Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

Six Simple Ways to Change Your Life

by Phil La Duke

Years ago I worked in talent development for one of the largest faith-based healthcare systems in the United States. I left it to pursue other career goals but it never left me, at least not completely. The system was founded when two religious orders merged after discovering that the youngest among the two orders was 78 years old. They came together to preserve a way of life that had existed over 500 years. Sure it ran hospitals, but more important was the spiritual community that it had created. Faced with extinction it set about an elaborate plan for turning over its legacy to the laity. I always took that very seriously. For me it wasn’t about organizational development or training, although these were certainly a big part of my job, rather it was about preserving a way of life.
Some time ago I shared the podium at the Canadian Society of Safety Engineers with an anthropologist and National Geographic photographer who talked about cultural extinction (which interestingly enough, he attributed to the growth of the written word). According to him, cultures are going extinct at a far faster rate than animals; it’s scary really, thousands of years of knowledge lost as cultures die daily. I was determined that I would do everything in my power to save this one culture to which I had been entrusted.
I wasn’t the only one so entrusted; there were scores of professionals whose primary jobs were to preserve the mission, culture, and vision of the consolidated order. One of the tools they had for preserving the culture was the Guiding Behaviors (note to the grammar vigilantes: I know this sounds like number disagreement but the Guiding Behaviors is considered one tool). As I reflected this morning, as I do every morning, on these behaviors it occurred to me that these would serve the safety professionals as much as anyone else. I have changed the wording of some of these to make them less specific to healthcare, but I doubt the surviving members of the orders will mind too much.

“We support each other in service”
The first of the behaviors is “we support each other in service” what better way for a safety professional to sum up his or her job? We don’t really save lives—not the way doctors or nurses do anyway—but we can always support people in making better decisions and while not directly saving lives influencing people to save their own lives or the lives of a coworker.

“We communicate openly and honestly, respectfully, and directly”
I’ve written volumes about the importance of open and honest communication. I still believe that the only path for safety professionals to get respect is by truly respecting the people and organizations they serve. It’s disappointing how many safety professionals disparage the people they are charged with protecting. People who feel respected tend to respond respectfully. We must always strive, not only to be truthful, but truly honest and not just with the people we serve but with ourselves as well. And let us never confuse hurtful speech with honesty. Before speaking we should ask ourselves, “is what I want to say true? Is it helpful? Is it intended to help someone or merely to make ourselves feel better? And finally, is it necessary?” if all of these things aren’t true then maybe we should just keep it to ourselves.

“We are fully present”
Perhaps the behavior I struggle with the most is “we are fully present”. Being fully present means that you keep your mind on the job—no multitasking, no distractions, no dreaming about the weekend. While it’s easy to see how staying fully present on the job would greatly benefit most workers—distraction on the job can be deadly—we also need to be fully present as safety professionals. This means really participating in meetings and really listening (not just waiting to talk) and working with others to accomplish things. Keeping your head in the game every minute of every day is really tough and if you try to do it you will come home exhausted.
“We are all accountable”
“We are all accountable” means more than holding others accountable, although that is certainly a part of it. We also must strive to hold ourselves accountable. Each day we must ask ourselves if we earned our pay. Did we make a positive impact in people’s lives, not just in the context of safety, but did we make the workplace (and the world) a more pleasant place? Did we really bring our “A” game or did we merely phone it in? We must also remember that we have a duty to be just in holding others accountable. We do not stand in judgment above those we serve, but we owe it to the organization and to the entire population to hold people answerable—both positively and negatively,
“We trust and assume goodness in intentions”
People screw with our work, our day, and our heads on a daily basis. But trusting and assuming goodness in intentions has taught me one of the most powerful lessons of my life: we screw with our own work, our own day, and our own heads far more often than anyone else ever could. They say that forgiveness is a gift we give ourselves and it begins by never taking slight in the first place. Instead of assuming that the Operations leadership is throwing us under the bus we should ask the person some questions. Most often we will find that because we assume that the person meant us no harm and was probably completely unaware of the issues he or she was creating for us. Assuming goodness in intentions brings a person real peace and strengthens relationships. There is a saying that if you keep meeting jerks all day long the jerk is you. I say that if you assume goodness of intention in all you meet you will live in a world like you could never imagine. Send out good stimuli and you receive good responses.
“We are continuous learners”
Too often we strive to teach. We are, after all, the experts in safety and what good is that expertise unless we share it with the organization? We get sad and frustrated when people don’t want to listen to what we have to say. But when we are continuous learners, when we focus not on what we can teach others, but what we can learn from them, we find that we end up teaching other so much more of value than if we were to just spout facts at them. Continuous learning involves a lot of introspection—we have to examine our mistakes and try hard to understand why things went wrong and what we can do to fix things them.
The World Loves a Hypocrite
While I try to live by these simple six statements I don’t always succeed; in fact I fail a lot. But the beauty of these guiding behaviors is that they are things to which I aspire. So now I charge you to share these aspirations with me. Try doing these six things for a week. You may fail, but remember in some cases success comes, not in the outcome, but in the attempt.

Filed under: Behavior Based Safety, Hazard Management, Just Culture, Performance Improvement, Phil La Duke, 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.

Filed under: Loss Prevention, Loss Prevention, Near Miss Reporting, Performance Improvement, Phil La Duke, Safety, Worker Safety, , , , , , , , , ,

The Greatest Threat To Safety Might Be Your Safety Training



By Phil La Duke

To assert that most safety training sucks is to reveal no great insight; it’s practically an O’Henry short story: training professionals steer clear of safety courses for fear they might miss some important point and imperil the learners and safety professionals lack the requisite knowledge of knowledge of adult education to construct an effective course. The result is well-intentioned organizations wasting millions annually on weak safety training that not only doesn’t protect workers; it puts them at risk.

There are a couple of basic things you have to decide whether you believe or not before you can draw any accurate conclusion. First, you either believe that safety training protects workers or you do not. (It’s something of a mute point, because in most countries Safety training is required.  It’s not required to be good mind you it’s just required that people complete it.) Second, you either believe existing safety training is sufficient or it is not.

Researchers in adult learning paint a fairly bleak picture of training in general.  Research has shown that up to 85% of the skills learned in training courses is lost before it ever has a chance of making it to the workplace, and further research shows that no skills taught in a class are retained unless the skills are applied within 48 hours of the course.

Before we continue I should make something clear. I use the term “training” not “learning” not “teaching” and not “education”. I know some people bristle at the term, “you train dogs, not people” but I was taught the difference between teaching and training through the following analogy: “you might be in favor of your sixth grade daughter receiving sex education in school, but you probably don’t want her getting sex training”.  Some of you might be offended by that example (lighten up) but I think it creates a visceral mental image of the precise difference between training and teaching.  As far as I’m concerned, education is learning ABOUT something and training is learning how to DO something.

This distinction has profound implications in worker safety.  Safety professionals pull their hair out in frustration, concoct elaborate schemes, and tilt at ludicrous organizational windmills in an effort to influence, motivate, coerce and cajole workers into working safely, when I put it to you these workers were never taught to work safely, they were taught ABOUT working safely.   This might sound like I’m playing semantic games here, but think about it.  What do people learn how to DO in a hazard communication course? That’s not to say that safety education isn’t important, and awareness too, while were at it, but if we want people to change how they behave—and despite whatever position you take on behavior and its relationship to safety I think we can all agree that safe behavior and good decision making is an essential to a safer workplace—we have to first give them the skills they need to behave safely.

This distinction also lies at the heart of why so few safety professionals, academics, and consultants have any real credibility with workers.  Credibility is only really gained when a person knows how to DO the job, irrespective of how much the person knows ABOUT the job.  This creates a problem for safety training; many decision makers assume that subject matter experts will make great trainers because they will have so much more credibility with the learners.  Of course not all grizzled veterans are horrible trainers, but many are really bad at teaching people the skills they need to do a job.  Any time I have endured a training course on any subject where the instructor takes pains to brag about his or her having spent 87 years doing blah, blah, blah…I knew I was in for long, pointless class.

The secret to better safety training starts with a professional designed course. I’ve explored that topic in greater detail in previous articles and blog posts so I won’t go into it much here, except to say that a well-designed course is like having a concrete plan for imparting the skills; a “learning road map”, if you will. The development of the course requires two kinds of expertise: expertise in the content, and expertise in adult learning.  There are no short cuts to this formula. If you try to cut corners you will end up not only wasting time and money, but potentially putting workers at risk.

But a professionally developed course is only the start.  The delivery of quality safety training is every bit as specific and important a skill as any other. Just because someone LIKES to present in front of a group or that fancy themselves a trainer.  A good safety trainer should be an expert in the discipline of training. Of course the instructor has to have credibility in the content, but that doesn’t mean that the instructor has to have complete mastery of the subject and have 150 years doing the work.

In the best classes, either a subject matter expert has been given training in presentation skills or is teamed with an experienced trainer.  But too often those charged with ensuring that courses are delivered simply trust the subject matter expert to “pull together a course” or worse yet, trust them to deliver the “course” they’ve been regurgitating for years.

As I’ve said in so many other posts, the best safety training isn’t the regulatory training most of tend to think of when people mention safety training. Rather the most important safety training is effective core skills training. Unfortunately, this training tends to be even worse than regulatory training and is even less formal than the worst regulatory training out there.  This is where things get dangerous, if we don’t provide quality training in how to do the tasks required of a job the workers will figure out a way to do it, and the way they find to do it will be the most lasting learning.  It’s tough to unlearn something that you learned from your own experience and even tougher to change those behaviors.

Filed under: Performance Improvement, Phil La Duke, Risk, , , , ,

Process Improvements May Be Hazardous to Your Healthj

By Phil La Duke

Processes are hazardous

There are a lot of useful things that safety professionals can learn from manufacturing, particularly Lean Manufacturing, yet surprisingly few safety practitioners—even within manufacturing—see the connection.  Two of these concepts that have a profound value on safety and risk are cycle time and takt time.  Takt time is generally defined as the maximum time per unit that it takes to produce something to fulfill the customer’s demands, and cycle time is the time it takes to do one job. Both terms are measures of capacity and key elements of efficiency.

That might not seem to mean much in terms of safety and risk, but it does.

Shorter takt times mean that providing goods (or services) to the customer is happening faster. This fact in itself doesn’t mean very much, but if you consider that to improve efficiency (for our purposes, efficiency will mean producing goods or services as quickly as possible without compromising cost, quality, or safety) you have to reduce your takt time, we start to see implications for safety.  Few of you would argue that “haste makes waste” and in fact, rushing to complete a job introduces the risk of injury, and that is exactly what can happen if we try to reduce takt time simply by cracking the whip and force the workers to work faster.

Similarly, cycle time is the time it takes to do one job. In manufacturing, it is the time it takes  to complete all the tasks at one station and this is typically described in minutes or seconds.  Years ago when I built seats for one of the Big Three auto manufacturers my cycle time was 55 seconds, and our takt time was around 16 hours (the time it took for one car  to go from hunks of metal, plastic, and cloth to a fully functioning automobile.) To improve the takt time you generally have to reduce cycle time.  The key to both these activities is to eliminate waste.  In the discipline of Kaizen there are seven kinds of waste, or muda as they like to call it, mainly so that there job feels like a cool karate class, but then I digress. The seven wastes are:

  1. Defects (and rightfully this should include injuries and damage to facilities or equipment, or environmental spills, from a process stand point, when a process fails, whatever the unintended consequence is waste)
  2. Overproduction (work done without an immediate order for it)
  3. Inventories waiting to be  \processed
  4. Unnecessary movement of stock (like moving things around your operation)
  5. Unnecessary motion of employees (people having to walk farther than necessary, for example)
  6. Overly processing (quality checks or redoing job because it wasn’t done correctly in the first place)
  7. Waiting (workers standing idle because they have nothing to do)

All of these sources of waste introduce variation into the process and where there is variation there is risk of injury.  So we want to eliminate waste and be sure that we preserve the safety of the workplace; sounds simple right? Well, predictably, it isn’t.

Apart from the obvious risks of rushing, let’s assume that there is an unidentified hazard in a job (for our purposes, it doesn’t matter if the job is taking orders at a logistics company, running a ride at a theme park, or building jet engines) if the cycle time is decreased it means that the job is done more times a day (assuming a steady flow of consumer demand) which means that the probability that the worker will be injured through interaction with the hazards grows proportionately. Think of like this let’s say you are a shoplifter (relax I know some of you aren’t really shop lifters) and you decide to steal a steak from your grocer. Two things come into play (actually more than two, but bear with me) the length of time to steal one steak (takt time) and the number of times you go back to the store to steal a steak (like any good shoplifter you go back to the same store over and over again because you know the layout and routines of the staff). Unlike the odds of say, flipping a coin that remain 50:50 each and every time you flip it, our scenario is a bit different.  While the coin will never change in a way that will affect the probability our chances of successfully shoplifting are in almost constant flux (security measures are likely to get “beefed up”, the store staff is more and more likely to recognize you and suspect that you may be the thief (assuming you weren’t seen in the act).  To reduce your risk you might decide to steal something else, something that reduces your takt time because it is closer to the exit, or you might decide to lower you cycle time to let things “cool down” before trying it again.

How is this important to safety? Well ergonomic strain can build to create the most costly injuries, and you don’t have to be swinging a sledgehammer to get one. A worker may be able to process invoices safely at three an hour, and might be able to ultimately increase his or her time to say, six an hour, without noticing any immediate discomfort.  But after doing six invoices an hour, 5 days a week, 8 hours a day for a month, he or she may begin to show symptoms of a repetitive strain injury.

There are other exposure risks as well.  Let’s say a doctor sees 4 patients an hour.  Each time a sick person comes in for treatment (assuming it is a contagious disease and not a chronic complaint or injury) the doctor risks getting ill.  If the doctor increases the number of patients (and in turn decreases his or her takt time) he or she increases the likelihood of contracting an illness. You can carry this example to working with asbestos or a radioactive activity. The more times you are exposed to a hazard the more likely it is that you will be harmed by it.

What this means in practical terms is that when we calculate probability we need to remember that: a) we are calculating not the chances that someone will interact with a hazard, but also the likelihood that that interaction will cause harm and b) both the number of times a worker interacts with a hazard and the duration of the hazard are important things to think about when considering probability.

The safety professional must be involved in these efforts to improve workplace efficiency not just to add value, although that is important, but also to ensure that the improvement effort doesn’t just trade one set of wastes for another, in this case, injuries.

Filed under: Performance Improvement, Phil La Duke, process improvement, Safety, Worker Safety, , , , , , , ,

When it Comes to Safety the Surest Way to Lose Is to Think You’ve Won



By Phil La Duke

Injury rates are down, the safety function is running like a well-oiled machine and senior leadership is happy, so now you can relax right? Wrong.  If safety is the probability of injuries and we know that the risk of injury is never zero, then most of us understand that we have to remain vigilant in our efforts to create a workplace with the lowest possible risk…blah, blah, blah. But realistically do we really need to keep trying new initiatives after we have licked the biggest hitters in safety? Isn’t that just some academic argument? Well, yes and no.  In some cases, we truly can wind down some of our safety efforts.  After all, it doesn’t make a lot of sense to be hyper-vigilant in workplaces where most of our hazards are well managed and quickly contained or corrected—that’s like continuing to look for your car keys after you’ve already found them (“where else MIGHT they have been but weren’t?”) Unfortunately, most of us aren’t working for organizations that are quite there yet and still have some work to do.

In fact, it’s highly unlikely that we will ever get there.  We tend to think as safety (and other business systems) as its own system when, in fact, all our business systems are interconnected in highly complex ways.  What’s worse is that all our business systems operate in a dynamic business climate and this continuously changing environment makes it impossible for us to ever pronounce the workplace permanently “safe”.


When we are confronted with a new situation we generally feel nervous, or tentative, or unsafe in some way.  Even the boldest among us is likely to exercise heighted care when first confronted with a new situation, but as we get used to the situation we become more comfortable. We acclimate to the changes and feel more comfortable taking what a less seasoned observer might describe as unwarranted or even reckless. This same process of acclimation that allows us to perform our jobs with greater levels of skill also puts us at higher levels of risk.

Over Confidence and Complacency

Many organizations fail to recognize that the hazards shift and evolve.  These organizations, reckoning that they have solved the safety puzzle become less vigilant.  It’s a dangerous phenomenon.  Hazards insidiously grow while the perception of danger diminishes, leaving the organization open to unexpected catastrophe. Some of you may be skeptical; it’s often difficult to accept that you may be losing ground when all indications are to the contrary. But as long as the work environment changes and your safety management system stays the same, you are at significant risk.  And the kinds of catastrophes that strike seem to come out of nowhere.


A key source of variation in organizations is turn over.  We talk a lot about the effects of employee turnover on the safety organizations (well at least I talk a lot about it) but one of the most destructive changes to the organization is executive turnover.  Executive turnover can throw the vision of the organization into a tailspin, but even moderate turnover at the middle of the organization can change the environment enough to cause variation sufficient to pose a significant hazard to the workplace.

 Disruptive Technology

A prime driver for change in an organization is disruptive technology.  Clayton M. Christensen Harvard Business School professor coined the term “Disruptive Technology” to describe a new technology that unexpectedly displaces an established technology. Most companies are successful because they have mastered sustaining technologies.  But disruptive technologies introduce hazards far beyond the changes brought by the technology itself.  Disruptive technology generally produces ripple effects that, owing to the organization’s lack of experience and familiarity with the nuanced nature of the new technology, can manifest in lethal hazards.


Drift is the natural tendency to move away from a standard or a norm.  When we drift we tend to believe that risks are justifiable and fairly benign—like driving a car and thinking yourself safe even though statistically the faster we drive and the longer we drive we will make dozens of poor choices, risky choices and errors.  Our subconscious minds experiment with ways in which we can drift from the norm; it makes us make mistakes to test the safety of quickly moving from one environment to the next. This process allows us to quickly adapt when our survival depends on it, but it also subjects us to the risk of injuries.

All these factors—from acclimation to drift—build to put us in harms way.  But the biggest thing we have to fear, isn’t, as FDR once said, “fear itself”, but the absence of fear.  We are often most at risk when we believe ourselves to be “safest”.

Filed under: Behavior Based Safety, Performance Improvement, Phil La Duke, , , , , ,

Mind Your Own Business: The Far From the Last Word On Building A “Safety Culture”

photo of the Diego Rivera Mall at the Detroit Institute of Arts taken by Phil La Duke

There is a nearly ubiquitous conversation ragging in the safety forums: how can one create a “safety culture” within my organization. This debate is troubling from a couple of perspectives.  First, there really isn’t any such thing as a “safety culture” the fact that people blather on about this topic shows a very deep ignorance of organizational culture.  Every organization of more than five people has a culture. In simplest terms, a culture is the codified collection of the norms, shared values, and rules of an organization. Cultures evolve to protect the organization’s interests and to determine what is acceptable behavior. In so doing, corporate culture makes it possible to govern the organization.

In some organization’s the corporate culture is so strong that changing from within is almost impossible, in fact, it is far more likely that a new hire will adopt the corporate culture rather than change it, no matter how strong the desire or ardently the new employee works for change.

I’ve studied corporate cultures and worked in OD for years.  I won’t bore you with a lot of pedantic excrement filled with a lot of jargon and theory, but if you want that, believe me there are plenty of people out there to fill your head with it.

Cultures are made up of shared values—kind of shared opinions of how important something is relative to the other elements of an organization.  Organizations tend to have a value of safety, that is, the organization places some value on safety relative to the other activities on which it can expend its resources.  Some cultures view safety as unimportant while others view it as of paramount importance, but all cultures place some priority on worker safety, and therefore, all organizations have a “safety culture” albeit some have a strong safety culture while others have a weak safety culture.

Even if a safety culture could be achieved (at some point it becomes a purely semantic argument) such a culture would neither be advisable or desirable.  A safety culture would mean that safety would be prioritized above all other business elements. Customer satisfaction, productivity, profitability, quality, and profitability all would take a secondary role over worker safety.  It sounds great, but in practical terms,  it doesn’t exist, nor should it.  No company exists primarily to ensure the safety of its workers.  In fact, most companies exist to make money.  This isn’t a bad thing; the safest companies in the world are the ones who went out of business because they didn’t make any money. Pursuit of a safety culture is a mish mash of Polly Anna idealism, cheap sales talk, and excuse making. (“I’ve done all I can; the culture is broken”).

As for the larger issue of a culture change, that may be necessary but that isn’t the job of the safety professional.  There are people with degrees in Organizational Behavior, Industrial Psychology, Organizational Development (OD), or other advanced degrees that qualify them to create culture change interventions. These people have years of Organizational Development experience before they are able to lead such a change; they aren’t safety professionals who have read a couple of books or attended a couple of speeches at a safety conference.   It’s been suggested that the skills of the safety professional and the organizational psychology field aren’t mutually exclusive; perhaps not. But just because someone read a couple of books about airplanes and has a flight simulator on his PC doesn’t make him a pilot. And frankly I would prefer a cardiac surgeon perform my coronary by-pass surgeon to a butcher, but effectively they share as many skills as a self-important puffed up safety huckster who believes—however earnestly—that he has the same skills as a professional skilled and experienced in OD.

So let’s shut up about creating a safety culture; it makes us seem even more out of touch than we already do.  We should however, foster an environment where safety is valued, but that isn’t a culture change, it’s a change in values.

Changing the values of an organization doesn’t take a whole lot of special skills.  A tenacious and conscientious safety professional can immediately start creating a heightened sense of value for safety within his or her organization.

Engage Leadership

I have written and spoken extensively on ways to engage leadership so I will just quickly summarize the key points here. In organizations that place a low value on safety professionals tend to have little or know credibility with the senior leadership in an organization.  Building credibility begins by speaking the same language and relating safety to the things that senior leadership find most compelling.  If the organization values sales above everything else, the safety professional should express the cost of injuries in terms of the amount of additional revenue it will take to replace the money spent on worker injuries.

Run the Safety Function Like a Business

Every safety function that is run like a business (i.e. the primary purpose of the function is to provide some service that is of quantifiable value) is much more likely to survive and thrive than those that are manage like overhead.  When the safety function sees itself as a for hire service provider it is far more likely to instill the kind of confidence required to build demand for safety.

Position Safety As a Partner In Improvements

For far too long, the safety profession has seen itself as serving a greater good that the rest of the organization, while the other departments busied themselves making money or improving quality, or making materials flow more efficiently, Safety saved lives. And while that is beyond important, it positioned safety as a parent and a policeman, but never a partner.  Safety became the smug outsider in the organization and then wondered why nobody trusted it.

But it doesn’t have to be like that, the Safety function plays an important role in bolstering operating efficiency (worker injuries interrupt production and make the operation less efficient), increasing profitability (worker injuries cost money), and creating a lean workplace (injuries are  waste).


Day after day I interact with safety professionals who deride leadership of their organization as indifferent or even hostile to safety.  These sad sacks talk in “us versus them” distinctions that make me wonder why they have jobs at all.  If safety professionals want to effect real change in how much value and priorities they have to be credible leaders not whiny crybabies who feel powerless to effect change.

People listen to those who have something to say, they learn from those who have something to teach them, and they follow people who are going to take them someplace better.  If you can’t these things for others there’s probably still important role you can play in worker safety, but shut up about culture; you don’t know what you are talking about.

Filed under: Behavior Based Safety, Performance Improvement, Phil La Duke, Safety, Safety Culture, Worker Safety, , , , , , , , , , ,

Does Safety Add Value?

As the function of Safety matures from a largely compliance based discipline to a continuous improvement based activity it’s important to recognize precisely the role of safety in the context of Lean, Six Sigma, or Quality Operating Systems, and central to that understanding is the concepts of waste and non-value added activity. Both these terms probably seem fairly familiar. We all have some idea of things in our lives that constitute waste but for the continuous improvement professionals. waste has a fairly specific definition. For people working to improve the capability of a process waste refers to the unintended outputs of a process that do not add any value to the products or services being delivered. Any process can be broken down into three components: Inputs, Transformations, and Outputs







The Basic Process The basic process works like this, we start with things, we do stuff to these things and we end up with things that have changed in some way. A process is like a recipe, and the inputs are our list of ingredients. But unlike a recipe our process will also contain a list of tools that we will need and a description of the physical environment (most good cookbooks assume you know that you will be working in the kitchen or at least at a barbecue grill). The process transformations are the physical forces acting on the inputs that change them in some way and create outputs. Every input changes in some way—dishes get dirty, workers get tired, kitchens get hot, appliances get a bit older and more worn (albeit sometimes imperceptibly). In fact, every input, whether man, machine, materials, and the environment, changes during our process. After the inputs have been changed transformed they become outputs, but not all outputs are desirable. And because they aren’t desirable the customer won’t pay more for them. Since the intrinsic value to the customer is unaffected by the transformation these outputs are described as non-value added activities, or more commonly, waste. Some waste is unavoidable (people tire, machines wear out, the environment heats up, etc.) while other forms of waste can be eliminated easily. Let’s take a look at a simple example, popping popcorn. We start with ingredients, equipment, a procedure, and someone to actually pop the popcorn:




 • A pan• A lid for the pan

• Cooking oil

• Unpopped popcorn

• Salt

• A Stove

• Natural Gas

• An electric starter

• A popcorn recipe

• Butter

• Salt

• A bowl

• A cook

• A kitchen

• A countertop

• Oxygen

• Lighting

• Heating


• Lighting

• Burning

• Melting

• Popping

• Cooking

 • A hot greasy pan

• A hot greasy lid

• Cooking oil residue on the wall and kitchen surfaces

• Popped, salted, and buttered popcorn

• Un-popped popcorn kernels

• Spilled salt

• A hot stove

• Consumed Natural Gas

• An electric starter that is slightly more worn than before

• Spilled Salt

• A dirty bowl

• A hot, tired cook

• A hot greasy kitchen

• A greasy countertop

• Consumed Oxygen

• Consumed electricity

Even though we only wanted one thing (buttered and salted popcorn) we had 16 (or more) outputs, and since we derive no benefit from these things they are waste. All of these outputs cost us money, whether directly in the case of wages or materials, but also indirectly in the case of money spent on cleaning products etc. But let’s assume for a moment that our popcorn chef accidentally burned himself. Do we derive any benefits from that injury? No and so it too is waste. If we insisted that the supervisor watch the popcorn chef and provide observations on his behavior and feedback on the safest way to do the job would that be something for which the customer would cheerfully pay? No. How about a incident investigation? Would a customer pony up for that? No. In fact, there is no safety activity that the customer will pay for in this scenario and why should they? Safety is not a value added activity, and frankly, any safety activity that doesn’t have a direct impact on the safety of the workplace is a waste. Now before anyone freaks out, there are a lot of non-value added activity that are necessary, and even desirable, including training, marketing, sales, and yes, safety. But the less a function changes the fundamental nature of the goods or services produced it is far more likely to produce waste. Let’s continue our example of the popcorn chef. If there are two companies providing popcorn and one has a less efficient process (that is, one has a lot more waste in his process than the competitor) the less efficient company has higher costs associated with brining its popcorn to market than its competitor. In order for the less efficient company to make the same profit as its competitors it will have to make up that cost somewhere else, either by paying lower wages, using inferior ingredients, raising prices, or skimping on cleaning supplies or work in a dirty kitchen. As the company with the inferior process continues down this path, its customers are far more likely to react negatively. Customers will not pay more for an inferior product or service simply because you can’t get your act together. They are far more likely to take their business elsewhere. Functions that improve the efficiency and capability of a process, while not value added activity, eliminate waste in the process and in so doing lower operating costs and allow the company to invest in marketing, training, safety, recruiting the best talent, upgrading materials and dominating its industry. For many safety professionals, it can be difficult to see how what they do impacts the bottom line, but by looking for ways to eliminate waste—in the core operational processes and in the Safety function itself—we can cut costs in ways that everyone can agree will benefit not just the company’s bottom line, but also the worker’s job satisfaction and quality of life.

Filed under: Loss Prevention, Performance Improvement, Phil La Duke, Safety, , , , , , , , , , ,

An Inspection by Any Other Name

I’m often asked by people both inside and outside the safety discipline the difference between an audit and a safety inspection. An audit is typically annual (or semi-annual) activity conducted by safety professionals to ensure compliance with safety regulations and internal policies. An auditor typically has a check list of items that need to be verified or assessed, and audits are usually done by either an internal safety professional or an external governmental agency. Audits are reactive. Audits are a “gotcha” that ostensibly is performed so that the safety professional—whether an internal department or OSHA, the Minister of Labour, or some other governmental agency—can coach the organization.  In fact most audits result in negative consequences and for the most part they are feared and detested, and in the majority of the those cases rightfully so.

Safety inspections are regular, proactive activities that are designed to identify workplace hazards and contain/correct them before an individual gets hurt. Safety inspections are conducted by first line supervisors and/or representation (in Union environments) and use a problem-solving, failure-mode (anticipating what could go wrong) approach. Inspections are proactive. The problem with safety inspections is no matter what you call them (and there are myriad names for essentially the same activity) people associate safety inspections with some negative outcome like those associated with audits.  The result is a well-intentioned buy largely simple minded attempt to rebrand the safety inspection to take away the sting associated with it.

In healthcare, Safety Rounding is growing in popularity.  Safety Rounds are safety inspections that are adapted for use in matrix organizations. Like Safety Inspections, Safety Rounds are regular, proactive walk-thrus, but instead of first-line supervision conducting the rounds, volunteers take on the responsibility in addition to their normal jobs. The goal of a Safety Round is the same as that of a Safety Inspection, but Safety Rounds focus parallel the “Environment of Care” requirements of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) audits. Unfortunately, the volunteer brigades tend to attract gung-ho staffers who don’t have much to do or who are shirking their core responsibilities in favor of the new assignment.  But even the best intentioned volunteers lack the authority to hold the people responsible for getting hazards corrected and in a short time the volunteers lose interest, become frustrated, or otherwise become ineffective.  I’ve seen the same thing happen in lean implementations where 5S teams were staffed by volunteers; without the power to force the first line supervisor to correct issues the same items are identified week after week, month after month.

But Safety Rounds aren’t without value.  In fact, in places where the manager that owns the area is held accountable, Safety Rounds can be extremely effective.  Safety Rounds tend to be more holistic than Safety Inspections and often those conducting Safety Rounds will ask hospital staff questions to determine the effectiveness of required safety training.  Safety Rounds may well be tied to Patient Safety, and when it is, the effectiveness tends to increase expontentially.

In Lean Manufacturing environments (which believe it or not aren’t restricted to manufacturing these days) Safety Inspections can be embedded into Layered Process Audits.  from 2008 to 2009 I spent one week a month for 15 months working with a manufacturer in Mexico to completely integrate safety into their manufacturing operating system.  One of the major breakthroughs that we made was the integration of the safety inspection into a layered process audit.  This had a profound impact on the effectiveness of the safety inspection because a) it met the requirement that a Layered Process Audit be conducted weekly and b) it documented all the process flaws into a database that made it easy for maintenance (or other departments) to correct the flaws.

Perhaps the most useless bastardization of a safety inspection is the safety observations.  Safety observations are based on the belief that if a supervisor watches someone working he or she can identify unsafe work practices and provide feedback to the worker on how to work more safely.  This practice overlooks many scientific principles that make it an expensive waste of time.  For starters safety observations assume that workers perform their tasks the same way every time they do their jobs and that the act of being observe will not alter the worker’s performance in any way.  Years ago I worked in an automobile factory assembling seats.  Once a year the engineers would do a time study where they would come and watch each operator work and count the steps involved in a given job.  Knowing that the engineers were likely to heap as much work as they possibly could on a job the operators would routinely add steps, slow their pace, and other wise queer the batter by providing the observer skewed data.  But even in cases where operators are not trying to confuse the results, the fact that their bosses are watching over their shoulders are likely to make the operators take more time to do their jobs and work more safely.  Unless an organization intends to pay someone to watch every operator every moment of every day, it’s not likely that the observations will bear much fruit and it’s highly likely that they will add costs and ignore variation in human behavior.

Some organizations have taken to calling the safety inspection a safety tour, and in so doing soften the stigma of an inspection.  I suppose that if renaming the activity makes it less threatening then we should by all means rename it.  My personal preference is to call it a Process Integrity Analysis, and I would not limit it to safety.  We have to do a better job integrating safety into the work processes, and stop calling safety out as a separate and discrete activity.  A Process Integrity Analysis should include analysis of process capability and reliability, quality, total productive maintenance, 5S, and Job Safety Analysis.  By examining a process holistically an organization can lower injuries, boost productivity, and increase quality.  If we position the “Safety Inspection” as just another element of process improvement Operations will stop viewing safety as an interruption of their jobs and start treating it as a critical discipline that drives productivity.


Filed under: Performance Improvement, Safety, , , , , , , , , , , , , , , , , ,

Clarifying the Idea of a Safety Culture

In the December edition of Facility Safety Management magazine I penned an article on Just Culture  ( ).  As I do with all my articles I post them in safety forums and ask for the community for their comments and feedback; do so helps me to improve as an author and to explore more deeply some of the themes that I initially post here.  One flows into another and back again.

In my most recent article I explore the dichotomy between Just Culture and the very real need to hold some employees accountable for their unsafe behaviors.  I don’t want to rehash the article here (if you think it would be of interest to you, than I encourage you to follow the link and read it, or better yet subscribe to the magazine.)

While all of the posts were positive and supportive of the positions of the article, (such is not usually the case) there were a couple of posts that surprised and concerned me.  I have talked ad nauseum about how tired I am of safety professionals parroting the “we need to change the safety culture” mantra du jour.  I am weary of people who don’t have a clue what culture even means talking about how we had oughtta do something, but I won’t revisit my feelings here and grouse about it anymore than I already have.  I would like to focus on the very real need for safety professionals to stop trying to change the safety culture.  It’s impossible.  Why? Well for starters there really isn’t such a thing as a “Safety Culture”. All organizations with more than 6 employees (this is the number where group dynamics tends to kick in) has an organizational, or corporate culture (I would define culture as the shared values and goals of an organization or to make it simpler—but perhaps less clear—culture is “how we do things around here”).  The degree a company values worker safety is a part of the corporate culture, but it is not a discrete element.  I don’t want to come off as pedantic or as if I am splitting hairs, but it is important to remember that safety (or lack there of) is only a segment of a larger whole.  Show me a company that doesn’t care about the safety of its workers and I will show you a company that likely has little regard for other process failures—like scrap, poor quality, or even customer satisfaction.

The opposite of a safety is not production.  Companies that have immature manufacturing systems have poor quality, injure workers, high scrap rates, and waste a lot of money.  Companies that seem to tolerate an unsafe workplace really tolerate poor business systems and process variation.

As long as we ask organizations to chose between safety and their core businesses (i.e. production) we will perpetuate the myth that a company can’t efficiently increase production without jeopardizing safety.  We as safety professionals need to help to foster a continuous improvement culture where injuries are a waste and a symptom of a process that is out of control.  By positioning safety as a means of increasing the organizations ability to produce more efficiently (injuries cost money and disrupt production—just recording the downtime caused by injuries can open the eyes of some old school production leaders) we can change the perception of the safety professional from that of a policeman or impediment to production to a key resource that helps production to run more smoothly and that helps to save money.

Unfortunately, many safety professionals still position safety as at odds with production, profitability, and efficiency.  Commercial enterprises (both for profit and not for profit) exists at least to make money; it’s a primary concern.  For profit organizations make money for their share holders and owners.  Not-for-profit organizations make money because unless they do so, they will not be able to serve the common good.   Money is the life blood of our world, without it organizations collapse.  If safety professionals want to continue employment in a capitalist society they have to accept the fact that safety is NOT the number one priority nor should it be.  Making money is the number one priority, but that doesn’t mean that organizations can turn their back on worker safety. In fact, companies that truly understand process efficiency understand most fully that worker injuries are the worst kind of waste and that an organization cannot be successful for long unless it makes every sensible effort to protect workers.

Instead of working to improve the “safety culture” safety professionals need to focus their efforts on areas that they can control, and those areas may surprise many safety professionals.


Before continuing, I should disclose that much of my background is in training, much more so in fact than safety.  I hold a Bachelor’s degree in Education and a certificate in Training, Design, and Development.  So it’s, I think, fair to say that I am biased in favor of quality training.  I am of the belief that the most important training in terms of protecting workers is not the traditional “safety” training.  This is an area that I explored at length  in my article, What’s Wrong With Safety Training and How to Fix It. (see the link on this page).  Traditional safety training is almost exclusively compliance based (we do this training because we are legally required to do so) and much of it is limited in scope to showing a video and reading a standard.  In the purest sense, it isn’t training.  But a well-designed and training course that provides mastery-level skills to workers is the best protection against work-place injuries. Assuming that our processes are capable (that is, they are working as designed) and are not inadvertently placing workers at risk than training that ensures the worker can do the job within the process should offer the best protection.  Unfortunately, most of this training, if it exists at all, is typically informal and is not the responsibility of the safety professional.  Safety professionals can, however, point out deficiencies in training that raise the risk of injuries.  This sounds like a harder sell than it need be: poorly trained workers are also more likely to slow production, have higher scrape and defect rates, and create other costly production problems.

Awareness Of the Relationship Between Safety And Productivity

Operations tend to focus on production.  Whether your organization builds widgets, treats sick people, provides professional services, or distracts rodeo bulls from goring a fallen rider, time is of the essence.  The faster you can provide those goods or services without incurring other costs the more money you can make per good or service provided; in business terms we call this “productivity”.  A key to fostering a culture that values safety is to capitalize on its value of productivity.  This is both easy and difficult.  On one hand it’s easy to capitalize on the value of productivity by positioning safety as a time saver rather than a time consumer, but I will return to that point in a moment.  On the other hand, some corporate cultures don’t seem to value productivity, in which case it’s tough to sell safety on that basis.  But most organizations value money and so one can generally build an interest in safety by demonstrating the effect a safety initiative has on the bottom line.  It’s also true that there are some cultures out there that don’t seem to value safety, productivity, or even money; if you find yourself working there get out.  A corporate culture that has no regard for money—even not for profit organizations—are run by imbeciles that will ultimately run the business into the ground and you will never be successful making rational arguments to the leaders of these organizations; get out and get out fast.

Linking safety to productivity is simple, but to do that you have to have some idea as to what productivity means. In most basic terms productivity is the time it takes to produce one unit of whatever you are delivering typically expressed in “per hour” increments, for example 100 automobiles per hour.  Efficiency is more complex, but in the interest of simplicity, I will just say efficiency is the cost of productivity; the greater the cost the less efficient a process is.  “Waste” is a term used to describe anything that costs money but does not increase the value of the goods or services (the customer will not more for the good or service simply because money was spent on these things.)  So in this sense injuries adversely effect efficiency in multiple ways.  First, injuries disrupt production which means the rate of production slows (because time is lost it now requires more time to provide the good or service). Second, injuries cost money (and the costs here are fairly well defined and yet often ignored) both in direct costs (medical treatment, fines, wages paid to injured workers, Workers’ Compensation costs etc.) and indirect costs (insurance premiums, Workers’ Compensation reserves, legal fees, etc.). And third, in some settings (food manufacturing, chemical manufacturing, retail, logistics) the injury may contaminate inventory and create even higher costs.  All of these factors drive up the cost of production, increase the cost of doing business, and reduce the organization’s operating efficiency.  If a safety professional captures and advertises the connection between safety and productivity and efficiency he or she will advance the cause of safety far more effectively than by squawking about the need to change the safety culture.

contingency planning and prevention

I am an outspoken advocate of prevention.  I have publicly stated my ardent belief that given enough time and information all injuries can be prevented.  But there is a big difference between the possibility that all injuries can be corrected and the possibility that all injuries will be corrected.  In some cases, things will still go wrong despite our best efforts to prevent them.  In other cases, the cost associated with preventing a failure mode is so excessive that it is completely impractical to try.   In still other cases, the possibility of an injury is so remote that efforts to prevent it are foolish and seen as overkill.  In all these situations, we have to have contingencies to reduce the impact of a process failure.  Contingencies are all around us and have been a big part of safety but many of us have forgotten about them and how useful they can be.  Fire extinguishers don’t prevent fires, rather they are contingency tools in case there is a fire.  Fire extinguishers help us to make sure we can control the fire (if not put out the fire  all together) until people can reach safety.  Similarly, tornado drills don’t prevent tornadoes, rather they are designed to reduce the likelihood of an injury caused by the tornado.  Safety professionals who do a better job distinguishing between preventive measures and contingency measures will do a better job of convincing the organization of the value of safety than those who err on the side of prevention.  We must always remember how the costs of prevention and contingencies effect the operating efficiency of the organization.

I know I am hard on safety culture, and I know I am hyper critical of the providers of “culture-based” safety solutions (and for the record I believe I was the one who coined that term although I rue the day I did) but if we are going to survive as a profession we have got to stop whining about a broken culture.  It’s time to  roll up our sleeves and partner with Operations to increase operating efficiency by increasing the safety of our workplace.  As safety professionals we have the opportunity to create the biggest increase in operating efficiency since the invention of the assembly line; it’s time for us to bring our skills to bear not just in the name of worker safety or corporate responsibility but in the name of process improvement; it’s time for us to lead.

Filed under: Behavior Based Safety, Performance Improvement, Phil La Duke, Safety, Safety Culture, Worker Safety, , , , , , , , , , , , , , , , , , , ,

Requiem For Prevention

I am a loud and ardent supporter of prevention.  In fact, I spent the last 6 years shilling a safety system based on six values, one of which was “Prevention is more valuable than correction.” Given my vocal, some might say obnoxious advocacy of prevention, one might be surprised to learn that I believe that in many cases prevention has gone overboard and that in many cases companies would be better served by doing LESS prevention and more contingency.  Heresy? Consider the  organization that spends tens of thousands of dollars each year preventing accidents that would likely have little or no chance of ever happening.  These companies have 20-person safety committees that meet once a week to argue about why an over burdened maintenance department hasn’t fixed a low-priority hazardous condition.  Prevention cost money and resources that may well be better spent elsewhere in the organization. Equally damning, are organizations that continue funding Behavior-Based Safety Systems that unnecessarily add heads, complexity, and cost to preventing injuries in the name of preventing one of the most prevalent and insidious causes of injuries in the workplace today: human behavior.  Unfortunately, these systems seldom deliver what they promise (i.e. a lasting change in human behavior) and can actually impede important business processes and the delivery of goods or services in the misguided attempt to control human behavior; it can’t be done, so stop trying.

That’s not to say that I am advocating a return to reactive safety practices, far from it.  What I am saying is that there is a time and a place for prevention, but prevention is not a panacea.  Simply put, you can’t prevent every accident, and in some cases you should be looking at what to do to protect workers when your best efforts to prevent an accident fails.

Variation in Human Behavior

As organizations, we’d all like to think that we hire smart, capable people, and for the most part we do.  We spend days (and thousands of dollars) screening candidates we ask them probing questions to find out how they reason, how they solve problems, how they think.  We do back ground checks and asks professional references whether or not the candidate is a worthwhile candidate.  We screen the candidate for illicit drug use, criminal misdeeds, and the things in life that indicate that whether or not the candidate has sound judgment. So we confidently hire the candidate and invest time and money training the new hire so that he or she can meaningfully contribute.  And then it happens.  The person that we spent so much time screening and training gets hurt and we think to ourselves, “if only that idiot would have…”  Huh? Now because the employee got hurt he/she’s suddenly an idiot?  You may read this and think that you are immune to such thoughts, but the majority of the people I hear describing injured workers as idiots are safety professionals.

They Call Them Accidents For A Reason

As much as we would like to assign accountability for injuries, the fact remains that in almost all cases whatever happened to injure the person was unintentional, or at very least, the person who committed the unsafe act didn’t fully comprehend the potential consequences of his or her actions; the accident was an unintended outcome; in short, the injury was an accident.  Accepting that things will go wrong, that people make mistakes, is a bitter pill to swallow.  We are taught to believe that making mistakes are bad, subject to punishment, and indicative of poor judgment or out-and-out stupidity. But everyone makes mistakes—we learn by trial and error and without mistakes there can be no learning, at least not organic learning that lasts.

Everyone Makes Mistakes, But No One Should Have To Die Because of A Mistake

I’ve read (I can’t remember where) that the average person makes 5 mistakes an hour. Multiply that by the 2080 hours in the average work year and you have a boat load of mistakes.  Some theorize that because biologically speaking change is reckless and dangerous (nature tends to have a “if it aint broke don’t fix it’ approach to survival; if a species is thriving it resists change.  In fact, change is so dangerous, that our bodies are hardwired to resist it, when we are confronted with change it triggers our flight/fight response and causes us stress.  Conversely, species that are unable to change are unable to adapt to changes in their environments and are driven to extinction.  So it would appear that we are damned if we do and damned if we don’t.  But if the research that found that the human brain will make 5 mistakes an hour is correct what possible advantage would there be in these mistakes?  Making tiny subconscious, non-cognitive mistakes could be our brain’s way of testing the environment by disrupting our routines in small ways.  If the mistake leads us to a better way of living we make serendipitous discoveries and innovations but if the mistake leads to an undesirable outcome we see it as an error. But in both cases our brains learn about the safety of deviating from its routine and we are better able to safely adapt.

Variation Leads To Errors

Experts in quality, particularly in manufacturing, cannot emphasis the danger of process variation strongly enough; when the process varies things go sour very quickly.  Manufacturing and process engineers have made huge strides in reducing mechanical variation, but the variation endemic to human behavior is so pervasive that it’s all but impossible to eliminate it, or substantially reduce it.  Outside of the military (and quasi military—police, security, etc.) it is very difficult to control human behavior.  Even variation in cognitive behavior is difficult; how many companies have problems with poor attendance? Certainly at least some of the causes of absenteeism are cognitive decisions where the offending employee simply chose not to come to work.

Focus On Contingency Not Prevention

Okay, relax.  I know that I preach prevention above all things, but when it comes to variation in human  behavior you just can’t prevent most of it.  And to make things even more complicated, human behavior can be very tricky to predict, and even more difficult to prevent.  We have to stop pretending that all our problems can be solved through preventive measures; sometimes—despite our best efforts—things go awry and when they do we had ought to have some contingency in place to prevent a mishap from becoming a disaster or a tragedy.  When it comes to contingency versus prevention it doesn’t have to be an either or decision.  I used to teach problem solving and we used a very simple tool for determining whether to use a preventive countermeasure or a contingency countermeasure.  We would rate both the probability and severity of an error in terms of high, medium, or low.  If the probability that the particular failure mode (engineering speak for a screw up) is high—in other words it is almost certain to happen under the given circumstances—then one should definitely find a preventive action.  If the probability is low (fairly remote, but possible) one would need to temper the response after considering the time and money it would require to implement.  Similarly, if the failure mode’s severity was high (if it DID happen the consequences would be severe) than one would have a contingency in place to protect workers, property, and inventory.  Of course if the severity was expected to be low one would again determine whether the protection offered would be worth the cost of the required resources.

Because one rates the severity separately from the probability, one ends up with two scores that must be considered together.  Certainly if the probability is high AND the severity is high one would implement both preventive and contingency controls.  On the other end of the spectrum, if both the probability and severity were low, one would likely only take action if the countermeasures were cheap and easy to implement. But the scores that are in between (medium probability and low severity, etc.) are subject to a lot more judgment-based decision making. This may seem like a serious weakness to some, but on the contrary, this subjectivity allows an organization to customize it’s countermeasures to its unique environment and situation.

Filed under: Behavior Based Safety, Loss Prevention, Performance Improvement, Phil La Duke, Safety, Safety Culture, Worker Safety, , , , , , , , , , , , , , , , ,



Guest blogs

La Duke in the News


Press Release

Professional Organizations


Safety Professional's Resource Room

Social Networking


Web Resource


Get every new post delivered to your Inbox.

Join 1,110 other followers

%d bloggers like this: