Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

Ten Tips For Creating Appropriate Safety Incentives


By Phil La Duke

Safety Incentives are increasingly eyed with suspicion by regulators who worry inappropriate incentives might lead to under reporting of injuries. Unfortunately, many organizations have legacy systems that provide financial rewards for injury-free time periods. These rewards rapidly become seen as entitlements. If you find yourself in this situation take heart, you can easily change the incentives to encourage people to engage in activities that will lead to safer outcomes. When you make changes to your incentive programs follow these 10 guidelines that will help you create effective incentives.

  1. Limit the Scope. Whatever incentive(s) you create must be fairly limited to scope. Link the incentive to a very specific behavior. The behavior should be clearly attributable to a proactive behavior by the associates eligible for the incentive. You must be careful that the behavior cannot be plausibly the result of other external factors. For example, reductions in Incident Rates could be the result of the behavior could just as easily be attributed to under-reporting of injuries or even chance.
  2. Select a Behavior that is Completely Within the Employee’s Control. When we create an incentive that is outside the control of the employee we create an incentive for people to lie, cheat, and steal. Don’t believe me? Hold people accountable for sales.
  3. Link the Incentive to Reduction of Risk. By creating an incentive that directly correlates to the reduction of risk, you engage the worker in risk reduction and workplace safety. Imagine the benefits of having a significant portion of your workforce actively looking for ways to reduce risk.
  4. Consider Possible Undesirable Outcomes. Too often we create incentives that not only encourage a desired outcome but also encourage behaviors that we never saw coming and don’t want; its important to do serious analysis of other behaviors that might be undesirable or even dangerous or illegal.
  5. Make Sure the Behavior Can Be Measured and Tracked. Incentives should be like SMART goals (specific, measurable, achievable, realistic and time-based), and the more the behavior can be measurable and tracked the more likely people will participate and be successful.
  6. Make it Personal. Team incentives may be easier to administrate, but that convenience comes at the cost of individual control over one’s fate. By linking the incentive to a behavior that is performed by an individual you provide true motivation and you reduce animosity among team members who might be unhappy about losing an incentive because of poor performer of another.
  7. Provide Equal Opportunity to Succeed. Anything you link to the incentive should be equally accessible to all associates eligible for the incentive. If some of the workforce is excluded from participating it can lead to dysfunctional competition and cries of foul play.
  8. Avoid Outcome-Based Criteria for Success. Sales incentives are classic outcome-based incentive systems and they are universally stupid. Sales professionals can control how many face-to-face appointments they make, they can control how many cold calls they make, they can even (to some extent) control how many quotes they write, but they can’t control the outcome (sales) show me a salesman who is having a rough sales year and I will show you a salesperson who is at least tempted to lie, cheat, and backstab. But if you reward individual behavior-based activities instead of the result you will encourage people to work hard to behave in a certain way that is likely to produce positive outcomes.
  9. Don’t Make the New Criteria for Reward Harder than the One It Replaces. This tip is easier than it seems. When you replace the old incentive (that is outside the person’s control) with an incentive that is within people’s control you guarantee that it is easier to achieve. You will likely have to do some heavy promotion of a change to ensure
  10. Put a Positive Spin On the Change. Whatever you decide to do, you have to be sure that the new incentive system isn’t seen as a take away or as a punishment.

Filed under: Safety

The State of Safety

Alexander wept when there were no more worlds to conquer

Filed under: Safety

Indicators Are Meaningless Unless They Lead to Managing Performance

broken cross

By Phil La Duke

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

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

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

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

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

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

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

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

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

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

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

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Joe Safety and the Infinite Toolbox


By Phil La Duke

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

Improper Tool Use

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

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


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

A Double Standard

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

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

Filed under: Safety

Safety Slogans Don’t Save Lives


By Phil La Duke

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

Safety First

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

So Why Do It?

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

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

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

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Bill Sagy, the Safety Pioneer You Never Heard Of

By Phil LaDuke

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

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

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

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

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

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

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

Filed under: Safety

I Factory Rat

By Phil La Duke

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

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

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

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

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

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

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

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

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


By Phil La Duke

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

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

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

Blame-Based Safety

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

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

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

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

Filed under: Safety

A Pyramid By Any Other Name

by Phil La Duke

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

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

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

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

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

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

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

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

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

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

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

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

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

Your Only As Good—and Safe—As Your Process


by Phil La Duke

Several weeks ago I posted an article that asked you to take a new look at safety. I asked you to consider that safety isn’t something that happens to workers or that doesn’t happen to workers, rather it is an indicator of the efficiency and effectiveness of one of five basic business elements: competency, process capability, management of hazards and risk, accountability, and engagement. In that post I explored the relationship between competency and safe outcomes, and in this week’s post I would like to continue to explore safe outcomes as they pertain to process capability.

I should begin by precisely defining exactly what I mean by process capability. Process capability is the extent to which a process (i.e. an activity designed to produce a predictable desired outcome) as practiced varies from the specification. Your process is not deliberately designed to harm workers so by definition something has gone wrong when someone is injured. Process variability is seen as the principle enemy to efficiency by most process improvement; variability is deviation from the standard and this deviation means that the process is less predictable; the greater the variability the more unpredictable the results and the more hazardous the process.

There is variability in every process; even robots and the best automated equipment are incapable of returning the exact same result in every instance. Typically machine and equipment performance measured in its ability to meet specific limits. Statistical Process Control (SPC) is a discipline developed to improve process reliability (how consistently it performs within control limits) these and other tools can improve process capability and create safe outcomes.

There are obvious things that we can do to improve process capability. For starters, we can develop Standard Work Instructions (SWI). According to the Lean Institute, “Standardized work is one of the most powerful but least used lean tools.” Standard Work involves identifying and documenting the current best practice. In so doing, the organization can identify a) differences between how the work is actually performed and how it was designed, b) the safest way to do the job, and c) identify and document continuous improvements.

Once you have created SWIs you have the means to properly train new employees, evaluate the performance and skill level of existing employees and as I mentioned in the first in this series people who have the skills to do the job are better able to do it safely and correctly. What’s more SWIs allow worker input into workplace improvements. So many organizations have invested in half-baked safety systems that pay workers to watch other people work and provide feedback, why not have them do something productive instead, like…I don’t know…develop Safe Work Instructions?

Standard Work Instructions are more than merely operating instructions, but my intent here is not to give free consulting in Lean Principles. Sufficed to say that investing in standard work improves not only your process but produces safer outcomes. Standardized work isn’t just for manufacturing—it can be applied to everything from driving to dry cleaning—but it is seldom used for non-manufacturing processes even in manufacturing, which is disappointing. Too often organizations resist standardizing non-production work by claiming that it is too difficult. If that were truly the case than how do we ever train anyone to do it?

In my experience a fair amount of workers will resist the very concept of Standardized Work, once when I was teaching a workshop in standardized work one worker indignantly told me that nobody was gonna tell him where he was going to put his (expletive) toolbox. So it’s not that easy to implement standards, of course, I was able to turn it around and win him over by telling him that he was going to tell US where his toolbox should go.

Total Productive Maintenance (TPM) is another great tool for influencing safe outcomes, while the snake oil salesmen will tell you that you don’t need to invest in capital, machines wear out, technology advances, and the design, care, and appropriate maintenance of your equipment is essential. It is outright stupid to believe that you can keep workers safe using outdated, poorly functioning, and wildly unpredictable equipment and, for that matter, battered and crumbling facilities.

Another Lean tool that has a direct influence on safer outputs is 5S, but then I’ve already written ad nauseum on the relationship between workplace organization/housekeeping and its relationship to workplace safety, and given the criticisms of late that I tend to repeat myself, I won’t go into here.

All the best tools and robust processes are of little value, however, if no one follows them. The second element that you have to consider in how process capability influences safer outcomes is “process discipline”, that is, the extent to which people work within the process. We tend to construct safety controls based on what people are supposed to do, and often forget that what happens on paper isn’t necessarily what happens in the workplace. As variable as equipment can be, this variation pales in comparison to the variability of human behavior. No amount of training, hackneyed theories, or the dubious claims from soft-headed safety gurus will change the fact that human behavior is incredibly complex, unpredictable, and rife with variability. This having been said, we need to stop trying to reengineer the human brain and start building engineering controls that protect workers when they make mistakes or even deliberately take unnecessary risks or behave recklessly. We need to recognize that everyone makes mistakes, whether it be human error or poor choices, nobody should have to die because they chose poorly. I know there are people out there who feel differently (shamefully even some people within the safety practice), people who believe that some people, because of their poor decisions deserve to be injured or killed, but for me, killing workers is still bad business.

Filed under: Behavior Based Safety, culture change, Hazard Management, Mistake proofing, process improvement, Worker Safety, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,



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