung up on linear causation of injuries:
Naturally it makes sense to focus on hazards, because without them the chain never begins. But we can’t be fooled into thinking that hazards are always the result of the Domino Effect. In some cases, many cases in fact, injuries are caused by multiple causes, contributors, and catalysts without a single proximate cause. That doesn’t mean that many aren’t the product of linear causation, but what it DOES mean is that simply by removing a contributor, hazard, or catalyst we haven’t eliminated the risk. Many of us are fooled into thinking that by finding the “root cause” we can relax, that the danger is gone, when in fact if another catalyst should later come into play an identical (or very similar) injury can occur.
In fact, the shear noise involved in this situation can seem to calm down once you have removed the catalyst that set the proximate cause in motion. So maybe before we charge after the next dragon we should consider whether or not we are using the right tools. More importantly, we should be looking at our greatest risks and asking ourselves, what hazards, contributors, and catalysts need to be present to kill a worker. The answer will likely shock and frighten you.