Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

Indicators Are Meaningless Unless They Lead to Managing Performance

broken cross

By Phil La Duke

You don’t get great outputs by managing results, you get great outputs by managing performance such that you produce great results. In safety we have spent a century trying to manage outputs and we wonder why our results are less than spectacular. To be sure safety has improved over the past hundred odd years, but this week marks the anniversary of two big events that serve both as an important reminder of how much we have accomplished and of how much work we have yet to complete. March 25 is the anniversary of the Triangle Shirtwaste Factory fire that, in 2011 galvanized the nation and opened the eyes of many about the unsafe working conditions in industry. March 23 saw the anniversary of the explosion and fire at BP’s Texas City refinery. So while a lot has changed and improved in safety Texas City (and the Gulf spill) shows us that we have to be ever vigilant. I won’t draw any more comparison between the two events—to do so would be unfair because there is little similarity between them except that they were safety disasters that killed or injured over a hundred people most of whom did nothing more unsafe than reporting to work that fateful day. But one thing they did have in common is that when it came to safety they managed outcomes. They absolutely made changes to the workplace in light of their respective disasters. They continued as they had done for many years; they managed outcomes.

Most of us continue to manage outcomes despite our fascination with leading indicators we still tend to manage in response to something that has already happened; we react, sometimes without even realizing it. There is an emerging debate as to whether serious injuries/fatalities have the same root causes as more minor injuries and first aid cases. I don’t think that’s the case, that is, I don’t believe that causes of fatalities are significantly different than the causes. What I DO believe is that we tend to be able to reduce minor injuries by managing outcomes but can only prevented by managing performance, not by managing outcomes.

I’ve written about five areas that, if managed properly, will produce safe outcomes. Just to refresh your memories these are:

  • Competency;
  • Process Capability;
  • Hazard and Risk Management;
  • Accountability; and
  • Engagement

To manage our performance in these areas we have to have leading indicators that meaningfully equate to actual peak performance in these respective areas, but also we need to act on the leading indicators to improve performance.

Let’s take a look at just one area for example; the first area where we need to manage performance is competency. When we put people in jobs for which they are not physically or mentally able to perform—not just at the date of hire but through the length of their employment—we put them at risk of acute injuries, long-term ergonomic issues, and of causing other workers to be injured as well. Even if we select workers aptly suited for the tasks we must train them to mastery-level skill level and ultimately we must make periodic assessments of the workers’ continued fitness for duty.

So essentially we need to manage three areas (minimum) for competency: 1) recruiting and screening 2) training and 3) performance management. Unfortunately, most safety practitioners aren’t qualified to judge the effectiveness of any of these areas, so they will have to work with other areas to develop metrics that measure not just whether or not something happened, but also how effective it was. For example, while the number of people trained on time is an important indicator of the importance placed upon training by an organization, what if the training is ineffectual? What if the training is poorly designed “death by PowerPoint” dreck? I’m afraid that we have gotten so enamored with indicators that we have forgotten that the point isn’t a binary “was it done or not?” but to analyze the indicators and intervene. Sure it’s important to know whether or not people received training before they are expected to work production, but it is as important (arguably more important) that those trained are trained effectively.

Leading indicators without any analysis of what the data is telling you and without any intervention to improve the activity is like taking attendance on the Titanic. Sure it’s important to have everyone accounted for, but if you don’t get into the lifeboats there is scarce little value in the exercise.

Many people complain that they can’t find the right leading indicators. Others complain that leading indicators don’t seem to be effective at preventing fatalities. In my experience both complaints are valid. If you don’t have the right indicators, and by the right indicators I mean indications that one of the five areas I mentioned above, you aren’t likely to get good results and if you don’t manage the performance in these areas you may even make matters worse.

To make managing performance for safer outcomes a reality the safety function must partner with other functions to enable and enhance operations. By partnering with groups like Human Resources, Training, and Continuous Improvement the safety function makes the entire organization more effective. As Safety contributes to the overall success of the organization its credibility and influence in the organization will grow and the safety profession will get the respect it deserves.

Managing performance is bigger than safety, in fact managing the five areas will produce more than just safe outcomes it will produce success.

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Joe Safety and the Infinite Toolbox


By Phil La Duke

Last week I had the sheer audacity to question the value of safety slogans in lowering risk and improving the safety of the workplace. The reaction was mixed but passionate. The reaction didn’t surprise me; after all, I frequently question the status quo, but something in the reaction did intrigue me. Safety professionals who disagree with my position but often construct a non-argument that x is a tool and like all tools there is an appropriate time and place and why would I dare condemn the tool simply because someone misuses it. “You wouldn’t throw away a hammer simply because someone misused it, would you?” one asked me. No matter what I question someone weak defender will simply shrug and say “it’s a tool…”

Improper Tool Use

As safety professionals we often warn workers of the dangers of the improper tool use. I know of many workplaces that have prohibited homemade tools, box cutters, and a host of other tools either because the tool isn’t designed or approved for the intended use (it’s out working out of process) or it has been designed and fabricated by someone who wasn’t qualified to do so. To be sure, some tools are absolutely too dangerous for most workers to use and safety professionals are wise to advise Operations to ban them. Not all tools are benign and some our out-and-out dangerous.

Of course the people who sell box cutters will tell you that a box cutter, if properly used, is no more dangerous than a safety knife with a self-retracting blade and they may be correct, but isn’t the point of the hierarchy of controls to substitute the unsafe tool (or a tool that could be misused and put the worker at risk) with something more appropriate? Why is it any different with outmoded thinking, the “tools” that we keep in our toolbox despite the fact that good sense tells us there are better, more effective ways of getting the job done?


If hand and power tools can be come obsolete why is it so hard for us in safety to accept the possibility that our most cherished tools may too someday become obsolete, if they haven’t already done so? Bloodletting was one the height of medical technology and more recently mercury was used to treat syphilis. History is full of scientific and technological dead ends and you can bet that wherever there was a dead end there was a crowd of people whose livelihoods depended on these technologies railed against the new technologies as unnecessary and who swore that it makes no sense to abandon a proven technology just because something is better.

A Double Standard

It would seem that when it comes to tools we safety professionals have something of a double standard. Tools that others use—box cutters and the like—can be easily cast away as dangerous, or outmoded, but then it’s tough to form an emotional connection to a box cutter. Unfortunately, many of our safety tools are based on the flawed premise that: a) the clear majority of injuries are rooted in unsafe behaviors b) these behaviors are deliberate and conscious and c) we can somehow modify these behaviors and control a population. Most tools and practices that I have called into question are rooted in this flawed premise. I will concede that the majority of injuries are caused by unsafe behaviors in fact I would go so far as to say 100% of injuries are caused by unsafe behaviors (if people aren’t doing anything they can’t be harmed, and if what they do harms them than by definition the behavior was unsafe). Okay, but so what? We haven’t exactly discovered the God particle here.   Where I take exception is the belief that these behaviors are deliberate and conscious and that we can somehow modify these behaviors and control a population. Safety incentives that are based on injury reduction, zero injury goals, behavior observations, and safety slogans are all rooted in the beliefs that most unsafe behavior is deliberate and if we just remind people to work safe we can eliminate injuries.

But not all behavior is deliberate. Human fallibility lays at the heart of being human nobody’s perfect and to use tools that assume that people will not make mistakes (or even behavior predictably and rationally) is dangerous and stupid. Furthermore, people will inevitably take risks and many of those risks will be uninformed and/or foolish, no amount of behavior modification will change that. Should all these tools be thrown on the trash heap? I think so. Not because they are occasionally misused by a rare few, but because they are fundamentally flawed and habitually used and perpetuated by a large portion of the safety profession. Are they dangerous? I would have to say yes. Organizations only have so many resources to deploy and if they waste valuable time, money, and energy on snake oil and obsolete tools they put workers at risk. Some tools don’t belong in our toolbox.

Filed under: Safety

Safety Slogans Don’t Save Lives


By Phil La Duke

It’s tough to bring professionalism to a trade that actively looks to make itself look stupid.  There’s only so many hours in the day and only so many resources and if we are wasting either it’s tough to go to the well and ask for help and money. And let’s face it, as safety professionals we to love make fools of ourselves.  On one hand we are perpetual victims, unloved, over-worked, and most of all, under-staffed and under-funded. On the other hand we spend our scarce time and meager resources doing things that don’t reduce the risk of injuries, reduce our operating costs or do really much of anything.  Chief among the waste of time activities that make us look soft- headed goofballs that are completely out of touch with any semblance of reality is the creation and promotion of safety slogans. What is the purpose of safety slogans? Deming specifically signaled out slogans in his tenth point for management, “Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force.” Do safety slogans create adversarial relationships? In way they do.  The fact that we post safety slogans imply that were it not for our little gems of wisdom the great unwashed would stick their entire heads in the machinery.  At their worst, safety slogans patronize and demean the worker.  Am I stating things to strongly? I don’t think so.  Safety slogans don’t raise awareness of safety; it raises and reinforces the awareness that safety professionals think themselves superior to the people who turn wrenches for a living.  It widens the gulf between blue and white collar. And while safety professionals may not recognize Deming for his genius, I think he hit the nail on the head with this point.  If we believe that all but the rarest injuries are the result of either unintended actions (human error/accidents) or poorly calculated risks, then a pithy saying isn’t likely to have much of an effect.

Safety First

Who among you has ever read a safety slogan and thought, “holy crap, I’ve been approaching my life completely wrong, I’m completely turned around on this. I need to make some changes”.  The long and the short of it is that safety slogans serve no purpose, offer no benefit, and yet we devote precious time and money to thinking them up, launching campaigns around them, and promoting them as if they were a crucial part of our efforts to lower risks.

So Why Do It?

Why do we persist in engaging in an activity that does nothing but make us look ridiculous in the eyes of the organization.  And make no mistake, thinking up safety slogans doesn’t garner safety professionals the respect or esteem of the organization simply because they coined the phrase “Safety: It’s Better Than Dying”.  We do it because we like it, and we never asked the question, “is this activity in the furtherance of safety?” Sometimes misguided executives press us to come up with a slogan and eager to curry favor, we rush forward in an orgy of sycophantic fervor, delighted at the exposure to the C-suite.  Trust me when I tell you this is exposure you can do without.  As uncomfortable as it may be, we are better served by declining this request and fetching coffee and bagels instead.  Exposure that perpetuates the C-suite view of safety as simpletons who you call when you want something a kindergarten teacher would refuse to do.  Far better to explain to the executive that your finite time would be better spent engaging in an activity that would return real business results.  Not a lot of safety professionals would feel comfortable speaking up to an executive, but your first interactions with executives set a tone for the relationship; do you want to be taken seriously? It begins here.

What’s Wrong With Having A Little Fun With Safety?

When I have railied against safety slogans before, I invariably get some soft-baked safety guy roll his eyes, smirk and ask, “what’s wrong with having a little fun with safety?”  I am something of an expert in fun (I have had fun that will forever keep me out of any elected office, has gotten me barred from entire countries, and damn near got me killed on multiple occasions), and I am here to tell you that if you think that coming up with safety slogans is fun you are out of your mind; you are doing “fun” completely wrong. I wouldn’t even categorize thinking up safety slogans as amusing or as a brief respite from mind crushing boredom. Let me be clear: I think safety slogans are stupid and make us look like simpletons.  Deming was right, we have got to get rid of them.

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Bill Sagy, the Safety Pioneer You Never Heard Of

By Phil LaDuke

The world works in mysterious ways. This week I wrote an excremental piece that after having written it decided that it never really came together. Sometimes writing is like that. I didn’t panic; this wasn’t writer’s block this was just one of those things that occasionally happen when one writes in the neighborhood of 10,000 words a month. Sometimes it’s a piece I can be proud of and sometime it’s dreck that should never see the light of day. And besides, I had a 3 hour + drive from my home in Detroit to my office in Holland, MI. Driving is a good time to think and there are ample examples of imbeciles taking unreasonable risks.

When I stopped to gas up I took the opportunity to check my messages and got the news. Bill Sagy was dead.

The vast majority of you have never heard of Bill Sagy, and why would you. The work he did with me was confidential as were the amazing results he and I achieved for our clients. I created a system and Bill implemented it. I was the corporate visionary and Bill was the executioner. Originally from the Youngstown Ohio area, Bill was a southerner who by accident of birth was born in the North. When I first needed a coach (I had been doing a duel role as project architect and process coach on engagements prior to this) I reached out to Bill. Bill was working as the quality manager for Mitsubishi in Normal Illinois when I called him to see if he knew anyone “who has a quality background and was willing to work in the South”. He said in his classic deliberate drawl “Yeah, me.” I laughed and told him to think about it and call me back if he came up with anybody. A couple of days later he called me and told me that he was serious.

I couldn’t believe my luck. Bill was an incredible find. He and I first met in 1996 when he was a team lead at GENASYS a joint venture between General Motors and American Sunroof Corporation (ASC). Bill was tagged for the assignment because he had come up through the ranks, beginning his career as a steel worker and Union man in his hometown. Bill eventually rose to the rank of plant manager of our Doraville Georgia plant where him and I got to be really good friends (I was head of Organizational Development and Training). I will spare you the details, but Bill and I had tremendous success in converting a workplace that was primarily comprised of warehouse workers with no manufacturing experience into a high performance workforce. I left ASC to join O/E Learning where I brought my knowledge of culture change to bear on the UAW-Chrysler BEST program that transformed Chrysler’s safety program (research it, it is pretty remarkable what UAW-Chrysler was able to achieve and most of it has been published or presented at professional conferences.) Eventually, I would lead the effort to create SafetyIMPACT! a generic safety transformation methodology that would have incredible results in its own right and for that I needed help. SafetyIMPACT! required a coach; someone who would spend time on the customer site helping to manage the emotional side of culture change. I didn’t want a behavioral scientist who had never seen the inside of a factory and I didn’t want a safety guy who would get too bogged down in the way things are supposed to be to go. I wanted a quality guy, someone how understood Deming and lean and someone unafraid to take chances. That was Bill. While was a bull in a china shop Bill was the stoic and staid implementer. I would dream something up to solve a customer’s problem and Bill would make it work.

Bill never got much credit; it wasn’t his style to take it. Whenever people would compliment him or give him kudos he would just shrug it off and say, “I didn’t do anything, it was all Phil’s idea”. Above all others, Bill never appreciated his contribution. When one North Carolina plant manager called me a “used car salesman” (I tend to talk and act too fast for many in the South) they took comfort in Bill’s affableness and slow, deliberate approach felt familiar and comfortable. You can’t fake that. One of my customers (and friend) once told me that when his wife asked how dinner was Phil went he said, “oh it was good, but you spend time with Phil it seems like eventually it turns into a commercial”. People didn’t feel that way with Bill. Bill was a good ole boy in the most positive sense of that word. He genuinely cared about people was able to get people to care as well without ever coming off as self-righteous, preachy, or softheaded.

If Bill were here today he would probably shrug and tell you that I taught him everything there is to know about safety culture transformation, but as much as I may have taught him, he taught me much and more. Working with him allowed me to take our model of safety transformation to the next level and beyond. He and I were in the process of putting together another deal that would have reunited us as a team. It’s a moot point now, but it will always leave me thinking “what if?”

At this point, the doctors aren’t sure what killed Bill. In directly it may have been his job that killed him. Years ago, Bill hurt his back on the job. He worked through the pain because the damage to his disc was too dangerous for surgery. Recently, after decades of on again off again pain Bill went in for laparoscopic surgery to have the disc repaired. When I spoke to him about three weeks ago he was recovering and looking forward to working with me again. It’s not yet known how he contracted the bacterial infection that would kill him, but I suspect (with no foundation whatsoever beyond the coincidental timing) he contracted it via his surgery. If it did than Bill died from a work related injury that, like countless thousands of workplace injuries and illnesses that will never be recorded as job-related. Maybe injuries aren’t declining after all. Maybe they are just taking longer and longer to kill workers. I’ll miss Bill, but I am more fortunate than you. I had the fortune to work with Bill and count him as a friend.

Filed under: Safety

I Factory Rat

By Phil La Duke

This week I conclude my series of posts on safety as an outcome. I began these articles by asking you to rethink safety; to think of it not as a discreet element unto itself, but as the outcome of well-managed business systems, particularly in the areas of competency, process capability, risk and hazard management, accountability, and engagement.

Engagement is one of those words that softheaded HR folks use that makes me nervous. It’s not that engagement isn’t important, in fact, it’s critical, but as Dr. Paul Marciano points out in his books Carrots and Sticks Don’t Work and Super Teams true engagement begins with respect, and I am here to tell you respect is in short supply.

Empowerment, employee involvement, human capital, etc. all sound great, until you get to the root of things and understand that in many cases these words mask the company’s true intentions. The idea that a front-line worker would ever have something worth listening to is an absurd concept to many of the salaried ranks, and the contempt with which many salaried workers feel toward their hourly colleagues is often palpable. Where there should be respect there is condescension, and workers can smell it as surely as whatever they stepped in that is currently stuck to the bottom of their Red Wings.

My view of the world is jaded. In 1985 I took a job working the line at General Motors building seats. I was a hardware installer which meant that I would attach seat locks (a 15 lb piece of rough metal that I would use an air wrench to drive two or three fasteners) to the base of a seat so that the seat back could be slid over the peace and secured to the seat back; I screwed for a living and I came home sore. I would attach 1,600 seat locks on an ordinary shift and 1,800 on an overtime shift. The work was dirty, back breaking, and had numerous hazards associated with it (the company at the time did not require steel toed boots, cut resistant gloves, or safety glasses at the time). In short it wasn’t work that everyone could do, so much so that of the oddly 188 people hired the same day that I was less than 90 made it through the first 90 days. But both inside and outside the plant we were seen as second-class citizens, factory rats. A man who worked the line next to me had earned three masters degrees and when I asked him why he didn’t go to work in one of his fields of study he laughed and said he wasn’t going to take a pay cut.

A lot has changed in the 30 years since I worked that line. Automation has replaced some of the most dangerous jobs. Machine controls and processes have become so much more sophisticated that many shop floor employees are almost skilled trades. But one thing that hasn’t changed that much is the attitude by many salaried employees that the people working the front-line are somehow beneath them, that the lack of a college degree is automatically equivalent to a lack of brains.   The attitude is often subtle but it’s still there, and it is far more prevalent among safety professionals than it should be.

I have heard safety professionals openly malign the front-line workers by questioning their intellectual abilities, and describe them as lazy, stupid, or working in their current roles because they don’t have any other choice. In other cases it is more institutional and insidious. I have been asked to dumb down speeches and even training programs because the average Joe on the shop floor won’t get it. And I’ve been told that unless I compared it to NASCAR most of the people will ignore it. Still other safety professionals think so little of the front-line workers that they have appointed themselves surrogate parents. Its in this climate of condescension that we are expecting workers to rise to the occasion and engage as equal partners in making the workplace safer.

Worker engagement begins with respect and respect begins with confronting our own biases and bigotries. And this is an “us” problem not a “them” problem. Too often in the safety community we blame all our ills on others; the execs don’t do this, production won’t do that. But this is an “us” problem, the only way we can get everyone truly engaged we have to stop acting as if we are the only people who care about safety and the only ones capable of making a difference in safety. We have to stop moaning about how no one will own safety but us and invite others into our world.

It’s impossible to fake respect and until we truly learn to respect all levels of the organization engagement is impossible. So how do we break this cycle? We can begin by expecting more from the shop floor, and warehouses, and shipyards, and steel mills. We can stop acting so surprised when the front-line workers make good suggestions. We can end schmaltzy child safety poster contests and overly parental awareness campaigns. Treat the workers like equals. Ultimately demand great things from workers and engaged workers will deliver.

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We Need To Get Out of The Business Of Blame and Shame


By Phil La Duke

Several weeks ago I began exploring safety as an outcome, as the product of well-managed business systems and not something that needs to be managed as its own element. The business systems I identified were: competency, process capability, hazard and risk management, accountability systems, and engagement. In subsequent articles I explored competency, process capability, hazard and risk management, and today I sat down to the keyboard intending to write about one of my favorite accountability topics, Just Culture. But as I ruminated on the topic I realized that what I really wanted to say transcends Just Culture.

For the uninitiated, Just Culture is a management philosophy designed to hold people appropriately accountable. According to one of the current thought leaders in Just Culture, (and author of the book Whack A Mole) there are three basic kinds of behavior: human error, at risk behavior, and recklessness (I became a certified Just Culture practitioner by studying under David Marx, and you can argue that carelessness is also a behavior, but David will argue longer until you give up and just accept these three. Trust me David is a lawyer and he is one hell of an arguer.)   So in begrudging deference to David, I stick to three. The larger message of Just Culture is that blame is a counterproductive and useless exercise that feels good but doesn’t really accomplish much except to piss off the people being blamed and make them defensive. If we take a look at the three behaviors, only recklessness deserves blame and shame. Someone, I honestly don’t know who, said, “error plus blame equals criminality” and that is the reason that Just Culture and a blame free response to foul ups is so important. Just Culture gained real traction in industries where blame was so pervasive that people would conceal their mistakes and hope for the best—no such a bad thing if you are painting a barn, but if you are administering medical treatments or flying an airplane the smallest oops can have dire consequences. If a nurse knows, for example, that she (and sorry for sounding sexist but nursing is still predominantly female and besides it’s my example so if I want to make it a female nurse or a hermaphroditic orangutan that’s my business, if it upsets you tell your therapist) has accidentally given the wrong medication to a patient and if she admits her mistake she will be fired, there is a good chance that she will at least be tempted to say nothing. (The orangutan isn’t going to say anything either but hey, someone should have thought twice before putting it in charge of administering meds). In high consequence industries where the tiniest mistake can kill people blame conceals the errors.

But I digress, as I said, I didn’t want this to be yet another column about Just Culture. It just strikes me as odd that we as a profession continue to extoll the virtues of a blame-free workplace and the wonderful opportunity we have to learn about the causes of injuries while promulgating blame-based systems out of the other side of our mouths.

Blame-Based Safety

A friend of mine is a columnist who is an outspoken critic of BBS. One of his chief criticism is that BBS systems tend to blame the worker. The BBS fanatics all try to shout him down (good luck, the guy cut his teeth at Dow, is a PhD with actual work experience, and literally has forgotten more about safety than most people (including and perhaps especially me) will ever know) but he is right: Behavior Based Safety tends to lead to a climate of blame and shame. Oh, to be sure the purveyors of snake oil will assure you that THEIR brand doesn’t blame the worker, but I have found that these systems, whatever their intent, lead to a climate of blame. If the intent is not to blame workers, when one begins with the assumption that the incident is the result of behavior on the part of someone, and in most cases that someone is the injured worker, it is impossible for the injured party to feel culpable.

Even something as simple as behavioral observations can create a climate of blame. Whenever someone stands in judgment of us it is only natural to feel defensive. But my intent is not to create another angry argument for or against BBS, because quite frankly there is a whole new trend toward blame-based safety, which holds that leaders are to blame for injuries. In there acts and decisions, in what they done and what they have failed to do. While there is no small benefit in drawing leadership’s attention to the role they play in worker safety, the time for accountability is before people get hurt.

I have said many times that everyone plays a role in safety, but too often we only hold people after someone has been harmed or property has been damaged. People need to be answerable for ensuring the workplace is free of hazards, for the decisions they make, and for managing one’s performance inhibitors (the things in one’s life that make human error and unnecessary risk-taking more common like stress, lack of sleep, drug or alcohol use, etc.).

Blame remains a pointless exercise because once we have determined who’s at fault there is no reason to look further (it’s the same reason your lost car keys are always the last place you look.) That’s not to say that people shouldn’t be held accountable, but people need to be held accountable for their actions irrespective of the outcome. This is a basic tenant of Just Culture that the extent to which one is accountable is independent from the outcome. Actions taken and decisions made in good faith are not punished no matter the outcome and recklessness is subject to discipline even if no harm occurred as a result. It’s a bitter pill for some to swallow, but swallow it they must.

Filed under: Safety

A Pyramid By Any Other Name

by Phil La Duke

Tip of the Iceberg --- Image by © Ralph A. Clevenger/CORBIS

In the past weeks I have challenged safety practitioners to view safety differently, to see beyond the fads, the snake oil, and to see safety for what it is, the product of well-managed business practices in the areas of competency, process capability, hazard and risk management, accountability systems, and engagement. I have explored competency and process capability and this week I will take a close look at hazard and risk management.

This topic is by far the most difficult to explore, not because its not well understood, but be cause it is so frequently misunderstood. So many of the basic tenants of safety—when done correctly—support this business element. Unfortunately, so few of these things are done correctly.

Take for example Heinrich’s insufferable pyramid. Safety practitioners all over the world still trot out Heinrich’s Pyramid as proof positive that if you have x number of near misses you will have y number of serious injuries and z number of fatalities. Safety practitioners cling to this concept like a tick on the soft white underbelly of business. But Heinrich’s Pyramid is a steaming pile of crap. Forget that evidence suggest that he may have made his evidence up, forget that no serious researchers (those who don’t collect checks for perpetuating this garbage) believe there is any statistical validity to the pyramid, and forget that Heinrich himself admitted that his research itself consisted of asking 1920’s front-line supervisors how injuries happened ten years or so after they actually happened. Forget all that. The greatest flaw in Heinrich’s Pyramid is that we never really know how many near misses, minor injuries, or unsafe acts there are so effectively we are missing half the information we need to make any meaningful inferences. But there I go again spoiling things for the safety professionals who: a) don’t give a rat’s testicle whether or not the pyramid is valid and b) are too lazy to replace it with something more meaningful.

Of course on the other side of the spectrum we have those who hate Heinrich with the venom and vitriol of the people who hate Heinrich Himmler. This school of thought holds that everything that Heinrich believed is wrong and damaging to the safety organization. These people, I believe, are throwing the baby out with the bathwater. While there is no value in trying to predict the expected number of injuries using Heinrich’s Pyramid, there is value to using the pyramid as an analogy to better help Operations value the benefit of correcting hazards. When forced (which is too often) to incorporate insipid pyramid into a training I am developing or presenting I explain it by saying that we know that for every injury there are numerous hazards that could have harmed us but didn’t, close calls, or minor injuries. We may not be able to use that to predict the number of future injuries but a heck of a lot of hazards represent a heck of a lot of potential for harm. That’s it, no hackneyed lectures about behavior.

Maybe the better analogy would be an iceberg. The above the waterline would be the reported injuries, recordables, DART Injuries, and fatalities and below the waterline would be the hazards, unreported minor injuries, and risk conditions. The point being that if we focus on the hazards before people get hurt we end up reducing the iceberg both above and below the waterline.

Managing hazards is pretty simple (which I’ll bet dollars to doughnuts is the reason so many safety practitioners hate it): find the hazards, contain the hazards, and track the hazard to its permanent correction. Of course implementing this simple process isn’t easy but making it more complex doesn’t make it any easier.

Managing hazards begins with identifying hazards and the best way to do that is to walk the work area and look for things that can hurt people. We don’t need to worry about whether or not the hazard is a physical condition or the result of an ancient curse, or the act of an avenging pagan god. This is not to say that we shouldn’t investigate the causes, but we need to stop obsessing and finding profundity in the ordinary.

Once we have found a hazard we must be sure that we don’t walk away from it without containing it. There is more than just the obvious reason (because someone could get hurt before we get around to it) there is legal liability issues to consider if you find and document a hazard but fail to contain (and record the containment) a hazard.

Tracking the hazard to completion adds another layer to the hazard management process and it provides real value. Meeting weekly to discuss the progress toward correcting hazards helps to build ownership among Operations, it makes the previously invisible visible and applies coercive force on the people responsible for getting things fixed (who often sweep fixing hazards aside for sexier work).

Keeping it simple is an easier sell to the organization than some complex mumbo-jumbo.

Correcting hazards tends to return more on the effort than just reducing injuries. Because we eliminate the root causes of system failures, we likely will eliminate other process bottlenecks that effect cost, quality, delivery, and morale.

Filed under: Safety, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

The Lie of Complacency

by Phil La Duke


In this week’s post, I was going to continue exploring the antecedent processes that organizations must manage if they hope to ensure safe outcomes, but I got distracted by a recent contention by a leading vendor of safety training that 80% of all injuries are caused by complacency. I have been hearing this more and more lately and it is driving me nuts. First of all, I question the basis for that contention. Several sources claim to have reached this conclusion based on research, but I suspect that they know about the scientific method as I do about piloting a zeppelin, which is to say zilch.

What is the Ahabesque obsession that safety people have with finding the single cause (or the most common cause) of injuries? The cynic in me wants to point out that companies whose business model depends on the perpetuation of a given hypothesis are likely to preserve it at all costs, but I think it goes deeper than that.

To begin with there is the real problem that most of these people have differentiating between qualitative and quantitative data; it’s a problem that used to be common in the quality function. Qualitative data is measured while quantitative data is counted. When we talk about the cause of injuries we need to consider qualitative data not quantitative data, in other words, it doesn’t matter what the most common cause of injuries are, what matters is what is the most serious threat to workers. Let me give you an example, the following chart represents the locations on the site that have the most injuries:

 injuries pareto

If you look at this chart it is easy to assume that your efforts should be spent at the Memphis facility, but because this is quantitative (counted) data and not qualitative (measured) data we aren’t making informed decisions. What if , for example, the injuries at the Memphis facility are predominately first aid cases, but the Charlotte facility are predominately fatalities? Does it still make sense to attack first aid cases or is it smarter to address the problems at the Charlotte facility?

So even if complacency is the cause of 80% of worker injuries (and PLEASE share with us the industry, country, time period, research methods, population, culture, etc. that these studies on which this conclusion was made), it doesn’t mean that attacking complacency alone will solve the problem, because what percent of our injuries are relatively minor and what percentage are killing people?

But specifically the idea that complacency is the primary cause of injuries is problematic. This company and those like them, would you have believe that there is one overwhelmingly widespread cause that transcends all industries, worksites, and environments is ludicrous to the extreme, and convenient if you are selling a methodology that is based on this specious argument.

Why am I so suspicious? Well let’s start with the definition of “complacency”. According to “complacency” is 1. a feeling of quiet pleasure or security, often while unaware of some potential danger, defect, or the like; self-satisfaction or smug satisfaction with an existing situation, condition, etc. Is this really 80% of the causes of injuries? Are people dying from exposure to poison gases because they are smugly satisfied? Are workers being maimed because they feel comfortable doing their jobs? Who thinks up this softheaded rhetoric and successfully builds a billion dollar industry around it? And what is wrong with us that we so blithely buy this snake oil? To quote Kermit the Frog, “Somebody thought of that and someone believed it and look what we’ve done so far” of course Kermit was talking about wishing on stars, but he might as well have been talking about the latest safety methodology.

Another element that works against this thinking is the assumption that our anecdotal experiences and observations are universal. Once again, this is great for companies who sell a single tool solution (or single premise) but for those of us who are on the receiving end it can be lethal or even fatal. As I pointed out in my post about Lone Gunman safety, we have to as a profession accept that there are multiple causes for injuries and the more we look for that single cause the more we delude ourselves into thinking that there is some kind of magic bullet solution.

Injuring workers is a complex problem and we have to resist the temptation to get sucked into some con game where a slick-talking salesman convinces us that we only have to…and all our problems will be solved.

Beyond all that let us suppose that complacency really is this hidden killer, what are we to do about it? Awareness campaigns? I used to work in the nuclear industry and knew plenty of people who grew complacent with the dangers of exposure to radioactivity, but they still didn’t take chances or short cuts. An awareness campaign or retraining them would have made no difference—the opposite of complacency isn’t awareness it’s anxiety. So would the people preaching that the greatest threat to worker safety is complacency really suggest that we increase the anxiety of the worker? Would they have us believe that a stressed and worried worker is safer than one who is relatively relaxed? Keep in mind that a stressed out worker is far more likely to commit errors and take unnecessary risks than the worker who is not stressed out. Add to that the stress produced by constantly reminding people to pay attention or to stay focused and you have people adding risk to the process in the name of safety.

Complacency is a danger on one way—complacent safety professionals who think they are doing a better job than they are. If complacency is responsible for 80% of injuries, maybe it’s the complacency of the safety practitioner.

Filed under: Awareness, Safety, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

No post this week

Sorry folks, suffering from a severe writer’s block this week and a fair amount of depression.  I worked on no fewer than 8 pieces that I discarded because they were rambling pieces of crap.  Better to post nothing than to waste your time.

Filed under: Safety

Lone-Gunman Based Safety

Multiple causes

By Phil La Duke

Ever since Jack Ruby gunned down Lee Harvey Oswald while being transferred from a Dallas police station to county jail debate has raged as to whether or not Oswald acted alone or if he was part of a larger conspiracy. There’s not much satisfaction in the “Lone Gunman” theory; it lacks the panache and high drama of a conspiracy, but beyond that, the Lone Gunman theory seems too simple, too convenient, and too pat. I got thinking about the Lone Gunman theory as it pertains to safety and think the comparison is apt.

I came to realize that most safety professionals see injuries as the result of “Lone Gunman” thinking after listening to yet another argument about the nature of injures. “Injuries are caused by behaviors” “no they’re caused by process flaws” “no they’re caused by…” it sure sounds to me like the people who argue whether or not Oswald acted alone. Sound crazy? Think about it: if you believe that the majority of injuries are caused by a single thing you are essentially dismissing the possibility that worker injuries are caused by a complex situations with multiple and often inter-related cause and effects.

The lone gunman theories are attractive; they boil our problem down to a single factor that we can rigorously attack and solve it. This kind of thinking is satisfying because it means that all we need do is to solve one problem and we don’t have to be distracted by all the other things that may or may not be causing injuries.

Now some reading this will immediately hide behind the fact that they never said that ALL injuries are caused by (fill in the blank) but that MOST injuries are caused by (fill in the blank). That’s a convenient (albeit cowardly) way to stack the deck in your favor but it’s a specious and facile argument, even if we can say with credibility that 99% of injuries are caused by a single cause we have always have that 1% that aren’t and that allows us to dismiss it as an outlier.. Dismissing causes that don’t neatly fit into your view of the world as statistical aberrations or outliers is just another form of calling a fatality an unforeseeable act of God.

No One is So Dangerous as the Man with the Whole World Figured Out

When we start to see any topic with a fanatic’s singularity we become dangerous. If we believe that most injuries are caused by a single cause—whether it be leadership, or culture, or process failures, or human error, or risk taking, or pixies, faeries, and trolls—we create a world where anyone who disagrees must be heretics and heretics must die or at very least publicly mocked behind the walls of anonymity of a LinkedIn discussion thread.

Call Us Legion, For We Are Many

I am distrustful of the “one-size-fits-all” approaches to injury reduction, which let’s face it, isn’t the same as safety and yet many of the programs, snake-oils, and magic bullets our there promise safety and only sometimes deliver injury reduction. It’s dangerous to think in terms of a lone-gunman cause for injuries (even when allowing for the possibility that there could be other lone gunman working simultaneously. The opposite of lone gun thinking is conspiracy theory, which okay, I admit, makes me sound like even more of a whack-job than usual. But for our purposes think of injury causes as being somewhat, or at least potentially, benign by themselves. We interact with hazards every day and in the fast majority of those interactions we don’t get harmed. But the more hazards that are present the greater the probability of injury and the presence of some catalyst causes us to be injured. Think of the straw that broke the camel’s back: up until that last minute the camel was uninjured, but given enough objects loaded onto the camel’s back eventually the camel will exceed its capacity to hold the weight.

There are many things, often working in tandem, that cause injuries and we have to stop arguing over whether the straw broke the camel’s back or whether the man who overloaded the camel was to blame, or whether the camel made poor choices, or whether both camel and man had been poorly trained, or whether we could provide an incentive for the camel’s back not to break and realize that there is seldom only one thing going on, and in most cases hazards work together to achieve a lethal synergy that can maim, cripple, and kill.

We Need To Look for Questions Not Answers

I taught problem solving for many years. One technique we used was called Situation Analysis. This technique is used to solve problems with more than one cause, has inter-related causes and effects, and grew over time. The technique was useful for solving broad problems (like…I don’t know…injuries). What I found interesting is that this technique taught people that if you only focus on one of the causes and ignore the others you won’t really SOLVE the problems you would merely make the symptoms go away until the other causes would cross a threshold causing the problem to return even worse than it had been before. I think of the conundrum of fatalities. Injury rates seem to be going down (although many believe that this is largely the result of under-reporting or more rigorous case management) while fatalities are staying flat or in some cases rising. This is the exact pattern one would expect from methodologies that attack one cause while ignoring others─ the problem seemed to be going away until it roared back worse than ever. It has left safety professionals scratching their heads, but if we attack the lack of safety as a complex problem that has multiple causes that are interrelated we might just be able to manage things better and save some lives.

I’m Not Alone

I know I may sound like a broken record, but when you sell hammers all the world looks like a nail, and while I have heard many say “well BBS is just a tool in my toolbox” (and I use BBS as an example because I hear this more then let’s say “human performance” or “leadership improvement”) I get skeptical. I want to ask what other tools do you use? When do you use them? When is it inappropriate to use them? But I don’t; frankly I’m tired of arguing with fanatics. One bright spot is that I am meeting more and more people who are beginning to think like me. Rockwell, for example, talks about the 3Cs of safety. The 3 C’s are Capital, Compliance, and Culture. Now I’m not here to promote Rockwell but I like where their heads are at on this. I’m over simplifying their spiel here but effectively what they are saying is that you have to consider all three of these things when attacking safety issues. Capital-you have to make capital expenditures to fund projects to improve your equipment. I would expand that to include your facilities as well, but I think their point is well taken. Compliance-let’s not forget that we have to follow the law and that basic compliance is the gateway to more advanced safety solutions. And Culture-hiring qualified organizational development professionals to make substantive changes in how your organization views and values safety is important. To hear Rockwell tell it, you can’t expect great results without looking at all three; I think they are right.

Filed under: Phil La Duke, Safety, Safety Culture, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,



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