Misleading Indicators

trash graphs

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

By Phil La Duke

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

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

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


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

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

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

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

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


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

Requiem For Prevention

by Phil La Duke

Requiem for Prevention

I am a loud (some might say obnoxious) and ardent supporter of prevention.  In fact, I one of my core values is “Prevention is the key to sustainable safety.” So given my vocal advocacy of prevention, you might be surprised to learn that I believe that in many cases prevention has gone overboard and that in many cases companies would be better served by doing LESS prevention and more contingent planning.  Heresy? Consider the  organization that spends tens of thousands of dollars each year preventing accidents that would likely have little or no chance of ever happening.  These companies have 20-person safety committees that meet once a week to argue about why an over-burdened maintenance department hasn’t fixed a low-priority hazardous condition.

Prevention costs money and resources that may well be better spent elsewhere in the organization—and not necessarily safety. Equally damning, organizations that continue funding convoluted safety bureaucracies that unnecessarily add heads, complexity, and cost in the name of preventing injuries.  Too often these efforts focus on one of the most misunderstood sources of injuries in the workplace today: human behavior. These systems seldom deliver what they promise (that is, a sustainable change in human behavior) and can actually impede important business processes and the delivery of goods or services in the misguided attempt to control human behavior; it can’t be done, so stop trying.

I’m not suggesting that we return to reactive safety practices, far from it.  What I am saying is that there is a time and a place for prevention, but its is not a panacea.  Simply put, you can’t prevent every accident, and in some cases you should be looking for ways to protect workers when your best efforts to prevent an accident fails INSTEAD of wasting time on prevention.

Variation in Human Behavior

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

They Call Them Accidents For A Reason

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

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

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

Variation Leads To Errors

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

Focus On Contingency Not Prevention

Okay, relax.  I know that I preach prevention above all things, but when it comes to variation in human  behavior you just can’t prevent most of it. If we could there would be no crime, no traffic accidents, and no medical malpractice.  And to make things even more complicated, human behavior can be very tricky to predict, and even more difficult to prevent.  We have to stop pretending that all our problems can be solved through preventive measures; sometimes—despite our best efforts—things go sideways and when they do we had ought to have some contingency in place to prevent a mishap from becoming a disaster or a tragedy.  When it comes to contingency versus prevention it doesn’t have to be an either or decision.  I used to teach problem solving and we used a very simple tool for determining whether to use a preventive countermeasure or a contingency countermeasure.  We would rate both the probability and severity of an error in terms of high, medium, or low.  If the probability that the particular failure mode (engineering speak for a screw up) is high—in other words it is almost certain to happen under the given circumstances—then one should definitely find a preventive action.  If the probability is low (fairly remote, but possible) one would need to temper the response after considering the time and money it would require to implement.  Similarly, if the failure mode’s severity was high (if it DID happen the consequences would be severe) than one would have a contingency in place to protect workers, property, and inventory.  Of course if the severity was expected to be low one would again determine whether the protection offered would be worth the cost of the required resources.

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

It would be great if we could accurately predict and prevent injuries, but the reality is we can’t. We have to be pragmatic and take important steps to ensure that when someone does have an accident, protections are in place to keep the injury from becoming life altering or fatal.

#accident-prevention, #attitudes-toward-safety, #behavior-based-safety, #contingencies-for-safety, #criticisms-of-bbs, #culture-change, #focus-on-prevention

Understanding the Causes of Injuries

By Phil La Duke

Perhaps the most over-looked step in making the workplace safer is an understanding of the nature of injuries.  It sounds simple—after all, isn’t this all just common sense? The nature of injuries may seem pretty obvious, but when you consider the many factors that can lead to injuries, things can get pretty confusing, pretty fast..

The nature of injuries has been the source of conjecture, competing systems, and bitter feuds since the industrial revolution.  For many years worker injuries were seen as an unavoidable cost of doing business.  Farmers got kicked by mules, miners were killed in cave-ins, sailors drowned, and metal workers burned to death; that’s just the way it was and nobody gave it much thought.

As business grew more organized and experts looked for ways to make operations run more smoothly attitudes toward workplace safety changed, albeit slowly. But it wasn’t until the Triangle Shirt Waste Company fire, and to a lesser extent the publication of Upton Sinclair’s The Jungle, that any substantive call for government regulation of safety.

On December 29, 1970 the U.S. Government formed the Occupational Safety and Health Act (OSHA) and in the ensuing years most people viewed safety as something someone does many, if not most, took the view that if people would be more careful they wouldn’t get hurt as much. It made sense then, and it makes sense now.  This belief set was further bolstered when the National Safety Council released its finding that something like 95% of all injuries were caused by unsafe behaviors.  It all feels pretty reasonable, it all makes so much sense, and yet it’s wrong.

Before the dullards blast my in-box, yes, I will grant you that BBS is a science, if you will grant me that so are eugenics, phrenology, cryptozology, parapsychology and a host of other fad and fringe fields are also sciences in that they use the scientific method and controls and all the other criteria for one to claim such a designation.  Sufficed to say, we have struggled under the misconception that we understand the nature of injuries when in fact, we do not.

That’s not to say that some injuries aren’t caused by reckless jackasses who act with wanton disrespect for the safety of themselves or others, but those incidents are, in my opinion rare.

Human Error

People screw up. They don’t choose to, they don’t want to, but they do. We live in an imperfect world and despite our best intentions some things go awry. We can’t truly prevent human error but we can work to protect people from the consequences of their mistakes.

Process Incapability

Often variability in our processes—both mechanical and human behaviors—can create hazards that hurt people. By having tighter controls on our processes we can often prevent these issues from becoming injuries, but as with human error we must also look to manage the risk of injury through the hierarchy of controls.

Risk Taking

A big contributor to worker injuries is risk taking.  We WANT people to take some risks (for example, a worker who violates a process in order to prevent an explosion) we just don’t want them taking unjustifiable risks or taking risks without understanding the jeopardy in which they are placed by taking these risks.  People will always take shortcuts, and unless we can train them in risk assessment and help them to make better judgments we can never hope to offer any protection against disaster.
Equipment Failure

Tools wear out and break sending shrapnel into the work place, grinding wheels crumble into pieces and fling stone at the heads of workers, and saw blades fail and go flying who knows where.  These scenes play out in the workplace daily and scarce little thought is given to these events.  A good Total Productive Maintenance (TPM) program can lower the risk both by making the failures easier to predict and allowing maintenance to change tooling before it fails.


For some, exposure issues are more environmental hygiene issues than safety issues, but in my book, if it can hurt workers then it’s a safety issues. Exposure is sometimes difficult to control because too often we only become aware of the issue when it too late to avoid the damage done through exposure.

Ergonomic Stress

As with exposure issues, ergonomic issues can be hard to spot.  Ergonomic injuries develop over time and injury occurs only after a threshold has been crossed.  These injuries tend to be serious and costly to treat.  Ergonomic injuries can be avoided by implementing a robust ergonomics program.

Poor Housekeeping

Perhaps the most common cause of injuries, near misses, and first aid cases is also the easiest to correct: poor housekeeping.  Poor housekeeping contributes to human error, makes risk taking essential, and can create everything from trip hazards to exposure risk.  A solid 5S initiative can prevent many housekeeping issues.

Nonstandard Work/Working Out of Station

Whenever we work outside the intended standard—whether it be because of part shortages, increased or decreased production, or simply workers working out of the designated work area.  This creates a situation that the people who designed the process never intended and perhaps never anticipated when they laid out the work area and associated protections.  This type of hazard must be tightly managed not only to protect the workers, but also to ensure quality and efficiency.

This list is neither exhaustive nor equally applicable to all workplaces; safety professionals need to take a hard look at the environments for which they are responsible—no external consultant or safety system provider is likely to know the hazards of your workplace as well as you do.

As long as safety management systems focus too heavily on one cause of safety while downplaying the others as less important, we will never make a sustainable improvement in worker safety.


#equipment-failure, #ergonomic-stress, #exposure, #human-error, #nonstandard-workworking-out-of-station, #poor-housekeeping, #process-incapability, #risk-taking, #worker-safety

What Are The Alternatives to Behavior Based Safety

By Phil La Duke


Last week I posted yet another criticism of Behavior Based Safety (BBS) and it drew the following comment

“Good morning Phil I hope all is well. The argument for and against Behavior-Based Safety is as old as the first implemented methodologies, yet it still persists in many different beneficial and strange forms. Some refer to incentive schemes as BBS, others just a psychology-based approach as BBS and others watch a video, read an article and attempt to make it work with widely ranging results on culture and performance. I believe BBS to be a situationally-appropriate tool for a small aspect of safety. Moreover, it should be a tool focused on better understanding performance and the influences on it, than an awareness or accountability mechanism. The latter tends to cause some of the problems you write about and I have seen as well. Rather than perpetuating the continuous critique, I would sincerely be interested in reviewing the specifics of the methodology/approach/tool you propose that will accomplish the same results in the small aspect of safety BBS benefits. Would you please share?”

This isn’t the first time I’ve been asked to share the alternatives to BBS. But this is no easy feat—first of all, as this comment suggests, there is far from a single source of truth that defines BBS and its elements. Before we can discuss the relative effectiveness of BBS we need to agree as to exactly what constitutes “effectiveness” of a safety management system.  The criteria I will use are:

  • Cost
  • Effort
  • Sustainability
  • Value

Most of the purveyors of BBS agree that the following are elements of a comprehensive Behavioral Safety management system:

  • Evaluation of Worker Behavior Using Checklists.

Trying to find a competitive system involves some modification of the behavioral observation.  Personally, I reject the idea that people get hurt because they knowingly and consciously behave in ways that put them in jeopardy.  I am supported in this belief by Joseph T. Hallinan, author of the book Why We Make Mistakes: How We Look Without Seeing, Forget Things In Seconds, and Are All Pretty Sure We Are Well Above Average; David Marx author of Whack A Mole—The Price We Pay For Expecting Perfection; and Zachary Shore the author of Blunder: Why Smart People Make Bad Decisions. Putting this philosophic difference aside, conducting periodic reviews of the work area that focuses on all the hazards instead of focusing on purely (or even chiefly on) behaviors is far more likely to lower the risk of process failures which not only endanger workers but also puts quality, through-put, and production at risk. What alternative is there to BBS? Several tools come to mind:

  1. Layered Process Audits. Layered Process Audits are checks conducted by various levels of management.  The primary purpose is to ensure that the process as performed conforms to the process requirements. Part of the Layered Process Audit system is the verification that all mistake proofing protections are in place and operational.  This is essentially an improved version of the behavioral observations that requires less effort, is far less costly, is relatively easy to sustain, and ultimately returns far more value than the behavioral observation.
  2. Kaizen Events. Kaizen events are ad hoc activities designed to improve the efficiency of the work area. Kaizen events involve the workers in the area who participate in improvements by identifying and eliminating sources of waste—including those things that are likely to cause injuries.
  3. 3.    5S Audits. 5S is a powerful tool designed to reduce process variation and make the work area more efficient and safer. It involves simple workplace reorganization that sorts, sets in order, scours, standardizes, and sustains improvements in the workplace.

Data Collection From Observations. Behavior Based Safety systems rely on measurements taken by watching workers perform their jobs.  While safety information should be routinely analyzed and trends should be studied to determine proactive initiatives, here again BBS falls short.  First, in an attempt to overcome Heisenberg’s Uncertainty Principle (which states the observation itself alters the factors being observed) BBS depends on many observationsTo achieve the desired number of observations BBS system relies on numerous  trained observers who observe their peers and provide them feedback on their behaviors.  Such activities rarely normalize the data to adjust for the Hawthorn Effect (the tendency for workers to improve simply because the organization is taking action).  Data collection relative to safety indicators are key to constructing a coherent safety strategy, but again, there are better (as it relates to Cost, Effort, Sustainability and Value). Let’s take each of these factors one at a time.  The cost of conducting observations are substantial—checklists must be constructed, workers must be trained both in evaluating and being evaluated, and the observers must be paid a wage to conduct the assessment—the effort (for the same reasons) is onerous; and the long-term sustainability of these activities is dubious.  Add to this the resentment and morale issues (up to and including Union drives or labor unrest) associated with peer-to-peer audits and you have a really bureaucratic system that creates head count and saps productivity. A far better solution is the balanced score card.   According to http://www.balancedscorecard.org/BSCResources/AbouttheBalancedScorecard/tabid/55/Default.aspx the balanced scorecard is “a strategic planning and management system … It was originated by Drs. Robert Kaplan (Harvard Business School) and David Norton as a performance measurement framework that gave managers and executives a more ‘balanced’ view of organizational performance.”  General Electric, hailed by many as a pioneer of modern management, was an early adopter of the balanced scorecard approach

Modern balanced scorecards has evolved beyond being a simple performance measurement system and has blossomed into to a strategic tool for planning and managing a business; it provides a visual representation of the progress against strategic initiatives.  Typically the balanced scorecard provides a framework for achieving goals in Safety, Quality, Delivery, Morale, and Environment (SQDCM). In addition to the obvious advantage of leveraging existing efforts and collaborating across multiple functions, the balanced scorecard imbeds safety into standard operating procedures—instead of acting as if safety was a discrete element it is rightfully treated as a pillar on which an effective organization is built.

  • Worker participation. An oft-cited reason for the “success” of BBS that it fully engages the workforce in safety management. Proponents of BBS extoll the virtues of this grass roots approach as opposed to a management driven top-down approach.  Many systems include incentives for making the workplace safer—safety BINGOs, bonuses for injury-free quarters, or similar initiatives.  A more economical, holistic approach is to use existing employee suggestion programs to solicit and reward ideas that genuinely improve the safety of the workplace.  It may not be sexy, but why create a parallel process that is limited solely to worker safety when a larger, more inclusive system already exists?
  • Focus On Specific Unsafe Behaviors.  BBS proponents tout the relatively scarce types of behaviors that cause the majority of injuries.  Here I believe that this is not in fact, BBS.  This is an attempt to use process based safety tools to address a shortcoming of BBS.  But let’s take a quick look at the practice of using Pareto chart analyses to target the behaviors of greatest risk. Pareto charts track quantitative (counted) data and not qualitative (measured) data.  This kind of data is generally (but not necessarily) derived from Area Maps or Body Maps.  Since the severity of the event is not collected in Pareto analysis (the data is assumed to be more or less the same severity and holds more or less the same risk of injury) it is inappropriate to use this data in determining the critical few behaviors that represent the greatest danger.  Furthermore, this type of analysis essentially ignores hazards that are largely environmental, organizational, or mechanical.  Instead of this approach organizations should focus on ALL hazards instead of focusing on behaviors.
  • Focused Feedback Performance.  In BBS feedback usually takes one of three forms: feedback at the time of observation; graphs of trends used in weekly discussion with work crews, and monthly discussions about safety by management.   While feedback on behavior is valuable it only can provide benefit in cases where the behavior was deliberate.  A large percentage of unsafe behavior is simple human error and no amount of feedback will change the fact that people make mistakes.  Another substantial source of unsafe behavior is behavioral drift (the tendency to slowly move away from the standard procedure until one unknowingly moves into risky behavior).  According to David Marx (in his book Whack A Mole: The Price We Pay For Expecting Perfection) contends that drift is an unavoidable part of human behavior.  Here again, telling someone that they drifted isn’t all that useful in changing worker behavior.  Finally, there is reckless behavior (defined as the willing choice to behave in a way so risky that no reasonable person could ever defend the behavior as in proportion to the perceived reward.) In cases of recklessness feedback on the behavior is unlikely to result in behavioral improvement.  Instead of focused feedback on behavior organizations would be far better served by implementing a Just Culture approach to safety combined with training in decision-making and a comprehensive program of error proofing.
  • Data-driven decision-making. How is this a differentiator of BBS? Aren’t all safety management system based, at least to some degree, based on data-driven decision making? Clearly making the decisions on data that is primarily based on behavioral data at the expense of other relative factors is not something to brag about.
  • Requires visible on-going support from managers and front-line supervision. Here again, this is not something limited to BBS. (And a contradiction with BBS’s claim that its success is rooted in the commitment of the workers and a grass-roots movement.) If managers and front-line supervision aren’t supportive of safety it will most certainly fail irrespective if it is a BBS, process based, continuous improvement, or Just Culture approach.. But in all cases I think this is a cop-out.  A good safety system should begin by engaging leadership before it starts laying out commandments.  When I custom-design a safety system I begin by assessing the leadership’s commitment to making the changes necessary to effect lasting change.  If I am not satisfied that this commitment exists I walk away. In my one-year engagements I have completely transformed cultures and produced for my customers sustainable and effective safety systems that they own without creating a parasitic relationship between vendor and customer.

This is just the tip of the iceberg—I didn’t even touch the many companies who make money by certifying people to perpetuate their crappy safety systems, sell “training materials” or dozens of trademarked consumable add-ons that end up unnecessarily costing the customer tens of thousands of dollars annually.

Did you like this post? Did you find it helpful? Was it thought provoking? Why not share it with your peers? I think they would appreciate it and I certainly would.

Is BBS just BS?

By Phil La Duke

Recently I was contacted by a student who is earning his degree in preparation for a career in Environmental Health & Safety.  He was given an assignment during his internship to research why Unions oppose Behavior Based Safety (BBS). It seems that in preparing for the assignment he happened across some of my writings that are critical of BBS and he wanted to know why I was so critical of BBS when so much of what I criticized would never be a part of what he was taught was not part of an “effective BBS program”.

First of all, I must applaud the young man for contacting me and asking me to defend my point of view.  I find that the on-going polarization in the debate in safety makes it rare that anyone actually seeks out opposing points of view; it would have been much easier to denounce me as uninformed, a nut, or provocative for provocation’s sake.  That having been said, I was alarmed that so many professors are still teaching BBS as undisputed fact.  This young man described me as one of the few opponents of BBS  he could find.  This is troubling on several levels.  I know of a growing number of people who are increasingly disenchanted with BBS but they openly tell me that they will not publicly criticize it because of the fanatics who shout down all other opinions or research that does not support their world view. In my writing, I admit that I have used very basic criticism of BBS because most people don’t even understand this very rudimentary criticism.

I believe (and I am not by any means alone in this) that BBS is inherently flawed; it’s a dead technology—even in its current state.  Its foundation is based on the erroneous and misleading statistic that 95% of injuries is caused by unsafe behavior.  Most experts that I know doubt the methodology that drew this conclusion. Along the same lines, the methodology Heinrich used to build his pyramid was species and is generally thought to be little more than one man’s opinion (that he reached after asking supervisors for their opinion with no scientific method to back up). Heinrich’s theories are on the periphery of BBS, but I believe there are substantial parallels in methodology.  Anecdotal data isn’t reliable.  Before you cite further studies, I will tell you that I have no respect for research conducted by companies and pundits who have billions in revenue at stake.  How likely are we to ever see the findings should the research prove that BBS is bunk?  I understand the argument that I have criticized older methods; I have heard that over and over again. But given that any criticism I make on a basic level draws, “that’s not the way we do BBS anymore” I remain unmoved. This response is like someone telling me the reason I don’t like eating squirrel and opossum anuses is because I just haven’t had them cooked right. After a while it gets to be like hitting a moving target…forgive me if I don’t continue to seek out the perfectly cooked and seasoned squirrel anus.

And despite the apparently underground outpouring of support for BBS, critics persist. Many companies famous for advocating BBS continue to be accused of encouraging under-reporting of injuries.  BP was once the shining example of BBS successes, do I really have to trot out its safety record?

Too many people continue to make corrections to there BBS as it fails; it’s flawed. It’s time to move past it, salvage what works, and discard the rest.

In other writings, I’ve said the following before, but just to be clear:

  • BBS is based on behavior modification.  When I say this, I either get one of two responses: “so what?” or “you’re over simplifying it”. Most behavior modification experiments ignore how people behave in populations, and safety is about how populations behave, not individuals. Nobody has ever satisfactorily answered this criticism and generally dismiss the statement by telling me that I don’t know what I am taking about.  Illuminate me.
  • People make mistakes; it’s a biological fact.  The reason people make mistakes is NOT because they are being careless. Current theory on mistake making is that the brain deliberately causes us to subconsciously test the safety of adapting by making little experiments.  Sometimes we call them discoveries and sometimes we call them mistakes.  All the observations, and reminders, and training, and all elements of BBS will not change the fact that people make mistakes, but we spend a fortune trying to; it’s misguided.
  • People take risks, and that’s a good thing.  People get up in the morning, they drive to work, they take short cuts, they take risks.  Taking risks are a necessary part of the workplace and BBS tends to pretend that it isn’t.  We need to do a better job of training workers to take risks appropriately and stop telling them to not take risks when we know that they will.
  • People wander away from the standards.  As we perform routine tasks we drift from the standard, BBS tries to address this, but does so amateurishly and ham-fistedly that it is difficult to take it seriously. Basic exercises designed to teach the difficulty in maintaining a standard easily demonstrate the impossibility of sticking to a standard when faced with variability in human behavior.
  • There needs to be a greater focus on protecting people from mistakes. Instead of trying to shape behaviors, organizations should manage the things that tend to cause people to make more mistakes. This approach would not only improve safety but would also improve productivity and quality and other factors as well.
  • One-Size Does Not Fit All.  BBS tends to take a one-size-fits approach, there isn’t an industry, environment, or population that the fanatics won’t claim that BBS is the answer, often before they even know the question.

All that being said, I think that there are elements of BBS that can be useful, but not as long as fanatics keep proselytizing BBS at all costs. There is such a strong population who will not listen to anything that does not proclaim the sanctity of BBS that most of the critics of BBS (and there are lots of us) have stopped talking.

Did you enjoy this blog? Did you find it thought provoking? Why not share it on Facebook, Twitter, or LinkedIn or by sending it to friends and colleagues via email.  I would sure appreciated it and I’m sure they would too.

#bbs, #flaws-of-behavior-based-safety, #safety, #worker-safety

Who Gives A Crap About Safety?

By Phil La Duke

Note: Some of you might be wondering where I’ve been and why my blog post is late this week. In the last three weeks I have been working at break-neck speed with my clients conducting Just Culture training at a major heathcare provider (which bounced me around from John’s Hopkins (not my client for now) to greater metropolitan Los Angelos, Detroit, and Chicago.  While I was able to write my blog posts, it made it tough to get them posted and promoted; sorry for that.  Those of you who haven’t already done so (and are disappointed when you don’t see the latest post) really should subscribe.  I don’t have any sponsors (I prefer to keep advertisers from meddling in editorial content) and I neither spam nor share subscriber information, so the only thing you risk is getting an email when there is something new on the blog.


If 16 U.S. children died at school every day there would be a revolution.  People would rise in outrage, proverbial torches and pitchforks lit, nooses at the ready, tar a boil, feathers cocked and primed; someone would pay. If grizzly bears ate 16 Yellowstone Park campers every day, the call would go out to gun the furry bastards down; society would descend on the hairy marauders like PCP-crazed furies. If every day somewhere a bridge collapsed sending hapless vacationers tumbling to their death on a rocky canyon floor, there would be similar outrage. But in the time it takes me to write and post this sixteen people will have died on the job (in the U.S. alone.) and for most of us it really doesn’t make all that much of a difference.  We read the account and think, “aw geez that’s a damned shame,” and maybe even whisper a prayer before we go about the business of living, stoic survivors of nature’s cruel ways.

A recent article by Dave Johnson in ISHN asked where the public outrage was regarding safety, or more accurately, the lack thereof. I’ve given the matter no small amount of thought and the conclusions I drew surprised me.  I was born and raised in metro Detroit in an area both affectionately and derisively referred to as “Downriver” a stained, second-hand quilt of communities peopled by the hardened steel workers, automotive assemblers, and sundry rough and tumble brutes that feed the beast that is the automobile industry.  We are the great unwashed, tough people in a tough town, where people where tee-shirts that say, “Detroit, where the weak are killed and eaten” and “welcome to Detroit, now go home”. We are the great unwashed you always hear about we’re proud of it. Don’t think you’re better than us until you can hump the line in the body shop for ten in heat that would kill a buttoned down Yuppie (yeah, we still call people that here…got a problem with that?) leaving only his uncalloused, girlie-smooth little hands in a puddle of goo on the shop floor.

People like us wear workplace injuries like badges of honor. Injuries at work are just our way of counting coup; we are the Great Plains warriors reborn, ghost dancing though the factory at time and a half.  We tell war stories about the time we fell off a ladder and broke four bones or got burned down to the bone. We pour one out on the curb for our fallen comrades who we watched die fallen heroes of a war for survival.  We don’t want to die, we don’t want to get hurt, but we are tough enough to take it.

A Legacy Of Death and Dismemberment

For my part, workplace injuries are my legacy.  Both my grandfathers died on the job.  My mother was 18 years old when she got the news.  A state trooper stammered through the details of the accident that took away her father.  The family mourned, of course, but not out of righteous indignation of, rather with the sort of quiet dignity one mourns the death of a soldier; a sadness tinged with a sense of pride borne of sacrifice. Details of my paternal grandfather are less clear.  He was a farmer and stumbled while pushing a wheel barrel sending the handle deep into his innards.  An incompetent doctor misjudged the seriousness of his injuries and the ensuing gangrene killed him.  No one shut their fist at the sky and yelled “why?” after all the job that killed him had provided for a wife and eight children, his death was greeted with fatalist acceptance; is luck had run out.

Closer to me, my father died of mesothelioma after decades of breathing asbestos. He died less than a year after being diagnosed; in agony, struggling to breath but never complaining. When he finally went, he held the cold steel stare of the Angel of Death and waited until the angel blinked before passing over to the other side.

When my brother came home and told us that his best friend had been killed on the job he had helped him to get he didn’t cry.  He didn’t go to pieces unable to deal with the fact that he was in a small measure responsible for the death of his friend.  He didn’t play “if I could do it over again” games. He stood there and took it.  That’s what we do, take it; we are life’s anvils.

For my part, I’ve lost count of the people I’ve lost.  The childhood acquaintance and known associate who died after falling into a vat of acid, the co-workers electrocuted on the job, the brother-in-law who died this year after sucking poison into his lungs in a workplace that Guinness Book of World Records once proclaimed the dirtiest square mile on the planet. I couldn’t begin to count how many people I know who have lost fingers, broken bones, and shattered their bodies on the job.  When you live where we live and do what we do you can judge us for our beliefs but be careful what you wish for; most of you can’t do what we do.

It’s not just Detroit: from the West Virginia coal mines to the avocado groves of California, to shrimpers in the gulf, to lumberman in Maine, we are everywhere.  We would love to believe that we can have a clean, safe job that won’t kill us, but for most us that’s not real.  Somewhere in the bowels of our souls we know that if we raise too much of a ruckus Wall Street will just move our jobs overseas, leaving us fighting and scrapping for jobs as bus boys and short order cooks.  We would rather die making a living wage than work three shifts at crappy “service economy” jobs.

We never expected that our jobs would be easy, or safe, or clean.  We watched, and continue to watch, a generation die horribly, but it’s the price we pay for a living wage.  We roll the dice every day we go to work and sometimes it comes up craps; them’s the breaks and nobody mourns the man who knew the risks he took before they killed him.  Casey Jones, John Henry, Big Bad John …ours is a pantheon of fallen workers who died plying their craft.  Far from pity we celebrate these mythic figures; giants among men.

So where is our outrage? That’s reserved for those who are trying to take our jobs away. Whether it be a greedy human canker in the executive suite or a safety do-gooder who makes it more profitable for companies to spill the blood of third world foreigners than ours. Outrage is a luxury of the leisure class, we got work to do, even if that work will one day kill us.

Did you enjoy this?  Hate it? Find it offensive or troubling? If so, I hope you will share it. The icons below will allow you to share this via Twitter, Facebook,  posting it to LinkedIn Groups or individuals, and even email it to individuals.  I maintain this and www.rockfordgreeneinternational.wordpress.com without direct compensation to promote Rockford Greene and my published work.  I’d sure appreciate it if you would help to pass the word to your fellow aficionados and or detractors. Thanks in advance, Phil

#outrage-over-unsafe-workplaces, #worker-fatalities, #worker-safety

Talking Dollars, Making Sense


The Great Recession likely has forever changed Operations leadership’s view of safety.  Gone are the days when safety professionals could lean on “it’s the right thing to do” to justify their actions and initiatives.  Operations leadership rightfully expects that the Safety function will contribute to the bottom line and show a return on investment for the funds it is given in its budget.

Quantifying the value provided by the safety function isn’t easy—most of what it does is cost avoidance rather than profit, and when one talks about cost avoidance, the conversation can quickly turn hypothetical. Despite these difficulties it is still possible to put together a compelling business case for safety.

Know What’s Important

Every industry has some measure that is more important than anything else, and that measure is seldom safety.  In mass production, downtime is an area in which Operations leadership is keenly interested, in other industries sales are what gets the most attention, still others it is delivery time or days in production.  While most (if not all) of these companies care about safety, safety is not seen as “keeping the lights on” and typically efforts to keep the workplace safer are seen as completely divorced from the other business measures.

The key to creating a compelling business case for safety is to express injuries in terms that Operations understands and to which it can relate.  Safety professionals must demonstrate the relationship between safety and whatever metric the organization links most closely to its success.  Years ago, I worked with a heavy truck manufacturer where a sharp safety professional was able to express the cost of injuries in terms of the additional number of trucks that the plant would have to produce to recoup the costs incurred because of injuries.

Know Your Costs

An organization’s cost of injuries should include both direct costs and indirect costs.  Direct costs are generally easy to gather and/or calculate.  These are costs like fines, medical treatment for the injured worker, and Worker’s Compensation costs.  Surprisingly, many organizations jealously guard Worker’s Compensation cost information from the safety department despite the obvious connection between the two areas. Indirect costs include things like loss of productivity, damage to products, and damage to the company’s image or brand.  Indirect costs are difficult to calculate and Operations leadership may see attempts to quantify indirect costs as juking the stats.

For example, let’s take a look at an injury where the worker cuts his hand and requires stitches.  Halfway through an eight hour shift a worker cuts his hand. The injury requires production to stop for 12 minutes, and a supervisor has to drive the injured worker to the clinic that is 10 minutes away.  It takes an hour to treat the injury after which the injured worker is sent home.

Direct Costs

  • 12 minutes loss of production (average wage of idled workers x average hourly pay x .2).
  • Wage of injured worker (wage x 4 hours)
  • Wage of supervisor while driving the worker to the clinic, waiting during treatment, and driving back to the workplace (wage x 1.4 hours)
  • Wage of janitor to clean up blood (wage x 15 minutes)
  • Cost of treatment
  • Wage of safety professional to complete required paper work.
  • Wage of the safety professional to conduct the incident investigation
  • Wage of the supervisor to participate in the incident investigation
  • Wage of witnesses who participate in the incident investigation
  • Wage of the Operations manager to read and react to the incident investigation
  • Wages associated with OSHA inspection
  • Fines

Indirect Costs

  • 12 minutes loss of production (average wage of idled workers x average hourly pay x .2).
  • Increase in insurance premium
  • Costs associated with decreased morale
  • Cost of legal consultation
  • Court Costs
  • Legal fees


It’s wise to present only the direct costs as actual costs, but it is also a good idea to reference the indirect costs as costs above and beyond those that you can quantify with hard figures.

Depending on how hospitable your Operations leadership is to safety, you may be able to skip the actual hard figures in favor of a estimated rate.  OSHA has a wonderful tool for calculating the costs of safety that includes both direct and indirect costs that the agency provides for free on its website. (http://www.osha.gov/SLTC/etools/safetyhealth/mod1_estimating_costs.html). The tool estimates the cost of a worker fatality at $910,000 (a ridiculously low number based on a National Safety Council study from 1998—but realistically this cost has probably not dropped from that time), $28,000 for a Lost Work Day injury, and $1,300 for a recordable injury. By entering one’s injury figures into the calculator one can estimate a fairly reliable cost figure.  This same website affords you the opportunity to calculate the impact of the cost of injuries on profit and sales as well.

Make It Personal

Several years ago I discovered a way to save companies millions of dollars by reducing their Workers’ Compensation costs.  After saving companies an average of $2.5 million (in one case saving a walloping $8.5 million in less than 8 months) I spent the next four years unsuccessfully trying to convince other companies to engage me for my services.  I learned later that I was not speaking the same language as my prospects.  On one hand I safety professionals who tended to be risk averse and shy about introducing me to the decision makers in Operations. On the other hand I had safety professionals who couldn’t see how what I was suggesting was different from what they where already doing or were reluctant to engage outside services.  In cases where I did have access to the Operations leadership I was equally likely to either make a sale or stiff resistance.  Nothing I said would pique their interests.  I was flabbergasted; didn’t they WANT to reduce injuries and safe millions in months?  Ultimately that particular business venture was a victim of the great recession and I parted ways with the company for whom I had invented it.  Recently I was talking about my puzzling dilemma with the COO of a manufacturing firm and he told me that the average plant manager didn’t care about Workers’ Compensation costs since that was considered a corporate cost and generally wouldn’t effect the plant manager’s bonus.  With that explanation things started to make great sense.  People respond to the things that affect them personally.  If I had positioned things just a little bit differently I probably would have been wildly successful.

If safety professionals want to be successful they have to find a way to make the decision makers successful and that is easier than most people think. The answer is simple: find out what is important to decision makers and relate safety in terms that they can understand.  Safety professionals need to be careful however, and never EVER exaggerate or misrepresent the costs.


#calculating-the-cost-of-injuries, #direct-and-indirect-cost-of-injuries, #safety-and-costs