Why Housekeeping and Static Electricity Are No Longer “No Big Deal”

DUST bomb

By Phil La Duke

The safety rumour mill is buzzing about the probability that governments are about to target a hazard that many of us really haven’t given much thought to: dust. I can’t tell you how many times I have been on audits where the merest mention of poor housekeeping send eyes rolling and smirks crackling like lightning strikes across the faces of both leadership and the rank-and-file alike. “You’re going to write up poor housekeeping? Talk about nit-picking.” Given that “slip, trip, and fall” consistently score among the top causes (or contributors) of workplace injuries I happen to think housekeeping is an important and easy way to keep workers safe, but increasingly housekeeping is becoming one of the most important ways to save worker’s lives.

According to the U.S. Chemical Safety and Hazard Investigation Board (CSB) there have been 281 combustible dust incidents between 1980 and 2005 and these have caused 119 worker deaths, 718 injuries, and extensively damaged numerous industrial facilities—and this is just in the U.S. When dust blows up it blows up big,

Of course, not all dust is combustible, and the number of incidents are still a relatively small issue in workplace safety, but the problem has received enough public attention that it is likely to become an increasing target for enforcement agencies word-wide.

Any thing that can burn can do so quickly especially when it is in fine particles and airborne. A lot has to go wrong for a major catastrophe: the dust has to be suspended in air, it has to be in the right concentration, it needs an ignition source, and there are often other conditions that must be present depending on the material. But even things that don’t typically burn (like metals) will do so if they are in the form of a fine dust.

It’s tough for laymen to wrap their minds around why something like metal dust or sugar would explode.  It doesn’t seem to make much sense after all, our Pop Tarts don’t explode when we put them in the toaster.  Understanding explosives might help.  There are two basic kinds of explosives: high explosives and low explosives. Both high explosives and low explosives have the same ability to create powerful destructive blasts.  Low explosives don’t detonate, however, in a sense they just burn so fast that they appear to detonate, but they don’t they are just burning all at once (explosives experts call this process deflagration.  Of course, the burn does happen fast enough to create great pressure (not as great as high explosives, but great enough to really mess up your day), heat, and light and this pressure causes the blast, so unless you are planning to blow something up (and don’t, by the way, there are enough whackos blowing things up in the world) the difference is fairly academic.  The point is when something flammable burns quick enough you get an explosion and at that point do you really care if it was caused by a high explosive or a low explosive?

The force from such an explosion is often substantial and often causes employee deaths, injuries, and destruction of entire facilities. Combustible dust is a problem in a lot of diverse industries from to food to pharmaceuticals manufacturing, to metal to mining or oil and gas. Not long ago an explosion of titanium in West Virginia left three workers dead, and of course for many of us the 2008 Georgia sugar explosion that killed 14 workers still looms large in our memories.

Even though the dangers of combustible dust are palpable and volatile, in the dust itself doesn’t pose a great deal of risk, like most hazards, combustible dust needs other hazards to create a disaster, and facilities need to do more than just focus on the dust itself (although, of course, they can’t ignore the dust).  Dust (or vapors for that matter, but this post isn’t about the dangers of explosive vapors) can’t explode without an ignition source.  This is where things can get a bit sticky—a lot of workers resist restrictions on items that might provide the necessary ignition source.

Anatomy of a Combustible Dust Explosion

All fires need three things: an ignition source, fuel, and oxygen, but a combustible dust explosion requires several additional elements, namely, sufficient concentration of the dust particles and confinement of the dust cloud. Despite the clear definition of the elements required for a dust explosion, many organizations do an inadequate (or downright poor) job of recognizing the hazard of combustible dust and an even worse job of mitigating the risks.

Controlling the Fuel

Eliminating the accumulation and concentration of combustible dust in the air is the single greatest protection against a combustible dust explosion, but even here companies often put themselves at heightened risk simply through the use of equipment that is poorly suited for the task.  An air filtration system that is poorly maintained, for example, can actually take dust that has settled (and thus far less a danger) and circulate it through the air.  Additionally, some vacuums used by organizations to remove the dust can provide an ignition source and actually exacerbate the dangers.

Obviously, the biggest source of fuel associated with a combustible dust explosion is the dust itself, but those identifying the risks associated with combustible dust explosions need to be mindful of other considerations like:

  • The presence of accelerants.  Many chemicals present in the facility may speed the spread of the fire and increase the damage to facilities, and more importantly increase the severity of injuries to workers. The careful placement and storage of these chemicals is an important factor in mitigating the risk associated with a combustible dust explosion and fire.
  • Release of toxic fumes. Often the resultant fire caused by the initial explosion cause materials to burn or melt and release harmful and even life threatening fumes. Companies should do their utmost to identify these materials and store them appropriately.
  • Emergency response and evacuation.  Explosions of the magnitude typically caused by combustible dust leave scarce little time for evacuation and emergency response.  It is imperative that emergency response and fire-fighting equipment be kept in good working condition and that all workers are trained in emergency response, evacuation, and the use of firefighting equipment where appropriate.

Controlling Ignition Sources

In some workplaces just getting workers to understand that smoking represents more than just a threat to their health is a challenge, and incredibly these workers are often so complacent about the dangers of having a lit cigarette in close proximity to flammables that it can be very difficult to get them to respect the danger of fire or explosion.  I remember auditing a manufacturing facility and finding a worker smoking a cigarette while working with acetone (beneath a prominent “no smoking” sign).  When I approached with the site safety manager the worker quickly flung the cigarette from his hand, narrowly missing a barrel of acetone soaked rags.

Even where workers understand the risks of smoking the risk from other ignition sources can be a difficult sell (and when workers discount the risk, the likelihood that they will comply with the controls put into place drop considerably.)  Some of the less obvious ignition sources are:

  • Static electricity. When most people think of static electricity they think of dragging their feet across carpet and giving some unsuspecting victim a mild electrical shock.  A spark less than the size of the one generated by this childish prank is enough to cause a massive explosion, provided that the other conditions are present.  And one need not scoot across the carpet to generate a static electric spark: a plastic bucket, PVC piping or even a cellphone can generate enough of a spark to ignite a dust cloud.
  • Heat. Hot work permitting is common practice in most industries, but depending on the criteria used to require a hot work permit, an organization may not be adequately protecting itself from a combustible dust explosion.  Ambient heat in some locations can be enough to ignite a combustible dust cloud in some rare conditions (but let’s face it, it’s the rare circumstances that kill us).  Cellphones and other electronic devices—particularly those that have been damaged or that have faulty batteries—are capable (if unlikely) of providing sufficient heat to be an ignition source.
  • Strikers.  Many organizations that prohibit the use of lighters on the premises will turn a blind eye to welders who have a striker hanging from their belts.  A spark is a spark when it comes to igniting a dust cloud and allowing workers to have a device whose sole purpose is to produce a spark dangling from their belts is a recipe for disaster.
  • Running Automobiles.  The combustion engine is a good source of ignition, and workers are sometimes reluctant to shut off a vehicle if they are only going to be out of it for a moment (like while opening or closing a gate, or other quick task).  Too often the cause of explosions of dust or vapors is a spark from an idling vehicle.

OSHA Standard NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids, provides some excellent advice on how organizations can control ignition sources to prevent explosions.

“The following are some of its recommendations[1]:

  • Use appropriate electrical equipment and wiring methods;
  • Control static electricity, including bonding of equipment to ground;
  • Control smoking, open flames, and sparks;
  • Control mechanical sparks and friction;
  • Use separator devices to remove foreign materials capable of igniting combustibles from process materials;
  • Separate heated surfaces from dusts;
  • Separate heating systems from dusts;
  • Proper use and type of industrial trucks;
  • Proper use of cartridge activated tools; and
  • Adequately maintain all the above equipment.”

The dangers of combustible dust aren’t new, or newly discovered, but if the rumours are true controlling and preventing these types of incidents will be given heightened priority among government regulators worldwide.  But apart from running afoul of regulators, isn’t it wise to be mindful of the dangers and to recognize that one need not work in a flour mill or sugar refinery to face the very real dangers of a combustible dust explosion?

[1] http://www.osha.gov/dts/shib/shib073105.html


#combustible-dust-2, #phil-la-duke, #preventing-dust-explosions, #process-safety, #worker-safety

Misleading Indicators

trash graphs

“If you don’t know where you’re going, how do you know you aren’t already there?”

By Phil La Duke

Nearly every safety professional worth his or her salt has been told that he or she needs to look at both leading and lagging indicators; it’s good advice, in fact, it’s advice I’ve given many times in articles and speeches over the years.  But in my last post (two weeks ago—I spent the last week at a customer site and with the travel travails I just couldn’t bring myself to hammer out a post, deepest apologies to my fans and detractors alike) I questioned the value of tracking (not reporting or investigating, mind you, just tracking) near misses.  Well, as you can imagine the weirdoes, fanatics, and dullards came out in droves to sound off and huff and puff about things I never said (reading comprehension skills are at a disgraceful low these days).  Not everyone one who reads my stuff is a whack-job however, and some of the cooler heads insisted that tracking near misses was important because near miss reporting is a key leading indicator; it’s not…and it is, but like so much of life, it’s complicated.

Near misses in themselves aren’t leading indicators; they are things that almost killed or injured someone, and most importantly, they are events that happened in the past.  Not that anything that happens in the past has to be automatically counted out as a lagging indicator, but unless you still cling to the idea proffered by Heinrich that there is a strict statistical correlation between the number of near misses and fatalities, near misses are no more a leading indicator than your injury rate, lost work days, or first aid cases.  They simply tell you that something almost happened, and nothing more.  Now some of you might try to argue that if you have ENOUGH near misses you are bound to eventually have a fatality, but that does hold up to careful scrutiny.  Leading indicators are often expressions of probability, and like the proverbial coin that is tossed an infinite number of times, the probability of the outcome does not change because of the frequency of the toss.  If you were to toss the coin 400 times and it came up tails, the probability that the 401st toss would come up heads is still 50:50. So knowing that tracking near misses doesn’t really shed any light on what is likely to happen mean we should stop investigating near misses? Certainly not, but we really do need to stop thinking that the data is telling us things that it isn’t.  On the other hand, near miss reporting is indeed a leading indicator; if we accept (as I do) that when people report near misses they: a) are more actively engaged in safety day-to-day (and I suppose someone could argue that this doesn’t necessarily correlate) and b) the more the individual reports near misses the better he or she is at identifying hazards (again, this is a leap of faith, but  I believe in most cases this to be true.) So if you want to gage the robustness of your safety process I suppose the level of participation in near miss reporting is a good indicator.

The whole exercise got me thinking about indicators, and how often safety professionals (and everyone else on God’s green Earth for that matter) tend to be mislead by data because of the erroneous belief that the data is saying things that it isn’t.


Regular readers of my blog will recognize the concept of “causefusion”.  The term was coined by Zachery Shore in his book, Blunder: Why Smart People Make Bad Decisions which he uses to explain how people mistake correlation and cause-and-effect.  According to Shore, causefusion works something like this[1]: People who floss their teeth live longer than people who don’t floss or who floss irregularly therefore flossing your teeth makes you live longer.  It makes sense, right? Yes, except that it is wrong.  There are other possibilities for this correlation, for instance, isn’t it possible that people who are more interested in their health overall might be more likely to floss regularly? In a world where eager safety professionals provide data to Operations people who are hungry for quick fixes, Causefusion happens a lot; and it’s a real danger because it leads us away from the true causes of injuries and may blind us to real shortcomings in our processes.

Another way that we can be lead by indicators is the paradigm effect. When we think of the word “paradigm” we think of the definition, “a typical example” or “viewpoint”, but in the world of science paradigm there is another, lesser known definition, “a worldview underlying the theories and methodology of a particular scientific subject” Joel Barker pointed out how damaging paradigms (in the scientific sense) can be.  Barker believed that there were many instances where the worldview is so powerfully believed that any new evidence that does not support the worldview is ignored. Consider the dangers of ignoring critical new information relative to worker safety because you believe in a particular tool or methodology so strongly that you can’t even consider another viewpoint.

A third way that we mislead ourselves is when we see patterns that aren’t there.  This phenomena is wonderfully described in another book that I really believe is important to the world of safety, Why We Make Mistakes: How We Look Without Seeing, Forget Things in Seconds, and Are All Pretty Sure We Are Way Above Average by Joseph T. Hallinan. According to Hallinan—and the latest in brain research supports his contention—the human brain tends to see patterns even where there are none.  So in cases where safety professionals desperately seek answers and are under pressure to initiate action, the pressure to see patterns where there are none can be extreme.

Perhaps the most misleading indicator is one of the most common: zero recordables.  Too often safety professionals (and operations, as well, for that matter) see a trend of recordables as evidence that they are at far less risk of injuries and fatalities than they are.  This isn’t to say that they AREN’T at less risk, but there isn’t anything more than a correlation between the two elements; they might be good but they are just as likely to be lucky.

[1] The example is mine and mine alone, don’t get all huffy and bother Shore.

#lagging-indicators, #leading-indicators, #measuring-safety, #phil-la-duke, #phil-laduke, #philip-la-duke, #philip-laduke, #predicting-injuries, #safety-measures, #worker-safety

Stop Me Before I Blog Again (2011 in review)

WordPress provides a pretty slick report that summarizes a blogger’s activity for the year, and I just figured out how to publish it.  I found it pretty interesting and thought I would share it.  But I also wanted to take a moment and acknowledge each of you and your role in my success (I won’t mention those of you who impede my success and are generally an anchor around the neck of my career; you know who you are.  All I will say is keep it up and see what that buys you.

Beyond the Blog

2011 began with me starting a major, long-term engagement with one of the world’s largest healthcare systems AND  kicking off  a project where, through Rockford Greene International, I ran the safety department for a small and struggling Tier-One automobile parts supplier. While I mentioned neither in my blogs (Rockford Greene International closely guards its client list to abet the guilty) both greatly shaped the content of my blogs, articles, and deranged emails to sundry politicos.  I also was engaged by a European luxury automobile manufacturing to do some executive coaching and process redesign, also through a Rockford Greene customer.

The bulk of my time,  however, was spent writing.  I had around 15 or 16 peer-reviewed articles published, wrote weekly (and sometimes weakly) posts to both www.philladuke.wordpress.com and www.rockfordgreeneinternational.wordpress.com all and all I produced somewhere in the neighborhood of 125,000 words in print last year; much of it right here.

This blog (and the Rockford Greene blog) continues to be shared by the ESHQ Elite managers once a quarter which drew many of you to the site.  For those of you who aren’t members of the LinkedIn group I would recommend you consider joining it; it is a terrific community. By mid summer, the blog had really taken off and now draws a steady audience (so much so that I sweat the Sunday deadline).

I spoke at the Michigan Safety Conference in Lansing, MI, in April and at the National Safety Council in October.  I submitted 2 abstracts for the ASSE show in June (which I covered as a reporter for Facility Safety Management magazine) but had both turned down.  That really irritated me, because two members of the selection committee specifically asked me to submit those.  After that experience and getting both abstracts rejected for this year, I have decided that ASSE doesn’t deserve me as a speaker, and I will not be speaking there again anytime in the foreseeable future. Unless they pay.  Most of other speeches I made to private companies who pay me to address their national or international safety meetings.  I am in the process of filling out speaking abstracts for conferences in Europe and at the National Safety Council, so if you are interested in hearing me speak, watch these pages.

I completed my certification in Just Culture, which amuses me since I have 5 works on the subject already published, but it was something a client required and what am I if not a sport.

In October, ISHN leaked a list of the Power 101, its list of the most powerful and influential people working in Safety today.  They quickly realized their error and pulled the list.  (It has since been republished and yes I am still on it.) I was interviewed by S+H Magazine, but that didn’t see print until 2012 so I don’t know if it is worth mentioning.

This year I am hoping to publish my first book, Selling Safety In Tough Times.  I have a proposal, but haven’t started looking for a publisher.  If anyone out there knows of a good literary agent, send them my way. I also have a submission (a late one—didn’t see the call for papers until the day it was due) for an OSHA journal.

I am hoping to get more speaking engagements and, of course, consulting gigs.  Will work for money.

But anyway, again thank you for your readership, your rancor, your interest and your community.




The WordPress.com stats helper monkeys prepared a 2011 annual report for this blog.

Here’s an excerpt:

A New York City subway train holds 1,200 people. This blog was viewed about 4,200 times in 2011. If it were a NYC subway train, it would take about 4 trips to carry that many people.

Click here to see the complete report.


#fabricating-metalworking, #ishn, #phil-la-duke, #phil-laduke, #philip-la-duke, #philip-laduke, #rockford-greene-international, #wordpress

What Can Traffic Fatalities Teach Us About Worker Safety?

Last week in metropolitan Detroit two stranded drivers were killed in two separate and unrelated incidents. Both cases can teach us much about worker safety, and indeed the nature of safety in general. In the first incident, an experienced fire-fighter was struck and killed as he changed a tire on a busy interstate highway during rush hour in the pre-dawn hours of a bleak Michigan winter day. A day later, another man was killed after he was stranded because his automobile was disabled. The two stories are important illustrations that some of our most cherished truisms in safety are bunk.

Let’s take a look at the facts of the first incident. A man decides to change a tire in the dark. As he gets out of the car to assess the situation maybe he notices that he is closer to traffic than he would like, maybe he doesn’t. In either case, he decides against repositioning the care. Not far away, another driver heads to work, she left a bit early and isn’t in a particular hurry so she decides to stay in the right hand lane. While the day is dark, unseasonably warm weather has made driving conditions unusually good—no ice, good visibility, she is paying attention, well as much as one can when one makes the routine daily commute. She’s careful by nature, she makes it a point not to text or talk on the phone while driving. She isn’t going particularly fast, but she is keeping up with traffic, like most drivers she drifts a bit in the lane, but she’s not swerving. Back at our first driver, he’s ticked off, this isn’t the way he wanted to start his day, and the tire isn’t just flat, it’s ruined. He hadn’t planned on the $150 or so expense of replacing a tire, especially with the holiday bills coming in. He didn’t need this and he’s getting more and more ticked off. A car whizzes by and his heart quickens, “that was close” he thinks, and he realizes that he’s in trouble, but the car is up on the jack and there is scarce little time to move the car, besides that would take more time. As the second driver negotiates the heavy traffic she notices too late the man crouched in her lane. A moment later the man lay dead run over by three motorists.

Less than 24 hours later, on a different patch of the same freeway, a small business owner’s car gives out and strands him, he struggles to get it off the road, he puts on the flashers, and mindful of yesterday’s tragedy makes sure the car is well out of traffic and completely on the shoulder. It’s 4:00 a.m.; he picks up his cell phone; “damn, it’s dead”. “Looks like there’s no choice but to walk to the nearest gas station and get help” he thinks. Reluctantly he gets out and starts walking to the closest exit. Meanwhile a postal truck swerves to miss one of Michigan’s ubiquitous potholes and strikes the pedestrian, killing him instantly. Are these so different from workplace fatalities? I don’t think so. In fact, I think there are some important lessons that challenge conventional thinking regarding workplace injuries.

Lesson 1: Many injuries, if not most, are a collection of hazards that only cause injuries when there is a catalyst. I call it Hazard Stack, and explore this idea a bit more in this week’s www.rockfordgreeneinternational.wordpress.com post.

Think of all the elements, that had to be present for the firefighter to be killed. He had to be too close to the road, traffic had to be heavy, a driver had to fail to notice that he was in harms way, and more. None of these elements alone caused his death, and the elements collectively did not cause his death, until there was some catalyst. Sadly we will likely never know what the catalyst was that caused this accident.

Lesson 2: Reminding People to Act More Safely is Ineffective in Keeping People Safe. The first case shut down traffic for 3 hours or more, in fact, all of northwest metro Detroit was disrupted. This was big news and was at the forefront of drivers’ minds for weeks. Despite this chilling reminder, an almost identical incident happened in less than 24 hours. I would be stunned to learn that either driver in the second incident hadn’t heard about the first incident, and yet this heightened awareness failed to prevent the second incident. Similarly, it is unlikely that warning signs or some sort of reward for not walking on the shoulder of a busy interstate highway would be effective.

Lesson 3: The Human Drive Toward Expediency Trumps The Need to Act Safely. Too often we see workplace fatalities that would have been prevented had the individual spent a little more time or suffered a small bit of inconvenience. But we need to understand that humans are hardwired to take risks—hell, getting out of bed in the morning carries with it at least some risk. But the need for expediency, to accomplish a task as simply, quickly, and easily is far stronger than our drive for self-preservation, at least to a point that is. Too often workplaces are configured so workers are forced to choose between expediency and safety. While employers generally want people to work safely, many times the message—produce efficiently and quickly—over shadows the message to work safe. Sometimes it may seem that employers encourage at risk behavior, but in general, employers do not want employees taking reckless chances. But we do take chances nonetheless. It real terms we don’t care what our employers are telling us to do, we want to get the job done as efficiently and expeditiously as possible.

Lesson 4: It’s Easy to Get So Absorbed In The Moment That We Lose Sight of the Big Picture. Consider our cast of characters, the Fireman, the Driver who struck him, the Postal Worker, and the Business Owner. All components of a large and complex system we call traffic. Each one is fairly absorbed in situation at hand, and the specific tasks associated with their activities (changing a tire, walking for help, driving to work, and driving as part of the normal workday.) Because each was so absorbed in each one’s individual task each has lost sight of the global process. Here again, this illustrates the lack of effectiveness of reminding people to work safely. It’s fair to say that none our cast believed that they were acting in a way that would result in a fatality, because if they had such awareness, one would expect them to have taken measures to change the environment. Walk on the grass along side the shoulder, reposition the car before attempting to change a tire, or move from the right lane to the center. We can’t be sure that all four didn’t see the situation as life threatening and decided to recklessly endanger themselves or others, but we can’t default to that thinking either. Safety is about managing both the big picture and the details.

Lesson 5: Accidents Happen More Frequently As The Risk Threshold Is Approached. Safety isn’t about not getting injured. Many people behave unsafely every day and aren’t injured, nor do they cause others to be injured; they’re lucky. Safety is about the probability that someone will be injured. As hazards become more numerous the risk rises until the probability that someone will be injured is all but certain, Because this is probability and not cause and effect, no work environment can ever be pronounced completely and irrefutably safe.

Lesson 6: While Training Is Important, Merely Knowing the Risk is Insufficient For Keeping People Safe. I have a lot of respect for firefighters and I use them as examples of how more people should work safely. For examples I have trained nurses who will complain that they often have to engage in high-risk activities because a patient’s life is at stake. I tell them how glad I am that firefighters don’t act that way. I point out that firefighters don’t rush into burning buildings to safe a person without first donning their protective equipment. It’s not because firefighters care less about saving people than nurses do, it’s because firefighters understand that dead firefighters can’t safe people. I am sure that the unfortunate firefighter who died that fateful day had far more safety training and awareness than the average motorist. This training and awareness did not save his life, however. I’m not arguing against training and awareness, but let’s not bank on these things alone saving lives in the workplace. Accidental fatalities are tragic whether they happen on the highway or in the workplace.

As I think about these most recent tragedies I am reminded of how similar they probably are to the kinds of injuries that happen in the workplace. Let’s learn from these cases and try to ensure that we apply these lessons in the workplace.

#behaviour-based-safety, #geometric-design-and-tolerancing, #hazard-management, #hazard-stacking, #just-culture, #loss-prevention, #phil-la-duke, #phil-laduke, #philip-la-duke, #philip-laduke, #process-safety, #risk, #risk-management, #rockford-greene-international, #safety, #what-can-highway-fatalities-teach-us-about-worker-safety, #worker-safety

In Defense Of Not-invented-Here Thinking

fa·nat·ic noun

  1. a person with an extreme and uncritical enthusiasm or zeal, as in religion or politics.

A couple of weeks ago a post I wrote found its way onto a LinkedIn Group discussion thread. The group in question is devoted to behaviour-based safety zealots who apparently enjoy telling each other how slick they are and how one methodology should be used at the exclusion of all others (or at least as the primary methodology)
This got me thinking about blind devotion to a methodology. And then I read an article that was yet another  criticism of Heinrich’s pyramid of risk. And then I read another article that defended Heinrich and asked if his critics might be too harsh in their comments.

And then it hit me,  the realization that growing  fanaticism, zealotry, and extremism is imperiling worker safety and enough’s enough. Here’s the bad news.  Working as a safety professional is hard.  There is no area of expertise that will make a one a safety superman, no single methodology that has a monopoly on making the world a safer place; there’s no panacea, no magic bullets, just hard work and dedication.

I know this isn’t exactly a epiphany—I’ve been warning people of the rising tide of people who place their ability to make money over the effectiveness of the snake oil that they continue to promote to people who don’t know any better—but it was none-the-less a fairly profound realization.

For those of you who don’t know, Heinrich was an insurance investigator who in 1931 wrote the book, “Industrial Accident Prevention: A Scientific Approach.” In this book, Heinrich asserted that  88 percent of accidents are caused by “unsafe acts of persons”.  Statistical analysis was in its infancy (at least in and industrial setting) and Heinrich’s risk pyramid: that is there is 330 accidents, 300 will not result in injury, 29 will cause minor injuries, and one will result in a major injury or a fatality.

What I realized was a) Heinrich was full of crap  b) it’s not his fault, and c) while he’s not all right, he’s not all wrong either.  His research methods and results are, after 6 decades or so, increasingly questioned.  But even if he didn’t fake his research (personally I don’t believe he did, at least intentionally) his methods, population, and conclusions were hopelessly broken.  The manufacturing environment in which he conducted his studies bear little to know resemblance to today’s workplace.  In those days, asking supervisors the causes of injuries was not likely to yield many answers that didn’t lay the blame squarely on the shoulders of careless workers.  I don’t disparage these supervisors or Heinrich; they reached the conclusion that any reasonable person of that period would have given their time and experiences.  But let’s consider the time,  in 1931 eugenics was considered legitimate science, Social Darwinism was one of the most popular social science theories.  Henry Ford was spouting White Man’s Burden, and Nazism and Marxism were both rising in popularity.  In short, there was a pervasive environment in which workers were believed to be little more than clever primates who once in awhile  could be expected to have the occasional lethal mishap.

In most parts of the world, we it is no longer acceptable to see workers as chattel. And if Heinrich were to have completed his study in these more enlightened times what percentage of worker injuries would be attributed to “unsafe acts of persons” aside from the zealots and fanatics who start with an answer (90%, 95%, etc.) and then conduct research to prove what they already believe.  Beware the man who conducts research the outcome of which can either preserve or endanger his livelihood.  If your livelihood depends on the world being flat, count on finding facts to support your need.  It’s human nature.

For the sake of argument, let’s say that Heinrich had the right of it; let’s pretend that his findings were accurate and correct. All that would mean is that given his population his conclusions were sound.  It wouldn’t however, mean that his findings were universal truths.  It wouldn’t be applicable to all industries, all areas of the world, or people. And yet, people continue to promote one methodology as applicable in most cases, even when they aren’t.

This may sound like yet another attack on BBS;  it isn’t. While there is certainly a time and a place for Behaviour-Based Safety (I am accused of being so virulently anti BBS that I can’t see the value in it, this is a false charge, but one I suffer relatively cheerfully.) it is the height and breadth of  arrogance to assume, without investigation, that worker behaviour is the primary cause of injuries.  But then again, it’s just as arrogant to assume that the process is to blame.

For years I sold a process that I invented as a work for hire. SafetyIMPACT! was a fairly prescriptive methodology that yielded terrific results.  But what made it tough to sell was the “not invented here” push back.  I spent 6 years working on safety improvements in the automotive industry, but the first time I tried to sell SafetyIMPACT outside the auto industry companies responded with “this isn’t the auto industry” and then “this is aerospace” and then “this is healthcare” and then “this is mining” and then…well you get the picture.  I always sort of rolled my eyes and thought these narrow-minded goofs just don’t get it; that they just didn’t understand that they weren’t that special, not that unique.

So I modified my style.  I turned the system I developed into a structure diagnostic tool that in one year would assess the situation, use the methodologies most appropriate to the situation, and build an infrastructure that would work for the organization.  After 15 engagements without a single failure I began to think that I had all the answers, that I had developed the magic bullet.

Last week I realized I was wrong.  I realized I didn’t have all the answers, in fact I didn’t have many answers at all.  I realized that all those people who refused to buy my snake oil were right; I don’t know who they are and I don’t know their specific challenges.  But if that was the case why was I so wildly successful? Because the key to success lies not in knowing what the organization needs, but in knowing that you don’t know what an organization needs and that you will have to research the situation.  You need to invent it here.

#5s, #88-of-all-injuries-are-caused-by-unsafe-behavior, #88-of-injuries-caused-by-unsafe-behavior, #accountability, #aerospace, #at-risk-behavior, #attitude, #attitudes-toward-safety, #awareness, #behavior, #behavior-based-safety, #behavior-observations, #behaviour-based-safety, #branding, #change, #combustible-dust-2, #construction, #construction-safety, #continuous-improvement, #contract-house-safety, #contractor-safety, #contractor-safety-training, #contractor-training, #core-skills-training, #criticisms-of-bbs, #culture-change, #deconstructing-heinrich, #deming, #distracted-driving, #driving-while-distracted, #edgar-schein, #empowerment, #enforcement, #engagement, #fabricating-metalworking, #fabricating-and-metalworking-magazine, #fleet-safety, #fred-a-maneule, #guiding-behaviors, #happiness, #hazard-management, #healthcare, #heinrich-revisited-truisms-or-myths, #heinrich-risk-pyramid, #human-error, #incident-investigation, #increasing-efficiency, #individual-accountability-for-safety, #injury-reporting, #james-reason, #jim-raney, #joy, #just-culture, #kan-ban-systems, #line-of-fire, #logistics, #loss-prevention, #manufacturing, #mining-safety, #mistake-proofing, #mistakes, #national-safety-council, #near-miss-reporting-2, #oil-gas, #oil-and-gas, #operating-efficiency, #organizational-change-2, #organizational-development, #peace, #pedestrian-safety, #performance-improvement, #phil-la-duke, #phil-laduke, #poke-yoke, #process-capability, #process-improvement, #process-safety, #regulations, #risk, #risk-management, #risk-taking, #root-cause-analysis, #rules, #safe-work-culture, #safety, #safety-branding, #safety-culture, #safety-culture-development, #safety-in-the-entertainment-business, #safety-incentives, #safety-observations, #safety-slogans, #safety-tours, #safety-training, #selling-safety, #selling-safety-in-tough-times, #sidney-dekker, #situation-analysis, #situational-analysis, #stop-trying-to-prevent-every-possible-accident, #strategy, #systems-based-safety, #talent-management-2, #temp-agencies, #temp-agency-safety, #temp-safety, #temporary-workers, #temps, #texting-while-driving, #the-enforceable-rule, #the-nature-of-mistakes, #traffic-fatalities, #traffic-safety, #training, #training-safety, #transformational-safety, #unsafe-behavior, #values, #variability-in-human-behavior, #why-we-violate-rules, #worker-safety, #worker-safety-net, #workplace-fatalities, #you-cant-fix-stupid

A Just Culture Starts With Just Leadership

Just Culture, a concept James Reason proffered decades ago is growing in popularity.  At its essential core Just Culture is pretty simple: people make mistakes and punishing people for making honest mistakes is a basic form of injustice.  Reason, and his successors, argue that organizations must foster blame-free environments where workers are encouraged to report mistakes and near miss if they hope to ever address the root causes of workplace injuries.

But implementing a just culture is far more difficult than merely deciding not to punish people for screwing up.  Far too many business leaders are unable to see past their petty biases and the traditional legal department party line that a blame-free culture needlessly and recklessly exposes organizations from malpractice lawsuits or other liabilities.  This is unfortunate.  So many business leaders are afraid to do what is right in favor of what is safe.

For a just culture to take hold and blossom organizations need a different sort of leader. A Just culture  needs to be led by what I describe as just leaders, and these executives are a rarity.

Traits of a Just Leader

Just leaders share characteristics that set them apart from the pack. These leaders see themselves as leaders first and foremost and they live there lives by a code of conduct that is set not be some artificial external criteria but by their personal values.


It takes a lot of moral fortitude to stand up to corporate attorneys who advise you on a course of action that pits you against your core values.  If the corporate attorney insists that you hang someone out to dry, it’s tempting to throw someone under the bus and blame the oily skinned legal department (or corporate communication or IT).  It takes real courage to stand up to the corporate pitch fork and torch toting mob screaming for the blood of some hapless bureaucrat who mad a bad decision in good faith, but that’s what a just leader does.  A just leader recognizes that courage lies not fearlessness, but in recognizing one’s fear and forging forward despite them.

A just leader is able to clearly articulate his or her values and institutionalize  those values into a work culture that is fair and just.


It’s scary what passes for vision these days. Corruption is rampant, which one could argue was always the case, but even when Chief Tammany bore witness through his lifeless wooden eyes, people recognized corruption, incompetence and dare I say it, corporate sin. Just leaders need vision and that vision must take them beyond what’s good for themselves and their stockholders.  Just leaders know that they cast long shadows and that to create an organization that will endure it takes more than their own skills and includes the skills of most everyone in the organization.

Recent years have seen the growth of a sickening cottage industry—executives who take companies into bankruptcy.  This is pointedly obvious in the auto industry.  There are a handful of executives whose only value seems to be screwing people out of money to which they are legally entitled via bankruptcy. These slim-witted weasels are hired to bankrupt a company not as a last resort reset of the company’s debts but as a corporate strategy.

A just leader looks beyond the goals by which his or her compensation is based  and instead focuses on how organizations can serve the needs of their stock holders, their environments, their employees, and their customers.  A good leader knows the importance of being a good corporate citizen.


Rudyard Kipling once wrote “if you can trust yourself while all men doubt you while still allowing for the doubting too.” Just leaders do this by consistently holding the line as others in their industry are melting down in panic.  Because these leaders have a clear cut vision you can always predict what they will do in a crisis,  you can set your watch by them and trust they will do what is required even if it is painful

Consistency isn’t easy, especially when an industry is melting down.  But no one will ever admit mistakes without knowing exactly what consequences are likely to befall them. So unless a leader can consistently react to unexpected circumstances a just culture can never emerge.


A just leader cannot expect others to be forth coming about their mistakes unless he or she clearly acknowledges his or her own mistakes.  Everyone makes mistakes and for a leader to gloss over his or her business faux pas is the height of arrogance and hubris.  Just leaders aren’t afraid to acknowledge their mistakes and the best of them learn from their mistakes and teach others the lessons they learned.

Honesty transcends being straight-forward with board members, the media, the workers, the unions, and the stockholders and reaches the depths of the just leader’s subconscious and lays bare the soul, in short the just leader is MOST honest with him- or herself.


Just leaders don’t just know the difference between right and wrong, they also know the difference between right and legal. In this day and age it’s easy to hide behind the law and commit corporate atrocities.  For most leaders doing something heinous is softened a bit if you can get your corporate lobbyist to get it legalized first.  Just leaders worry about what is right, not what is legal.  And when they act with integrity and transparency they need not worry about investigations or accusations.

Just leaders hold themselves to a higher standard than the one to which they hold all others and the one against which society measures them. And when it comes to creating a just cultures having the right leaders is more important than having the right consultants, the right tag lines, or even the right policies.

#attitude, #attitudes-toward-safety, #behavior-based-safety, #behaviour-based-safety, #corporate-atrocities, #courage, #dont-hurt-yourself, #efficiency, #honesty, #integrity, #just-cause, #just-culture, #just-leaders, #mine-safety, #rockford-greene, #safety-culture, #stop-trying-to-prevent-every-possible-accident

What ‘s Wrong With You People?

In my haste I had a typo or two and even an incomplete thought.  I did a quick edit just now, but I would hazard a guess that it’s  far from perfect…Phil

This week I joined two or three new groups on LinkedIn. That’s my fault. For whatever reason I seek out the company of people who post largely inane opinions and spend their time arguing with strangers. That’s not to diminish LinkedIn; I’ve met many really great people through the site, unfortunately I’ve also met some honest to dogs imbeciles. Recently I weighed in on whether or not a company should consider itself world-class (the author didn’t think it germane to the discussion to hint at precisely in “what” company should claim such an honor) if it fires its employees for things they do on their own time (as in while off work). The topic generated some minor buzz, largely centered around Chrysler workers caught by a local Fox news show should be fired for drinking on their lunch hour (nobody questioned how three autoworkers drinking on their lunch hour in a city with a population smaller than Columbus, Ohio with a murder rate of 40.1 per 100,000 residents rose to anything approaching news worthiness). I couldn’t bring myself to continue the argument—nobody seemed to much care about the pseudo topic—but it got me thinking: is any company so free of risk and so flush with resources that it can even consider doing this?

As far as the absurdity of trying to govern worker’s off-the-clock behavior, Henry Ford tried something similar when he hired private detectives to follow his workers to see if they were smoking, drinking, or otherwise doing something decidedly unFord-like. In the case of Ford, the effort hastened union organization and generally collapsed under the weight of its own complexity. Even given today’s sophisticated technology the cost of snooping on your workers far exceeds the financial benefits.  Add to that the fallout from workers when they find out they are working for a voyeuristic creep, and you end up in a no-win situation.  The argument was pointless and while safety professionals continue engage in pointless debate about which latest fade is way cool, people are dying.

This topic hits pretty close to me. My father died from mesothelioma. I watched him devolve from an energetic and active retiree to a shell who could barely move, much less breath. My father never blamed his employer, who he believed took every reasonable precaution to protect him. But he was incensed to learn that the asbestos manufacturers who provided materials to his employer knew and failed to disclose that information. I have a brother-in-law with days to live. He has lung cancer likely caused by working as a millwright at what was once reputedly listed in the Guinness Book of World Records as the dirtiest square mile on Earth. One doctor initially thought it was caused by silica exposure, another by some other industrial exposure. I’m not privy to his exact medical records so I doubt I’ll ever know the truth.

I have a brother, who years ago was overcome by fumes and fell from a pallet that was raised using a forklift as a makeshift platform used to paint the ceiling. A task that not only was he instructed to do by his supervisor, but one that the mouth-breathing thick-witted brute of a supervisor stood by as it happened. The fall left him close-head injured with short and long-term memory loss that only through God’s grace did not cause him any long-term disability. I’ve lost friends to a horrific array of industrial accidents—two co-workers to electrocution, another who fell in an open vat of acid, I could go on, but at some point it becomes macabre. None of these people took frivolous risks, drank on their lunch breaks, or thumbed their noses at safety regulations. They were just guys looking to make a fair day’s wage and go home the same way they came to work.

Thank God the safety professionals around the world have the time and intellectual energy to argue about what sorts of unsafe behaviors workers engage in off the job. After all, doesn’t safe behavior off the jobs safe lives too? Isn’t that important too? Well…no. If I chose to mow the lawn barefoot and drunk as a monkey I am making my own choice. I assume the risks and face the consequences. (Let me state for the record that mowing the lawn barefoot while drunk (as a monkey or otherwise))  is foolhardy and should be discouraged but despite the recklessness of such actions I am in an environment controlled by me.  It is an inalienable human right to make a wage without the unmanaged risk of injury.  When we enter into an employer-employee relationship the employer has a more, financial, civic and legal obligation to do everything in their power to protect us.  And THAT is the issue of the allegedly drunken Chrysler workers (trusting Rupert Murdock to provide you the truth is like trusting Charles Manson to house sit). It’s not that tax payers bailed out Chrysler and now we somehow own not only the company but the workers as well, it’s that drinking during lunch and returning to work endangers multiple other workers who are working safely and minding their own businesses.  That Fox film crew could have raised the alarm, but instead chose to get the ratings; it’s practically depraved indifference.

Let me get to the crux of my issues.  When safety professionals sit around arguing about this pointless crap, people are dying. While people in ivory towers debate whether safety is the fault of unsafe behaviors or failed processes people are horribly maimed and deprived of their livelihoods. And while safety professionals sit around congratulating themselves for lower recordable injuries or for the neat new incentive program because injury reporting is driven underground or because “effective case management” has taken a recordable off the books, things don’t get any safer.

Through all of this there is an opportunity cost. For starters, we are losing the war in the court of public opinion. People around the world who are actively trying to convince the public that worker injuries are largely the fault of bad luck; careless, drunk, or stupid workers. Even then-President of the United States decried the people who exercised their legal rights to hold companies responsible for knowingly putting people in harms way as filing “frivolous lawsuits”.

As the economy worsens more and more people are prepared to trade job safety for jobs. In a world where there are 27 million slaves (more than ever before in the history of mankind) worker safety rights need to be protected. Despite the rapidly deteriorating opinion as to the importance of worker safety there is little attention paid to the problem at professional conferences. Peruse the abstracts offered at the majority of the expos and conferences and you will see plenty of talks on culture, on incentives pro and con, and a fair amount on regulation. But scare few speakers take on the most serious threat to worker safety faced today: the belief that safety as a profession is irrelevant. We safety professionals have to be more than theorists. We have to be more than money-grubbing snake-oil salesmen. We have to worry less about pointless minutia of or trade and work to raise awareness of the importance of safety professionals who know how to do their jobs, do them well, and make meaningful advances in the trade.

It’s time to wake up.

#attitude, #attitudes-toward-safety, #behavior-based-safety, #behaviour-based-safety, #chrysler, #culture-change, #does-safety-cost-jobs, #dont-hurt-yourself, #drinking-alcohol-while-on-lunch-break, #frivolous-lawsuits, #jefferson-north-assembly-plant, #just-cause, #mesothelioma, #mine-safety, #oil-and-gas, #philip-la-duke, #philip-laduke, #rockford-greene, #rockford-greene-international, #safety, #safety-culture, #safety-recognition-programs, #uaw, #worker-safety, #worker-safety-rights