Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

When It Comes To Injuries, the Simplest Answer Often Isn’t the Correct Answer


OccamsRazor

By Phil La Duke

Occam’s Razor is one of those things that a lot of people cite, more have heard of it, and in safety, many more use it to jump to conclusions. Perhaps the most often cited simplification of Occam’s Razor is “when looking for an explanation as to why something happened, the simplest explanation is usually the correct explanation.” Before the army of pedantic boobs mobilize and reign down a flurry of insults at my oversimplification of Occam’s work (which, for the record, experts don’t believe he actually invented) I should say that I fully and whole-heartedly admit that a) this is indeed an oversimplification but it’s not my oversimplification, and b) this oversimplification really belies a misunderstanding of what Occam’s Razor really says. La Duke’s Razor would be “The easy solution to worker injuries is generally the most popular, irrespective of its effectiveness.”

That having been said, too often, incident investigations assume that the simplest cause is the correct root cause and that conclusion, while comforting, is irresponsible ─ even dangerous. Take the all too common root cause of “operator error”. The conclusion that a worker was harmed because he or she erred is satisfying; if an investigator asks “why?” the answer is the variation on Murphy’s Law that says, “shit happens”, or for those of you scandalized by my scatological idiom, “nobody’s perfect”. The contention that everyone makes mistakes is a facile but deeply satisfying conclusion. When investigators conclude that a plane went down killing all aboard because of “pilot” error, we sigh a collective “thank God it wasn’t terrorists” sigh of relief, slap each other on the back and it’s “Miller Time”. Occam’s Razor and Murphy’s Law support the errant worker as proximate injury cause and who are we to argue with a dead guy and a fictitious guy? Certainly a fair number of injuries result immediately or soon after a worker errs, but until we understand exactly why a worker erred we will never have a complete understanding of the circumstances that led up to the injury and without that understanding avoiding future injuries caused by these unknown elements are complete luck. (I am fond of pointing out that in general lucky people win lotteries; I’m not sure I would categorize someone who narrowly escapes serious injury as lucky; they just aren’t fatally unlucky.)

Some injuries are tough for us to see beyond the obvious and the easy. Take for example the time I was walking on a sidewalk abreast of a colleague and a customer. As the three of us walked side by side we approached a temporary sandwich board and instinctively moved to the left to avoid the sign. As we did so, I stepped partially off the sidewalk and fell striking my knee against the sidewalk. My pants were torn and I skinned my knee. The most severe injury was too my dignity. If we use the standard 5 Whys it goes something like this:

Problem Statement: Worker tripped because he stepped off a sidewalk which caused him to lose his balance and fall and strike his knee against the side of the pavement.

Why? Worker moved to avoid a temporary sign but failed to verify that the area to which he was moving provided sufficient space to safely walk on the surface.

Why? Worker was distracted by a conversation he was having with his companions and committed an error.

Why? The worker was distracted because he was discussing a safety issue with his colleague and customer.

Why? The group was on its way to a lunch meeting.

Why? Because there was no other time to have the meeting and also have lunch.

Why? etc.

Such facile, linear logic sure feels good, particularly because (whether we admit it or not) it leaves the injured party holding the bag, sprinkle in some creative case management and garnish liberally with administrative pressures to achieve zero injuries and you can substantially improve your safety performance without reducing your risk one wit.

Truth be told, the simplest explanation doesn’t scratch the surface of the factors in play in this example. Off the top of my head here are some of the key contributors to the incident:

  • A sandwich board sign was placed on a crowded sidewalk that impeded pedestrian traffic.
  • The height between the sidewalk and the parking lot was slightly higher than usual.
  • The sidewalk was uneven
  • There was heavy pedestrian traffic
  • The sidewalk was adjacent to parking (the front of the come cars were parked against the sidewalk and in some cases cars were hanging over the sidewalk.)

The simplest explanation is that I wasn’t watching where I was walking and I fell. In other words: I screwed up and I got hurt, and to some extent I would have to agree. My first instinct is to admit that I needed to be more careful and watch what I am doing. But as pat an answer as that is, it doesn’t begin to tell the whole story. I WAS watching where I was walking, however, the sudden shift of the pedestrian traffic forced me to decide to move off the sidewalk (which would have meant walking into parked cars), collide with my colleagues (which would have forced them back into the sandwich board) stop until the path was clear (which would have risked having the people behind me collide with me), or step on the edge of the sidewalk and take care to maintain my balance). People take risks like this every day, heck I’m sure I’ve taken risks like that many times in the past and not been harmed. My assessment of the risks associated with my actions are that I probably won’t get hurt and if I do get hurt it probably won’t be serious; it’s easy to waive off any precautions as overly cautious.

It’s tempting to see simplest possible cause as the proximate cause because if we do it absolves us of having to do anything meaningful in the way of prevention. If the proximate cause of the injury is my carelessness the organization need only tell me to be more careful. If complacency is to blame for an injury the organization only has to tell people to stop being complacent. But if the problem is complex the prevention is likely to be difficult if not impossible. Let’s look at the example of my fall. What could we do to prevent this convergence of hazards? A quick look at the hierarchy of controls is pretty disheartening.   Realistically eliminating the hazards (heavy pedestrian traffic, cars parked adjacent to the sidewalk, a sandwich board blocking the flow) while possible isn’t feasible. We all know how hard it is to engineer out hazards once the bricks have been laid and mortar poured. Substitution is equally unfeasible, realistically the only thing we can substitute would be the sandwich board which the shopkeeper would likely resist any substitution, having selecting the sandwich board for its effectiveness and relatively low-cost. That leaves us with administrative controls ─ the police could ticket drivers for parking too close and blocking the sidewalk, outlaw sidewalk sandwich boards, or even establish rules requiring pedestrians to walk single file down the side-walk ─ and I think we can all imagine how effective these would be. I suppose we could require everyone to wear knee pads but count me out.

So we are left with two choices here equally loathsome: either we can take the easy route and decide that my injury was the result of my own carelessness and remind me to be more careful, or we can decide that the injury was the result of many interrelated factors that combined to raise the risk of injury to a level where someone was bound to be injured, and make corrective action difficult if not impossible.

It amounts to this, philosophically I believe as many do, that all injuries are preventable, but I also believe that sometimes preventing some specific injuries just isn’t feasible so individuals and companies decide it’s just better to live with the risk.

Filed under: Hazard Management

Dispelling the Complacency Myth


fatiguemanagement

By Phil La Duke 

The latest scape goat for injuries seems to be complacency. The latest in conventional By Phil La Dukewisdom holds that people get hurt because…well…they just need to be more careful. In fact, complacency is such a convenient villain that a major safety management system provider has built a business around it. The only problem is that many of the conditions described as worker complacency is anything but the case.

The dictionary definition of complacency, “1: self-satisfaction especially when accompanied by unawareness of actual dangers or deficiencies or 2: an instance of usually unaware or uninformed self-satisfaction”[1] which would imply that those who blame complacency for worker injuries believe that workers become over confident and therefore indifferent to the dangers around them. But according to an article on http://www.westfieldinsurance.com “complacency happens because workers, supervisors and management perform many functions on a continuous basis. Almost all jobs are repetitive in nature, and the more we repeat what we are doing, the better the chance at becoming complacent without even realizing it. Therein lays the potential danger”. It would appear that in the author’s view, complacency in the workplace is more akin to over confidence than true complacency.

Finding complacency as a root cause, in my opinion, is just another in a long line of “blame-the-injured” cop outs. If we accept the explanation offered by the article on Westfield Insurance’s website (no author is credited) complacency develops as people become indifferent to the dangers after doing repetitive tasks for hours. The answer, therefore, is to find a way to force people to pay closer attention to the tasks at hand. Unfortunately, such an approach is not necessarily supported by science.

I am not prepared to say that overconfidence and a corresponding desensitization to dangers as one spends more time in close proximity with at risk conditions isn’t a key factor in workplace injuries, but I am always a bit suspicious when safety professionals “discover” the next big injury cause. Certainly people will get complacent and over confident, but there are also other factors at play.

Mental Fatigue

If people are getting harmed because they are overconfident and take short cuts it makes sense that keeping the workers mind on task would make the most sense, but research in the physiology of the human brain[2][3] shows that intense concentration on a repetitive task causes mental fatigue, and the longer the period of time one spends intensely concentrating the greater the fatigue, and the greater the fatigue the higher the likelihood of human error[4] and the corresponding increase in the risk of worker injury.

This creates a quandary for the safety professional─ not enough focus on the task at hand and workers put their safety at risk, but too much concentration on a task also puts them at risk. What’s worse is that in the middle is behavioral drift (the practice of slowly and subconsciously moving away from the standard operating procedure.[5]

How Much Concentration Is Too Much?

Boksem, et el, found that mental fatigue was evident within one hour of intense concentration and other studies have found that moderate mental fatigue can impair judgement[6] . Mental fatigue (or sleep deprivation) leads to:

  • Impeded judgment. Fatigue impedes the worker’s judgment and reasoning ability so attempts to get workers to concentrate may actually be increasing poor decision making.
  • Lack of manual dexterity.  A loss of mental acuity because of fatigue has been shown to decrease people’s manual dexterity; assuming that the job requires some level of manual dexterity fatigue leads to greater risk of everything from slips trips and falls to the proper use of tools and even PPE.
  • Lack of alertness. Invariably, the brain will fight any efforts to maintain prolonged concentration on a task and fatigued workers may become groggy and absent-minded.
  • Diminished ability to focus on details. A fatigued worker is far more likely to miss critical steps in a process, and when a worker is working out of process he or she is far more likely to be injured.

Multiple sources list fatigue as one of the top five causal factors in workplace incidents[7] so while experts may attribute upward of 90% of workplace injuries to unsafe behaviour, most fail to answer the question of why a worker behaved unsafely. Increasingly, that answer is linked to a fatigue.

If one hour of concentration on a task is enough to increase the risk of worker injuries that how much more risk is there to workers who are working longer hours. Research has found[8] an 88% increased risk of an incident for individuals working more than 64 hours a week.

Damned If You Do, Damned If You Don’t

So it boils down to this: workers who don’t pay enough attention to the task at hand are at far greater risk of injury, but workers who pay too much attention to the task at hand are at even greater risk. It would be easy to either suggest unworkable solutions (a ten minute break every ten minutes, for example) but even if these techniques were enough (and research has shown that returning to a non-fatigued state where performance returned to normal are difficult and time consuming[9]). In effect, there is no practical solution to eliminating the risk of complacency, behavioral drift, or mental fatigue. We can’t ─ no matter how hard we try ─ eliminate human error and risk taking so we should instead focus our efforts on mistake proofing. We need to channel more of our energy into protecting people from their mistakes instead of trying to reengineer the human animal.

[1] Merriam Webster On-line Dictionary

[2] Effects of mental fatigue on attention: An ERP study, Maarten A.S. Boksem, Theo F. Meijman,Monicque M. Lorist

[3] Mental fatigue, motivation and action monitoring Maarten A.S. Boksema, Theo F. Meijmana, Monicque M. Lorista,

[4] Whack A Mole Marx, David

[5] For more interesting facts about behavioral drift, see Behavioral Drift’ Threatens the Safety of Flight Operations http://www.nbaa.org/ops/safety/20130909-behavioral-drift-threatens-the-safety-of-flight-operations.php

[6] For more information on the effects of fatigue on workplace safety see my article, Asleep on the Job Published: 19th Mar 2014 in Health and Safety International

[7] Chan, 2010

[8] Vegso et al (2007)

[9] Environmental Influences on Psychological Restoration, Scandinavian Journal of Psychology, 1996, Hartig, Terry, Gook, Ands, Garvill, Jorgen, Olsson, Tommy, and Garling, Tommy

Filed under: Behavior Based Safety, Risk

Safety In the Age of Wikipidiots


wikipeidiot1

By Phil La Duke

“It is better to keep your mouth closed and let people think you are a fool than to open it and remove all doubt”—Mark Twain

I haven’t posted an original post in over a month. I decided a while back that posting for the sake of posting served no good purpose. Not that I haven’t had anything new original to write, it’s just that I have started no fewer than six pieces that degraded into lengthy meandering pieces with which I was never quite satisfied; those of you who are long time readers must know that my bar for satisfactory work is set pretty low and can conclude that while the pieces have had some kernels of truth and fresh perspectives they weren’t worth the paper on which they were printed. I have been working on an original published piece for the Michigan Manufacturers Association which will be out in the organization’s digital June issue, a follow up piece for the same magazine for June, three pieces for Entrepreneur which are far and away more of a pain in the ass than they effort could ever be worth, and my monthly column for Fabricating & Metalworking which inexplicably haven’t even been read by my editor let alone seen print (do me a favor and drop him an email and ask him why mriley@fandmmag.com I’m more than a bit curious myself.) But most of my in the last two weeks has been spent sparring (both publicly and privately) with one of my many detractors; the particulars of said feud aren’t really important, but what IS important is that all of the back and forth has inspired four different posts (the first one being the one you are reading).

The argument devolved into a “is so, is not” where the detractor did nothing but heap condescension and abuse on anyone who dared question his interpretation of what I found to be specious conclusions to dubious research. I quit the exchange early, as it was, as I am so found of saying “like trying to do a card trick for a dog—no matter how hard I tried, how slowly and patiently I explained my point, or what I said, he just wasn’t going to get it.”

One of the other participants in the public quarrel quoted something that James Reason said of the safety profession in the early 70’s (those of you who simmer in pedantic rage at my lack of citation can look it up, I have neither the desire not the ambition for such an undertaking). The quote had to do with the great schism in the safety community over whether or not injuries were the outgrowth of individual error or system flaws. I’ve spent the better part of two years reading scientific and behavioral science research on why we make mistakes and I am somewhere in the middle of this debate. But the concept resonated with me (and I use the word “resonated” in the truest, purest form) I found the concept of this most basic philosophical disagreement echoing through my thoughts, coming to me at odd moments, and nagging at me. I realized that my work in safety is probably a waste of time, that I might as well be standing on my balcony addressing an army of ceramic lawn gnomes; in other words I am not likely to change anyone’s mind about safety.

Who Needs Facts? I Got Me An Opinion!

When future historians trace the origins of the demise of Western Civilization my guess is that the Wikipedification of society will be seen as a key factor. People today are quick to believe what they want to believe, seek out other opinions disguised as facts that support their largely untenable positions. It’s not just Wikipedia that has created this “if enough people believe it then it must be fact” mentality. A few years back Google modified its search algorithm to steer people to web pages that were aligned with their beliefs. It seems that people don’t want to have their beliefs challenged and learn; rather they want to be reassured that whatever stupid dreck they’ve come to believe isn’t nonsense after all. We have created a world where facts, logic, research, and even scientific findings are subject to a vote; while Lot looked for ten just men, today all one need do is find one delusional crackpot with a message we find reassuring and we can discount science, history, and…well just about everything. It doesn’t matter if we have a smoking gun definitively and indisputably disproving a methodology or belief, the people who derive a living from spewing their soft-headed pabulum will simply shout it down whilst speaking to rapt audiences eager to believe in their hog wash.

So What’s the Point?

Ostensibly, this doesn’t seem to have much to do with safety, but it does. If we continue to give equal credence to charlatan and visionary alike people will die. Innocent people are being killed in our workplaces every day. And when people over simplify safety with their magic bullet solutions—which are lucrative and easy to sell—they have blood of innocents on their hands. I know of a company that invested heavily in a well-known snake oil solution and had a fatality. I am still haunted by the blood-splattered poster and I wonder if the victim was able to see the irony in his gore festooning a poster reminding him to work safe. I wonder as he lay dying if he was able to think of anything beyond what must have been incredible pain, and if he was able to think, if he would care that so many people around the world bought the snake oil worked, drank the Kool-Aid, or simply agreed that reminding people to work safe would save his life. Or did he think of his widow and his children, if the dead could edit Wikipedia what would he have to say on the subject?

The Attention Spans of a Fruit Fly

I write for a lot of outlets, and when I am given my first assignment I always get the same spiel: No more than 500 words. Why? “my reader’s don’t have time to read anything more than that, and frankly 500 words is too much”. We aren’t just getting dumber as a society we are demanding that people dumb it down. I gave a speech recently where the second of two was cancelled because my message was “too sophisticated for workers” (my speech was on what it meant to have safety as a value) I was literally replaced by a guy who set fire to stuffed squirrels to demonstrate the dangers of arc flash.

Stupid Is As Stupid Does

I have never wanted to be stupid. I have had a strong thirst for knowledge and seek out opinions diametrically opposed to my own. It can be scary to read books by experts that artfully lay out an argument that makes such perfect sense that it shakes your beliefs to the core, but it’s necessary to grow as a person. I don’t think I’m in the minority but you will never go broke selling stupidity to the stupid. I spend my spare time reading non-fiction books on safety, just culture, mistake making, the physiology of the human brain and how our emotions shape our decisions. It doesn’t make for fun weekends or scintillating dinner conversation. (You might be surprised at the level of uninterest (apparently this is not a word, but I don’t mean “disinterest” which means not really caring one way of the other, but of the absolute dearth of interest) in how synapsis work, or what part of the brain we use to make decisions, or why biologically making mistakes is not only unavoidable but necessary for survival.)

Is There No Hope?

I realize, I confess, that I print a pretty bleak picture. But when we stop listening to experts in favor of money-grubbing mouth-breathing safety profiteers we risk more than our own careers we risk the lives of others. I should note, for the record, I don’t really think of myself as an expert on worker safety, rather I think of myself as a guy who reads all the articles, books, and opinions of true experts and translates their work into simple truths that I share with a handful of safety professionals who by and large are just looking for solutions to problems that are beyond their ability. They’re looking for fast answers and quick fixes—in safety time isn’t money time it’s blood—and I do my best to find and share them.

I started this post with a quote (at 1388 words I wonder if anyone is still reading this) about staying silent and being thought a fool (I guess we’ll know by the number of people who post comments correcting me on the source. I checked my sources (as I generally do) and found that this Mark Twain quote had been attributed to no fewer than 8 sources. I thought it appropriate to start the article with something so easy to verify (who said what) on which know one seems to be able to agree. For the record, Abraham Lincoln said something similar (“Better to remain silent and be thought a fool than to speak out and remove all doubt”) but both he and Mark Twain were both quoting (or more accurately paraphrasing) Proverbs 17:28, or Proverbs 18:28, or A Farewell To Arms, or Curious George Goes To The Beach let’s put it to a vote; what difference does it make?

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

“Safety Manager Charged in Worker’s Oven Death”


Phil La Duke:

Think you are immune to prosecution…think again

Originally posted on EHS Safety News America:

The former safety manager at a Santa Fe Springs, Calif., tuna-processing plant faces a maximum sentence of three years in prison and/or a $250,000 fine if convicted on felony criminal charges related to the 2012 oven death of an employee.

The rare charges against a safety professional were brought by Los Angeles County District Attorney Jackie Lacey, who alleges that Bumble Bee Foods, the company’s former safety manager Saul Florez and the company’s plant director Angel Rodriguez willfully violated worker safety rules.

According to Lacey, 62-year-old Jose Melena, a six-year employee of the plant, entered a 35-foot-long oven in October 2012 to make a minor repair. Co-workers were unaware that he was in the back of the oven as they loaded it with cans of tuna, closed the door and turned it on. During the two-hour heat-sterilization process, the oven’s internal temperature rose to about 270 degrees. Melena’s severely burned…

View original 187 more words

Filed under: Safety

Superstition-Based Safety?


safety ritual

by Phil La Duke

Does this sound familiar: You do what all the experts say, you read articles on how the world’s safest companies, or you come back from a conference ready to implement the hot safety tool? But instead of creating your safety Utopia your efforts fall flat. You end up doing all the right things but—far from getting the remarkable improvements you’ve been expecting—your efforts fall flat. You end up trying idea after idea but nothing seems to make a difference.

I have been on far too many sales calls where I was stopped cold be the same objection: “we’re already doing that”. I would always get frustrated, because I in my arrogance I reasoned that given that I had invented this process there is no way on God’s green Earth that someone else was “already doing that”; except that they were. It really messed with my head when I first realized that what I thought was this profound and innovative approach was being doing done by numerous other companies around the globe. I shouldn’t have been surprised, my approach is based on the practices and values of the world’s safest companies and since many of these practices were widely known and used it was reasonable for these people to believe that I had nothing new to offer. Except there was one important difference: my approach rapidly improved safety performance and drove down the monies companies spent on worker injuries—both the frequency and severity of injuries fell exponentially, so if these folks were doing the same thing, why weren’t they getting the same results?

I’ve spent a fair amount of time pondering how two so very similar approaches can produce such dramatically different results and I have reached several conclusions:

  1. Requirements without Context. When people are given an assignment without a clear explanation of why they are doing it the behaviors become ritualistic. After a time these behaviors become deeply imbedded into the culture and since the population has no understanding of what these events are supposed to accomplish they just keep doing them often complaining bitterly that they are getting nothing out of the activity. Think of your safety meeting, what exactly are the expected, tangible outcomes? Do these meeting achieve these outcomes? Are achieving these outcomes worth the time and effort spent to achieve them. It’s important to recognize that people don’t always recognize ritualistic behavior (I’m not talking about drawing pentagrams on the floor after all).

Perhaps the most common ritual is the safety metrics review. Why do we review our metrics? If all we do is trot out our latest performance without asking ourselves what these figures are telling us than the safety metric review (no matter how wonderful our leading and lagging indicators are) then we are wasting our time and the company’s money.

  1. A colleague of mine used to describe most companies’ safety efforts as “administrivia”. I like the term. For me it conjures up images of people dutifully going about their business without any expectation of change. In many organizations, safety is filled with administrivia; things that we do because our policies say we must or things that we do because someone other organization says we should, or things we do because it’s a safety tradition. There are many things that we do in safety that may have added value at a time but don’t any more. There are still others than add value but not enough to justify their continuation. All of these things attach themselves barnacle-like to the organization and slow us down, make is less nimble, and unproductive.
  2. Compliance Without Understanding. In some organizations the corporate office has laid out a strategy or a plan and the sites have dutifully implemented its elements. All is right with the world. Unfortunately, those at the site don’t really understand what the purpose of what they are doing. Because they don’t understand why they are doing what they are doing they don’t ascribe the same importance to getting it write, doing it on a regular basis, or even be able to ascertain whether or not it has been done correctly. The lack of understanding leads again to ritualistic behaviors and superstition-based safety, but in this case, the ritualistic behavior will never be questioned or even seen as anything improper.
  3. Absence of Connection. Companies with world-class safety performance connect everything they do to improve safety into a performance improvement system. Many organizations miss this and instead create independent and discreet activities that limit the effectiveness of the safety efforts. Without a flow of clean data that can be interpreted by the people with the power to act on the data these activities simply produce data that is inaccessible to those who need it. Furthermore, without a connection between the activities it is impossible to get an accurate read on the effectiveness of the safety efforts; trends get more difficult to see and accurately interpret which leads to misinterpretation of the data. In some cases the organizations start to see trends where there are none and are misled into thinking that a course of action is working (or not working) when the opposite is true.
  4. Organizational Inertia. Sometimes the organization gets so caught up in tactics and activities that it loses sight of the fact that in the end results are all that matters; we get no points for trying hard if we fail. Organizational Inertia is akin to the worker who is disengaged; the man or the woman who is just punching the clock caring neither about success of failure. Inert organizations will continue doing things in the name of safety because they are afraid that if they cease these activities someone will accuse them of not caring about worker safety, far better to continue ineffective activities than to be branded as antagonistic or indifferent to worker safety.

All of these factors make the difference between high-performance safety infrastructures and safety pomp and pageantry, between safety systems that work and those that don’t, and in some cases they make the difference between life and death.

Filed under: Safety

What’s Wrong With Drinking The Kool-Aid


poison kool aid

By Phil La Duke

Recently ISHN published an article by me (about the uselessness of slogans) that has drawn a fair amount of both criticisms and questions. In one case, a long-time reader and friend posted something of a response, and though I am arrogant, I am not arrogant enough to believe that his LinkedIn post was completed directed at me I am arrogant enough to believe that his post was at least somewhat prompted by the article. A few days later, I received a request to join the network of someone who too read the post/article and voiced her concern on how best to address the tendency on the part of both safety “professionals” (her quotes, not mine) and corporate leaders to push, slogan-based pseudo-psychological time and money wasting activities so pervasive in the safety field.

I believe that there is a great philosophical divide in safety that one can illustrate as a four quadrant model. On one axis we have behavior (I adopt the Anglo spelling of the word because that’s the way most of the world spells it) on one end and process at the other; all safety practitioners fall somewhere along this continuum. The other axis is bordered by individual responsibility versus organizational responsibility. What this means is that everyone who derives a living from safety believes that either injuries are caused by behaviours or process flaws or either the organization or the individual bears primary responsibility for safety. For the record I am a centrist in this debate although like most I can drift to a quadrant depending on my mood or the topic.

safety quadrant

As I have said on many occasions, I ardently believe that there are tools that simply don’t belong in the safety tool box. For example, there are still people out there that believe that disciplining workers for getting injured is a useful tool. While it is certainly appropriate to discipline people for recklessness, I don’t believe that it is ever appropriate to discipline people for human error, that is, something they didn’t intend to do and yet made an honest mistake. This is just one example of a “tool” that I think most people would agree doesn’t belong in the safety toolbox. I am taking the easy way out, of course, but there are a fair many more controversial tools that I could have mentioned but that would simply raise the hackles of many safety professionals and would interfere with an unemotional debate.

I have posted that “it’s just a tool and every tool in the toolbox has a use” is a tired argument and I believe that it is; it’s what people say when they can’t construct a logical argument against a point I make that questions the value of a “safety” activity. Saying “twisting the heads of ducks is just one tool in the safety professional’s toolbox” is just a passive aggressive way of saying “well that’s YOUR opinion”. Say what you want about me, but there is nothing passive about my aggression. I make these points because I want to get to the heart of the issue, and that issue is the alarming frequency with which safety practitioners use superstition and folk wisdom instead of science. Nobody likes to be told that their cherished tools are useless gibberish but at some point we have to call the emperor naked.

Too often we in safety start with a solution and work backward to make it fit the problem; we begin using the tools and methods that we enjoy, find easy to use, or understand. It’s human nature to gravitate to the familiar and safety practitioners are no different. I’ve called techniques psychobabble and antiquated. Some of these “tools” flat-out don’t work and others may still work, but there are far better, more effective and less expensive ways of accomplishing the same thing. I include Behaviour Based Safety as one of these tools. As many of you know, I am an outspoken critic of BBS. Why? because if you ask 10 BBS proponents to define it you are likely to get 11 different responses. How can a methodology be effective when its top proponents and advocates can’t seem to agree on its very definition? I honestly believe that it does lead to a “blame-the-worker” mentality. Not in all cases of course, but the danger is real and always there. When I make these criticisms people don’t defend BBS they say I don’t understand it or that the organizations that I have seen have implemented it inappropriately. We can blame the organization as improperly applying the methods or tools, and we can blame the BBS practitioner as being misguided, or we can blame a host of other things, but the damage is still done.

For the record I don’t believe that everyone who sells or advocates BBS is selling snake oil or a knuckle dragger, but some are. Many believe that what they are doing is the best bet for improving worker safety, other have spent their career selling something that is increasingly dubious and when it comes to safety this is unconscionable. But as my LinkedIn colleague pointed out, clouding the water by filling the C+ suite’s heads with ill-defined schemes for making the workplace safer puts workers at risk.

Many BBS practitioners advocate behaviour modification as a useful tool for “changing our lives for the better” and I couldn’t agree more. But shy of a cult, behaviour modification is typically not successful in changing the behaviour of a population. The workplace is an interactive population and the sciences of sociology, anthropology and other social sciences are ignored by many BBS theorists. Frankly were it possible to use behaviour modification to change the behaviours of a population we could end war, crime and a host of societal issues by using it. We would live in a Utopian society…and yet we don’t.

When I post it is my ardent hope that safety professionals will rethink their practices and ask themselves if what they are doing is returning value that is commensurate with the cost and effort that it requires. Alas, far too many in the safety community are unwilling to even consider change and will always keep tools in their toolbox solely because they like them and are comfortable using them even if they are destructive and dangerous.

How do we make these safety practitioners that their ideas are misguided, nonscientific, and dangerous? Sadly I don’t have any answers. How do you convince Jenny McCarthy that her contention that vaccinations cause autism? People argue that her position is not supported by science but their arguments fall on deaf ears. How do you use logic to sway people from the persistent emotional belief? You don’t. Now, imagine these people who are so emotionally tied to an erroneous belief derive their incomes by getting others to invest in these emotional beliefs. You don’t have another tool in the toolbox you have another glassy-eyed convert lining up for a glass of Kool-Aid. And what’s wrong with someone “drinking the Kool-Aid”? Let us never forget that the expression “drinking the Kool-Aid” refers to the mass murder suicide of the members of Jim Jones’ People’s Temple followers. So what’s wrong with “drinking the Kool-Aid”? It’s laced with cyanide.

Filed under: culture change, Organizational change, Safety, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Who Will We Kill Today?


The Tomb of the Unknown Worker

By Phil LaDuke

Somewhere in the world someone will die on the job today.  Maybe it will happen across the world from you and maybe it will happen next door to you, but they will die nonetheless.  Whoever it is who loses his or her life on the job, some things are likely to be true. The about to be recently deceased person is disproportionately likely to be poor, have less than average education, and or working in an unskilled position. There’s a good chance he or she will be young and in many cases he or she will be either a temporary worker (“temp”) or a contractor.

In the U.S. April 28th   is Worker Memorial Day; it’s a day not widely celebrated in the U.S. We love to remember our war dead and herald their sacrifice and we should. On Memorial Day, we remember our war dead because they laid down their lives for a greater ideal, whether we agree with the cause or reject it with all our being, whether we are hawks who are ready to go to war at the smallest provocation or doves who oppose war at every turn, we remember and honor those who answered the call. What then of those who died on the job, those young and old whose deaths served no noble purpose? What do we owe those slaughtered and maimed in our mills and mines, factories and warehouses? Unless these deaths spur us to action—meaningful, substantive changes in how we view the death of a worker (and what we do in response to these incidents) whether they be full or part-time, contractor or employee—we not only fail to honor their lives but we cheapen their horrible and untimely deaths.

I have heard one too many time the tale of a worker killed on the job. After the crocodile tears are shed and words like “senseless tragedy” and “completely preventable” roll off people’s lips in somber tones invariably someone makes will sigh and shrug in a what-can-you-do?” dismissal of the horror of dying while at work. And what’s worse is that in many of these cases, the safety professionals breathe just a little easier, when the worker is a contractor (at least it wasn’t one of ours).

While much fuss and fury are made about those who die at work, I haven’t really seen a lot of progress in reducing the risk of fatalities; it’s like Mark Twain’s famous quote about the weather “people are always talking about (it) but no one ever does anything about it”. To be sure things seem to be getting safer. Injuries are down. Well not all injuries—serious injuries and fatalities remain flat—but some injuries are down. Unless they’re not.

Let’s not deceive ourselves anymore. A good share of the reduction in injuries has nothing to do with less people getting hurt. There’s the issue of under-reporting (hell there has been a whole cottage industry within safety that either deliberately or inadvertently encourages workers to lie and say an injury was non-work-related or not.), but there is also the trend toward outsourcing the dirtiest and most dangerous jobs to contractors. I’ve written several pieces on the sickening trend toward pushing the most hazardous jobs onto small, mom-and-pop contractors.

The smaller the contractor the less likely that it will be subject to OSHA regulations, have properly trained employees, or even the right tools. Whenever I see a residential roofer working hauling roofing materials up and down an unsecured ladder, working with no fall protection, and generally doing things that would make a suicidal tightrope walker cringe I think about the tens of thousands of people who are working for small firms who have little to no regard for worker safety.

Small businesses have become iconic in the United States. Want to cut business taxes? You need simply reference struggles of the small business. Want to ease (or eliminate) safety regulations? Again all you need do is point at the poor suffering small business. Wanton disregard for a worker’s basic human right to live through the workday is being justified in the name of easing the burden of small businesses. Before anyone shakes their fist at the sky and decries me a Bolshevik, I have, throughout my career owned small businesses, and while I am at it, at 5’7” I am still a small businessman. I know the pressures of trying to make payroll and trying to manage cash flow. I am not indifferent to the very real challenges of running a small business, but my sympathy stops at killing my friends and family, at allowing my children or the children of others to die simply because the mom-and-pop shop can’t afford to protect them.

The blame doesn’t lie completely on the shoulders of the small business. Many and most big companies have transitioned from having large full-time workforces in favor of smaller core workforces augmented by contractors. In the1980’s in U.S. the move to sourcing work traditionally done by employees to “independent contractors” was fueled by an increasingly tighter global market coupled with the recession and greed. Fobbing work off on to contractors was smart business: you could pay the same wage (or less) without the burden rate (typically the worker’s wage, benefits, and sundry employment costs). What’s more you didn’t have to provide benefits, and a smaller workforce (that is, fewer fulltime employees) meant that in many cases your company would be were exempt from regulations they would have faced if they had more fulltime employees). Add to that the fact that independent contractors are far less likely to form unions, and that you don’t have the hassle of wrongful discharge lawsuits if you decided to throw away the contractor like a used Kleenex, and fewer full time workers meant lower payroll taxes and you have a real tempting alternative; so much so, it seemed stupid to have employees at all.  As time went on, companies saw an even bigger benefit: a company could outsource the most dangerous jobs and lower its Workers’ Compensation and or insurance costs. Hiring contractors to do the jobs that were most likely to get your people killed or seriously injured would get you off the hook if something went sideways. Of course, as many companies have since found, things don’t always work that way, legally speaking.

In the minds of too many corporate cultures the death of a contractor is someone else’s problem.  The loss of life is terrible, but there are many terrible things in life that we just can’t concern ourselves with, like world hunger or unrest in faraway places the death of other people’s employees is a shame, but it isn’t our problem.

Like Lambs to the Slaughter

Many of us view the issue of outsourcing our fatalities as one of those far away problems (I am willing to bet more people worry about contracting Ebola than they are about losing someone close to them in a workplace fatality) but in the U.S. we have a generation of new grads who cannot find jobs. Saddled with predatory student debt that can routinely rise above six figures, these recent grads are forced to work for temp companies just to subsist. My daughter has two degrees from Loyola (Journalism and English) and has an impressive résumé as an editor and writer (she would want me to emphasize that she does NOT edit my misspellings-and-grammar-abominations infested blog posts) and yet she works as a teachers’ assistant making a pittance above minimum wage. It’s people like her and her peers that are forced into “subemployment” and who we, as a society throw to the wolves of the contractors.

We love to get high and mighty in safety and talk about making safe choices and exercising stop work authority, telling our workers that no job is worth dying for, but what choice do twenty- something workers have when the decision before them is to risk their lives (and let’s face it, most probably be okay) or use stop work authority and lose their subsistence jobs that they struggled hard and long to get.

We may not have been able to save our war dead, but we can damned sure save the workers employed in these deathtraps. We can start by asking questions; what kind of safety records do the companies we employee personally (roofers, landscapers, etc.) have? What about the companies we do work with professionally? What about the companies in our stock and 401K portfolios? If we look the other way in the name of profit we are as guilty as the foreman who tells the temp to do something life threatening the first day on the job. Unless we do all this and more we are complicit in these deaths.

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

Creating Leading Indicators


by Phil La Duke

Several weeks ago I wrote a post on indicators, which spurred a bit of interest in what I saw as appropriate indicators for the five antecedent processes to which I ascribe safe outcomes (just to refresh your memory, I am referring to: competency, process capability, risk and hazard management, accountability systems, and worker engagement). Several readers seemed disappointed that I didn’t spell out leading indicators for all of the processes. I have been mulling this over for several weeks and I’m afraid that what I am about to write will disappoint and maybe even frustrate some of you; and yet, as is my wont, I am going to write it anyway. I won’t give you leading indicators for these processes. It’s not that I don’t want to give away the secret recipe, quite the contrary, I have been writing this blog since 2008 (with a major interruption where at the insistence of an employer at the time that resulted in me scuttling the blog and deleting all posts prior to that time.) and have generated about 35,000 words of free advice in service of the safety community. You may not have always agreed with it, taken it, or even appreciated it, but it can never be said that I withheld critical information because I thought I could sell it to you instead of providing it for free. My thinking is that if you can do it without me you would, and if you were to do it in partnership with me you would end up with a better result faster, but then I digress.

When I first conceived this article I thought I would write a straight-forward piece outlining the leading and lagging indicators and lay out what I would see as the best choices for the business processes that I always seem to prattle on about; and then it occurred to me that there is scarce little value in me telling you what indicators to use. You see, there aren’t any shortcuts in safety, and that includes safety professionals. This is a problem that plagues the safety profession. Safety practitioners are so obsessed with keeping up with the proverbial Joneses that we often lose sight of the fact that safety practices aren’t and shouldn’t be universal. Is it so hard to believe that a practice that is applicable to construction may not be applicable to mining? Or even something that may be right for one company may not be right for another? In the interest of editorial openness I suppose I should remind you that I make my living providing essentially custom solutions (sure I have an 80% template and yes I use methods that have worked in the past, but I don’t have a one-size-fits-all solution that I keep reselling.)

Too much in safety are derivations on a theme and too few in safety are willing to either question these themes or come up with something truly original and more importantly something absolutely appropriate to his or her industry, company, or circumstance. It’s far easier to copy something that someone else is doing or buy something that a snake oil salesman is selling the solution d’jour.

So while I won’t tell you what indicators to use to measure these antecedent processes and where they are leading you, I will share with you how to create sound leading indicators.

Before we get to how to create leading indicators, we should remember the importance of pairing leading indicators with corresponding lagging indicators. Lagging indicators have taken it on the chin of late, and that’s a shame. Lagging indicators, when properly paired with leading indicators, are important ways to get a complete picture of the health of your safety efforts.

The key to creating leading indicators is to draw a line of site from an action to a planned result. Let’s say you are trying to lose weight (something with which I struggle) if you want to create some leading indicators you first have to identify things that tend to result in sustained weight loss. Doctors are keen to tell you that the best way lose weight is to consume less calories (diet) or burn more calories (exercise). So you could set your caloric intact and level of exercise as leading indicators. Those of you who have tried to sustain a weight loss effort already understand that these indicators really don’t help you that much. So what can we do to make them better?

  • Set Performance Goals. Indicators are bits of data that tell you how either you are doing toward your goals or help to you to stay focuses on activities that will help you achieve your goals. It amounts to this: without goals indicators are simply pointless exercises.
  • Get specific. Instead of tracking the amount of calories you consume, you would probably get better results if you set specific caloric goals; for example calories per meal instead of a broad goal of “eating less”. The more broad the indicator
  • Guard against unintended consequences. Think of fad diets. Fad diets generally work in creating a short-term goal (i.e. weight loss) but often have destructive side effects related to a nutritional imbalance (if you ate nothing but potatoes you might lose weight, but you would also likely contract scurvy) okay, maybe not, I don’t know how much vitamin C is in a potato and don’t really care. Even so, the more broad the indicator, the more likely there is to be “noise”. By noise I mean other factors that may be causing a change that have nothing to do with your efforts. Continuing our weight loss example, you might find yourself dieting and exercising and conclude that these activities are causing rapid weight loss, but you may have a serious medical condition or metabolic imbalance that is causing (or increasing) your weight loss. This get’s even more likely as we start using leading indicators designed for other industries.
  • Make sure you can gather good data. I have an ap on my iPhone that helps me to track what I eat. I set a weight loss goal, a timeframe for completing it, and the ap tells me how many calories I can consume to be on track to meet my goal. The ap matches up with my Nike Fuelband and adjusts my caloric total based on my activity level. These are two great leading indicators that are easy to track. Good data makes it easier to keep from being mislead by the indicators.

In a nutshell, that ap is a good explanation of indicators: you set a goal, you identify the activities most likely to result in the results you desire, and you measure your progress toward those goals.

Filed under: Safety

Ten Tips For Creating Appropriate Safety Incentives


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

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