Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

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.

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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.

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2014 New Year’s Resolutions for Safety Professionals

by Phil LaDuke

Last year I wrote a list of New Year’s resolutions for Safety Professionals. The piece proved popular and people this time of year seem to come looking for them. I decided to write this piece without looking at the previous list and after doing so taking a look at them to see if I am capable of any sort of growth. 2014 has been a rough year for me. I lost my father-in-law and one of my few remaining uncles to work-related illness and despite by best efforts through writing and speaking and working I don’t seem to have changed anything, not a single mind. But this time of year makes the best of us reflective and after doing some soul searching and reflecting I came up with a short list of things I think we as professionals can do to be even more effective:

  1. Seek first to understand before seeking to be understood. Okay, I borrowed this one from St. Frances of Assisi but I think safety practitioners need to adopt it, especially those of us who sell safety services and solutions. We need to listen to the organization and ask probing questions—not in an attempt to lead people to our preordained solutions but so that we can understand their pain points, we cannot solve a problem that we don’t fully understand.
  2. Keep things simple. When we offer advice we need to do so because we truly want the other to benefit from our wisdom and experience not because we want to show off or demonstrate our brilliance. The best advice I have received in life was simply stated and to the point. Perhaps the absolute best advice ever given me was a single word, “stop” (my friend Ken said to me as I was about to mindlessly walk into the path of speeding Chicago traffic). We don’t need to write grand, self-serving treatises to be effective.

We have become a profession of theorists who, when proven wrong, change the rules. We need to get back to basics, as my boss if fond of saying “the best companies get the basics right and they get them right every time”. So what are the basics? Competency, Risk Management, Process Capability, Accountability and Engagement. But on an even more basic level we need to tackle the basics of hazard identification, containment, correction, and communication.

  1. Be kind. I know it may sound hypocritical of me to preach kindness but as a wise man once said to me, “make the day, don’t let the day make you”. To a large extent what we send out comes back to us and when we are kind people are more likely to be persuaded by us than when we are jerks. Besides, being the safety jerk is my job. When someone has been injured they are particularly vulnerable, “I told you so” or “you should have…” never soothed an injured worker.
  2. Serve the Organization. I spent last weekend poring over incident reports and Workers’ Compensation reports and I was struck by how often we assume the injury was intentional until proven otherwise. Are their liars and cheats who want to fake claims? Sure, but far more of the injured are victims and if we just lived our lives in service to the organization instead of standing in judgment of the injured we would see that most injuries are painful, embarrassing moments in the lives of workers. Do we have to protect the company against fraud? Absolutely, but let’s resolve to do so without treating everyone as criminals.
  3. Collaborate. We cannot be successful trying to do this alone and we have to swallow our pride and reach out to other disciplines. I have seen so many safety professionals wrestling for control with the continuous improvement group only to have both groups remain impotent in the organization. Reach out and help someone and ask for help in return; at the end of the day we’re all in this together.
  4. Teach. To be truly safe workers need to be able to do their jobs and they need to have mastered their jobs. I wrote this to a safety executive once and he wrote me back with scorn. “Why do they have to master their jobs?” he scoffed at me. I resolved right then and there never to do business with him. I don’t think he can be reached and if he can learn, he cannot learn from me.
    But in answer to his question, why do they have to master their job? Because the level of mastery of one’s job equates to the level of risk one operates under while working. Workers who don’t know how to do their jobs—or our just marginally competent—are far more likely to be injured or to injure another worker. This is most acutely evident in how companies view training temporary workers; in the minds of many better to kill a temp than to waste money training one. It’s ugly, but it’s true.
  5. The more we sharpen our skills as safety professionals the more good we can do, but I’m not talking about learning the latest safety fad. We need to learn how our businesses work, how our organizations survive, and how our companies make money. We can’t change anything unless we know how our businesses work. Instead of going to the same tired professional conferences and hearing the same tired speeches from the same tired hucksters why not attend a business seminar, or a Lean Management course? You will be a better professional for it.
  6. Safety is a tough way to make a buck, and it’s getting tougher. Hang in there, this isn’t a job for quitters.

Last year I gave you 10, but this year only eight. But I will make you a bargain. If you do these eight come see me and I’ll give you another 10.

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Why BBS will Live Forever

By Phil La Duke

Just when you think the debate over Behavior-Based Safety has faded from the landscape something brings it crashing back into your consciousness. For me it was a recent article (and the response to it) by Dr. James Leemann. Jim asked the question “will Human and Organization Performance (HOP) finally supplant BBS” as the prevalent approach to worker safety? As one might suppose the BBS zealots and whack-jobs came crawling out of the woodwork to complain.

I’m a big proponent of HOP because it fixes system problems not the blame. HOP goes beyond the behavior and address the system-wide antecedents, the things that precede and encourage the very behaviors that influence safety. I don’t think it’s a perfect system for protecting workers but I believe that safety is the output of well-managed business systems and so HOP makes a lot of sense to my clients and me.

The backlash to Jim’s article was predictable; the usual suspects accused Jim of not understanding BBS, not having seen BBS properly deployed, etc. etc. etc.

The whole argument exhausts me. I’ve said before that arguing against BBS is like telling someone you don’t like eating fricasseed squirrel anus. The first response is always, “well you just haven’t had it cooked right; you need to try MY fricasseed squirrel anus—you’ll love it!” So you try there version and it tastes even worse that the last time. But you still don’t, in the eyes of the fricasseed squirrel anus lobby, have any real standing, how many squirrel anuses (anusi?) does a man have to eat before the nut jobs cooking it will allow that said man to refuse on the grounds that squirrel anus is unpalatable?

To speak up against BBS is, in the mind fanatics, to speak out against safety, God, apple-pie and motherhood; it doesn’t matter how much evidence you produce that BBS doesn’t work, creates bloated bureaucracies, and encourages under-reporting of injuries, you will never convince the true believers that BBS is anything less than the one true path. It’s like trying to convince Lynette “Squeaky” Fromme that Charles Manson isn’t a pure soul; talking about it is like doing a card trick for a dog.

I’m at a loss to explain why BBS lingers in the same way I’m at a loss to explain why some people still believe in the Loch Ness Monster when most of the most credible evidence has since been exposed as so much bunk, or why there are Big Foot sightings in every state of the Union (including Hawaii), or why people believe in alien autopsies while others refuse to believe that the moon landing was anything more than a government conspiracy with a Hollywood twist.

For some BBS is an important source of income and in those cases it is not inconceivable that either they unethically cling to something that they know is snake oil or they have convinced themselves to ignore information that threatens their livelihoods; either way they have the strongest possible financial incentive to refute any claim that BBS doesn’t work. It’s much like a child who begins to doubt the existence of Santa Clause but is terrified that if he or she voices this doubt the Christmas gravy train will end and there will be no more Christmas present bonanza; the pragmatist in each of us will play it safe and perpetuate the Santa Claus myth even though long after we ourselves have long stopped believing.

For others BBS is a crutch on which they lean to compensate for the lack of real competency in safety. When one doesn’t quite get it, one clings to those things that they CAN understand. If you have a safety practitioner who lacks understanding of the basic safety regulations will find BBS a comforting alternative, with it’s simplistic “just reward safe behaviors” philosophy. Many people who don’t know the hard science side of safety will gravitate toward the simple argument that “if 80% of injuries is caused by behavior then we should focus on behaviors”.

In a broader sense BBS has a wide appeal to the key players within an organization. Management likes the “let’s hold workers accountable for working safe” underpinnings of BBS. Safety professionals like the number of resources that fall under their control; they get to spend money and engage in a wide range of activities. Employees love the pizza parties and safety BINGOs and safety bonuses. And of course vendors love the revenue it brings in. There is a conspiratorial feel to all this that sets off alarm bells.

Still others, and I believe this is the largest group speak about BBS in philosophical terms. Those in this group will insist vendors have a behavior-based safety system in place as a condition of doing business; it’s a nice thought but what then constitutes a “behavior-based safety” system? Is it enough that the safety system address unsafe behaviors? If so, this is fundamentally flawed unless the definition includes some context, and because all behavior exists within a context the definition would have to be exhaustive to be of any use whatever. What’s that old saying about the road to Hell being paved with good intentions? Wikipedia, granted nobody’s vision of a credible source, defines Behavior Based Safety as “the “application of science of behavior change to real world problems”.or “(their spelling error not mine). A process that creates a safety partnership between management and employees that continually focuses people’s attentions and actions on theirs, and others, daily safety behavior.BBS (again their screw up) “focuses on what people do, analyzes why they do it, and then applies a research-supported intervention strategy to improve what people do” Let’s take that one phrase at a time:

“application of science of behavior change” according to the science of behavior change is behaviorism. And according to the American Board of Professional Psychology (people who it would seem ought to know) “behaviorism” “emphasizes an experimental-clinical approach to the application of behavioral and cognitive sciences to understand human behavior and develop interventions that enhance the human condition.” I’m pretty sure that BBS as practiced is just about as far from this as can be reasonably imagined.

“A process that creates a safety partnership between management and employees that continually focuses people’s attentions and actions on theirs, and others, daily safety behavior”. Here, while many BBS systems aspire to this none can honestly say they have achieved it, for if such a system does exist there would be no injuries, no near misses, no need for the hapless companies to frantically feed the BBS money machine.

“focuses on what people do, analyzes why they do it, and then applies a research-supported intervention strategy to improve what people do” Again, while BBS may do all these things, to what end? They haven’t and never will prove that all this focus and research changes human behavior one whit, nor does it change the ingrained tendency for people to make errors, take risks, and behave unpredictably. No, I am not condemning anyone who requires his or her vendors to have a behavior-based safety system—just using safety performance as a criteria for selection will save more lives than not doing so. I am not condemning anything really, I just want to know why merely asking the question “is it time to dump BBS and consider another approach” is seen as abject ignorance or malicious heresy. Is a world without BBS so threatening and scary?

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

Insights on Culture

By Phil LaDuke

On Friday I went to the neighborhood bar as I am wont to do from time to time. While there I saw a regular who works with my brother in an open die forge. I passed the pleasantries with him and asked him how he was. He said he was doing a lot better and was healing. I didn’t know what he was talking about so I asked him. He explained that he was burned badly at work; second-degree burns over most of his lower leg. He quickly produced a cellphone and proudly displayed a gruesome photo of a badly burned leg. As I looked at the sickening display he recounted the details. He prefaced his story with a quick, “It was my own fault, I was so (expletive) stupid”, and told his tale of his not paying attention to a hot piece and having his pants catch on fire. Instead of using sand to put out the flames he panicked and ran. There were some jokes made in poor taste about the old Bill Cosby “Stop, Drop, and Roll” television ads, and I asked him how much time he missed. “Not a day. I took it like a man.” Took it like a man; his comment made me think about culture.

Culture is all the rage in safety these days. Circa 1972 James Reason made the observation that before an organization can create a “Just Culture” it must first create a “Safety Culture”. Reason wasn’t talking about worker safety, at least not in the way we tend to think of it. Unfortunately, the snake oil salesmen have glommed onto the term like lampreys on a fish’s soft white underbelly and subvert it more and more each day.

My acquaintance’s story tells us a lot about culture and the relationship between safety and culture. It occurred to me that there are levels within culture and if we are hoping to change the culture of our organizations we need to examine the nuances of culture. Each level of safety culture is characterized by a perception of a reaction of some sort; each one is driven by a fear of some sort.

Fear of Discipline

The other day I was late for a doctor’s appointment and I was tempted to speed; I didn’t. My first thought was, “I don’t need a ticket”. The idea of spending money on a ticket and the time it would take up just didn’t seem to favorably balance against the time I might save. As many times as my doctor made me wait (ultimately I had to wait in the doctor’s office anyway) I figured I was owed some slack. In the moment of decision, I placed more value on compliance than I did on the potential value.

Fear of Loss of Reputation

As I reflected on my decision I thought about culture. What, I asked myself, would I have done if my speeding had been through a school zone. What influence would the opinions of my friends and neighbors have on my decision. I think it would be fair to say that for many the risk of damaging our public image (coupled with the fear of discipline) would put more pressure on me to conform to a norm and to adhere to the values of the community. My desire to preserve my reputation was stronger than my desire to get to the doctor’s on time.

Fear of Culpability

Of course there also was my concern for public safety. I’d like to think that most of us want to behave safely when the lives of innocent school children are at stake. But even when the situation isn’t about endangering school children there is on some level a desire to be a good person and good member of the population; a good citizen, if you will. In our heart of hearts we all want to conform to the shared values of the culture. We go along to get along.

Putting It Into Practice

If these fears are the drivers of culture then what are we to do with this information. Well think back to the guy in the bar who set fire to his leg. Clearly the culture of his company valued guys who “man up” when it comes to injury. Here is a guy who is working while heavily medicated; doped up on pain medication. This is a culture that values a lower DART rate than it does the safety of the remaining employees (how do you think the performance of a heavily medicated employee will be effected?). This is a culture that encourages workers to “man up” and work while injured. This is a culture that doesn’t seem to value worker safety much. I realize this is harsh criticism and that I can’t really make judgments on the company simply because of an account from an injured worker. I think it’s important to note that the worker in question likes his employers and generally has good things to say about his company. The net sum total is this worker’s willingness to go to work rather than to stay home and recuperate he didn’t do it out of fear of repercussions he did it out of fear for his reputation and to conform to the shared values of the population.

The takeaway here is to change your culture you first have to understand the coercive pressures you put on people every day. You need to ask yourself three basic questions:

  • What value does the organization place on discipline? Are people hailed as heroes for “manning up” or dismissed as wimps because they report injuries or seek appropriate medical attention.
  • How are people who value safety viewed? Are they seen as solid professionals
  • How is risk viewed? Are people with a low risk tolerance seen as top performers or as “worry warts”?

The point I’m trying to make is that you may be fostering a culture that actually promotes the things that you are trying to change.


Filed under: Behavior Based Safety, Hazard Management, Just Culture, Safety, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Incentives and Indicators

By Phil La Duke

The use of incentives is something of the Great White Whale of safety. Safety practitioners often find mounting pressure to use incentives to reduce workplace injuries. Incentives are popular because they seem to make sense—and I am not against incentives, provided that they encourage the right things. Sadly, incentives too often create unintended consequences, chiefly because the incentives are for the absence of injuries instead of the presence of safety.

There is a gulf between the apparent absence of injuries and the presence of safety and unfortunately neither of these are particularly easy to measure. One can’t measure the absence of injuries because one must depend on the injuries being discovered—either via self-reporting or discovery by the organization. Effectively zero injuries (or any number of injuries for that matter) is zero reported injuries; it’s a case of “we don’t know, what we don’t know”. But measuring safety is just as difficult because we don’t really have a hard and fast definition of exactly what constitutes safety. What we describe as “safety” is more accurately “safe enough” and ask seven Safety Practitioners what Safe Enough means and you are likely to get 19 answers. Safety is a continuum and is relative so it cannot be accurately (in and of itself) measured. Safety can only be measured as a state relative to another state. Something can be said to be safer than something else, but as long as any risk exists something can never be pronounced completely and utterly safe. If we can’t pronounce something qualitatively “safe” we have to rely on indicators, unfortunately, incentives are often misapplied or misinterpreted. It’s impossible (well at least foolish) to talk about incentives without considering indicators, and if we are going to provide incentive for the right things we need to understand, first and foremost, what indicators are telling us.

The Absence of Evidence is Not Evidence of Absence

The most commonly used indicator of safety is the extent to which injuries occurred. If people were injured it’s appropriate to say that they weren’t safe; that’s intuitive and people like it because it’s a simple calculation to make, provided that people report injuries. But as I’ve said, safety isn’t just the absence of injuries; it’s also the presence of things that drive a safer workplace, and that is the crux of the issue with indicators and incentives. Let me illustrate: the opposite of injuring workers (i.e. an indicating a lack of safety) is the absence of injuries. What does the absence of injuries indicate? Safe work habits? I know many people with incredibly unsafe work (or driving) habits who don’t get hurt, so while it’s possible that a lack of injuries indicate safe work habits it’s equally (perhaps more) likely that a lack of injuries indicates luck. Could it indicate that no one has been hurt? Possibly, but here again it could also indicate that people have been concealing their injuries. Could it indicate overly zealous case management? It might. In fact, there are numerous things that a lack of injuries could be indicative of so we can’t really use them as a good indicator.

Look For the Things That Produce Safer Outputs

I’ve come to realize that “safety” is really an output of sound business practices in five areas (there are many subsets within these areas, but five is a nice manageable number):

  • People who are incapable of doing their jobs—whether it be because of a lack of training, or physical incapacity or insufficient intellectual ability—are less likely to work safely than the workers who possess these attributes.
  • Process Capability. Work environments that lack a standard way to do the job that contains minimal variation are safer than work environments where workers half to figure out how to do the job each time they repeat a task. Similarly, workplaces with weak process discipline (the practice of following the prescribed process) are less safe than environments with strong process discipline. In other words if your jobs and tasks are poorly defined or your people are working out of process you are at greater risk of injury than if you have a well-defined process that people don’t follow.
  • Risk Management. Organizations that appropriately assess and mitigate their risks are far safer than organizations that don’t manage hazards.
  • Accountability. From the CEO to contractors, it is important to hold people appropriately accountable for doing their jobs correctly. Accountability systems must reflect corporate justice (in Just Culture parlance console human error, coach risk taking, and discipline recklessness).
  • Engagement.  Workers who are actively trying to improve the safety of the workplace because they believe that it’s the right thing to do are more likely to produce safe outcomes than those who aren’t engaged.

If we can accept that these five processes, if managed appropriately, will produce safe outcomes (and for the record, there are others, but like I said, they can be managed within these categories, but if you choose others I won’t gripe.) than we can look for things that indicate the presence of well-managed processes in these areas.

Indicators of Well Managed Processes

Indicators of well-managed processes may differ from industry to industry, even from site to site, but in broad strokes we can measure indicators of success in these areas.

Indicators of competency

How do you measure competency? If you don’t know ask your training department; you are likely to find that they are adept at measuring competency, but here are some suggestions:

  • % trained. Personally, I wouldn’t limit this to safety training, although the percentage of people who have successfully completed training on time is a good indicator of competency. Of course it’s not the only indicator and the more indicators you use the stronger your confidence can be that whatever you are measuring is true. Since we are only looking at five areas we can use several indicators for each and have a much stronger correlation between the indicator and reality.
  • % hired with all required/desired skills. We all know that job postings are essentially wish lists and there is seldom a new hire that hits ALL the requirements. The greater the percentage qualified the higher the likelihood that the person will be able to perform safely.
  • Those individuals with higher skills tend to have higher productivity than those who don’t, so while productivity is an indicator for more than just competency it can be useful in conjunction with other indicators.

So how do we create incentives around these factors? Simple: reward people (at all levels) for completing their training on time, for hiring more skilled workers, and for maintaining high productivity.

Indicators of Process Capability

This is the easiest area for which to develop indicators because in many organizations there are already measurements that we can use to gage safety:

  • Unplanned downtime. Unplanned downtime tends to indicate process breakdowns and the greater the frequency of unplanned downtime the higher the likelihood that workers are at risk of injury.
  • Like unplanned downtime, scrap indicates a process that is out of control. Workers who are working in a process that is out of control are by definition working out of process. Since we tend to see more people hurt while they are working out of process this is a good indication of the level of safety.

Indicators of Risk Management

For our purposes we will define risk management as how the organization identifies, contains, corrects, and communicates hazards (including injuries). In this area there are a lot of things from which we can choose:

  • % of walk-throughs completed on time. Whether you have BBS audits, Safety Observation Tours, Layered Process Audits, you probably have some formal requirement for the supervisor to identify hazards. Your requirement should have a frequency requirement that is easy to measure. The indicator here is mathematical—the less time someone is exposed to a hazard the less risk of injury. Meeting the requirement to complete these tasks on time is a strong indicator of safety.
  • Number of hazards per tour. Hazards (especially behavioral) are dynamic so the number of hazards a person finds each tour correlates to the safety of the workplace.
  • Number of overdue hazards. The priority assigned to the correction of a hazard should have a corresponding deadline and when that deadline isn’t met it indicates an increase in the time of exposure and perhaps a degradation of the containment measures.

Of course there are a lot more indicators you can use in this area, but I think you get my point.

Indicators of Accountability

Accountability should be just; the punishment should fit the crime. Justice is largely circumstantial—not every situation can be treated according to the same standard of accountability. Would you discipline a worker who mistakenly used the wrong we chemical and caused property damage as you would someone who engaged in sabotage? Or would you react the same way to a worker who faced with two pretty bad choices (after careful analysis) decided to choose the lesser of two evils as the worker who engages in clear recklessness? Of course not.   Unfortunately we can’t feasibly measure the justice of a decision, but we can of course measure the number of write-ups, improvement plans, and similar efforts. We should also be looking at the number of times we “caught them doing something good”. Some examples I can think of off-hand include:

  • Number of disciplinary actions. Clearly the number of disciplinary actions directly correlate to accountability; the more disciplinary actions the higher the accountability. But what if there are few disciplinary actions simply because there are less people who are acting inappropriately? Clearly this indicator cannot be interpreted alone and should be paired with an indicator that people are being recognized and rewarded for desirable behavior.
  • Number of employees recognized for exemplary service. The number of people who are recognized for doing things like identifying a serious hazard, participating in safety efforts, leading a safety event, or something similar is also an indicator of accountability—rewarding desired behaviors. By pairing this with the number of disciplinary actions one can get a better picture of the overall performance of accountability.

Indicators of Engagement

Engagement, like process capability, is likely already being measured by your organization, but you can use some combination of the following to ascertain the level of worker engagement:

  • Number of Grievances. Unhappy workers tend to have more “performance inhibitors”; that is, the things like stress, preoccupation, anger, frustration, etc. that increase the likelihood of human error. Not to mention unhappy workers may make poor choices rooted in frustration.
  • Number of Suggestions. The flipside of grievances is suggestions. The greater the number of suggestions for approval the higher engagement tends to be.
  • Participation in continuous improvement efforts. People who care about their work tend to get involved in making it better and this tendency is a good indicator of engagement.
  • Participation in safety meeting. Participation in a safety meeting, like so many other indicators, cannot be seen as an absolute indicator of engagement; it could indicate that someone would rather sit in a meeting than do what they are paid to do. But when taken with these other indicators it can provide insight into the level of engagement of workers in an organization.
  • Here again is an indicator of more than a lack of engagement, but this is a strong indicator of the relative safety of a workplace. High absenteeism is linked to poor morale, unhealthy working conditions, workers not managing their performance inhibitors (drinking to excess, drug use, sleep deprivation, etc.), but more than that, high absenteeism means more replacement workers who tend to be less skilled at performing the job. This ties into competence, process capability, and perhaps even risk management.
  • Moral is also an indicator of many factors, but low moral does correlate to higher incidence of human error and risk taking.
  • Turnover is a good indicator of an overall healthy or unhealthy workplace. As people are churned it lowers competency and impedes process capability.

Okay, but what about incentives?

One can only effectively set incentives that reduce the chance of unintended consequences after one has appropriate indicators of safe outputs. Once one has determined the best measures for the desired state one can then create appropriate incentives. When developing incentives:

  1. Look for (and avoid) potential unintended consequences. Too often incentives create an environment where the desired behavior isn’t rewarded and people game the system.
  2. Don’t provide incentives (or hold people accountable) for things they can’t control. When you provide incentives for things people can’t control the only real incentive is to lie, cheat, and steal. Takes sales incentives for example. While a salesman can control how many meetings he has with prospects (which is necessary to MAKE sales) he can’t really control whether or not a sale is made. This leads to bickering between sales professionals, stealing of clients and leads, undermining competitor’s success, and generally stabbing one another in the back. It actually diminishes teamwork, collaboration, and ultimately the likelihood of success for the company.
  3. Make it meaningful. Not everyone likes to be recognized or rewarded in the same way. Be sure to consider different people’s needs.

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News In Brief

By Phil La Duke

Just a couple of brief topics before I get into this weeks’ post. First, it is with sadness that I announce the death of my uncle. Robert P. LaDuke died this week, another casualty of workplace illness. Uncle Bob had been suffering with mesothelioma. The bastards who knew it would kill workers but concealed this fact to protect profits remain at large. No one will ever be held accountable for his or her depraved indifference. The lawsuits (that George W. Bush derided as frivolous) will never come close to allaying the enormous human suffering these people caused. Were we in China they would have been taken to a sports stadium and shot dead. May God have mercy on their souls;. I mention this not as a ploy for sympathy but as a reminder that the death toll will continue to rise, not just from asbestos but from hazards not yet known or imagined. At any rate, RIP Uncle Bob.

On a much lighter note, I have started a new group on LinkedIn: Best Practices in Health and Safety. I’m envisioning it as a place where safety practitioners can go to get and share the best practices and thought leadership in worker safety. I won’t tolerate commercials and promotions so I think it will be worthwhile; at very least I won’t have some half-wit deciding that I can’t post links to my blog to the discussion groups.

Also, my abstract to speak at the National Safety Council’s Texas Safety Conference and Expo in Austin next March. I will be speaking on the role that social networks can play in safety and I think it will be a spirited, lively presentation.

There WILL be a post today, but right now I have to watch football

Filed under: Safety



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