By Phil La Duke

“Every system is perfectly designed to get the results it gets.”

-       Paul Batalden, M.D.

There are two ways that things happen in the workplace: the way they are SUPPOSED to be done and the way they ARE done.  It’s a simple fact. And yet so many safety professionals and business leaders ignore this fact and this fact lies at the heart of worker safety. We all know that people deviate from the standards; they drift from the standard operating procedures, take short cuts, and make mistakes.  Machinery wears out. There are materials shortages; equipment failures and facilities hazards combine to make injuries all but certain. And yet when tragedy strikes, we talk about what was supposed to happen and scratch our heads in wonder and ask why it didn’t happen the way we thought it would.

It’s a ludicrous dynamic but one that plays out daily in workplaces across the world. This charade puts workers at risk.  Workers are expected (at least on paper) to do things the way they are prescribed by the standard work instructions but in the real world things don’t always go according to plan.  Sometimes this variation leads to serendipitous discovery, but more often it leads to injuries.

The problem with trying to keep the workplace safe is that while the workplace seems static and fixed.  Imposing a single, rigid procedure in place governing a amorphous and changing series of events is like trying to saddle a whirlwind. It’s madness to try to impose a single correct, safest way to perform a task. Instead, we have to consider safety holistically.  We need to equip workers with the skills and tools they need to assess each situation and to modify the way they do their jobs according to context and situation. The secret to keeping workers safe is in making them mindful of the need to adjust and modify the way they do their jobs and to empower them to make decisions related to how they do their jobs.

There are some practical obstacles to this approach, but the task isn’t insurmountable.  A good, robust procedure will likely cover most contingencies, and a list of if/then decision trees can be developed to guide the worker in the decisions required for those statistical outliers.

For this holistic approach to work, workers need to be trained in problem solving, decision analysis and several other quality and analytical thinking tools.  But don’t go crazy, the world doesn’t need yet another convoluted process to confound workers and empty the pockets of desperate business leaders.  Think simply.

First, invest in training in the core business skills.  If the workers understand the mechanics behind precisely how the company makes money—what key elements must be managed most effectively to ensure profitability, what factors in the business climates have the most impact on the bottom line, and all the other things that a good executive needs to know about the business—the workers can make better decisions and take educated risks that can lead to a more efficient operation.  Next, establish clear guidelines that identify where the worker is empowered to make decisions about how to do the job.  While it may be appropriate to do a step out of sequence to compensate for part shortages, it is not appropriate to avoid tying off while working at heights or ignoring lockout requirements because the time in the protected area is negligible.  By clearly delineating where deviation is appropriate and where it is not the worker can apply his or her judgment with confidence.

Finally, hold worker accountable for managing the risk of deviation.  If the worker is unable to complete the task following the prescribed standards, he or she must mitigate the risks (not only to safety, but to quality and cost as well).  Workers who understand their work, how the business works, and where he or she is empowered to make decisions are infinitely more valuable than workers who are terrified of making a decision because it might be wrong.

This management style may be scary for some managers, especially safety professionals.  But consider this: workers are already out there doing this.  When asked to do the impossible most workers (at least the ones we value the most) will do what is possible and hope for the best.  Few workers simply give up when the prescribed process isn’t possible, rather, they look for ways to substitute materials for those that they are missing, they use makeshift tools when the approve tool isn’t available, and they make uninformed decisions because they haven’t been properly trained to make better decisions.  As workplaces are staffed with less and less supervision it is imperative that workers be trusted to make the decisions related to the tasks that they do hundreds or even thousands of times a day. We have to stop patronizing workers by saying that they know the job more intimately and expertly than anyone ever could and start acting as if this were true (it is by the way).

There’s a lot of talk about empowering workers and holding them accountable for safety.  That’s great, but such empowerment requires training, guidance, and most of all trust.  Workers will likely rise to the occasion if the organization treats them like the intelligent, hardworking, and conscientious workers that they are.  But these workers also can smell condescension and lies a mile away. Holding workers accountable for making good decision and safe choices requires trust.

Organizations that are successful in building qualified, skilled decision makers who are empowered to deviate from the standard, take calculated risks, and make important decisions about their worker will find themselves successful in ways they never dreamt possible.  Not only will the workplace become safer, quality, morale, and cost management will also improve.  The benefits of this approach far outweigh the risks and costs associated with it.

By Phil La Duke

In the world of continuous improvement, there is the concept of “Cost of Quality”. It’s a bit counter intuitive.  The term after all, doesn’t refer, as you might expect, to the money companies must spend to ensure that products and services are delivered at the utmost value, but the money companies lose by screwing things up.  You might wonder why those who coined the phrase didn’t just call it “Cost of Defects” or “Cost of a Lack of Quality”.  But the term, as misleading as it may seem, goes deeper than the cost of defects.  Cost of Quality considers direct costs like scrap material or rework, and indirect costs like loss of faith on the part of the customer.  Those who examined the cost of quality was far more complex than a handful of metrics and attempt to get a fuller picture of the true costs associated with poor quality.

There’s a lot safety professionals can learn from the Cost of Quality.  Think of it as the “Cost of Safety”.  These costs aren’t about counting the cost of safety glasses or wages paid to the safety department; rather it’s about the real costs of an unsafe workplace that goes far deeper than the cost of treating injuries. The cost of unsafe workplace can be calculated by tracking both the direct and indirect costs of an unsafe workplaces.

Direct Costs

Direct costs are often obvious costs that are easy to calculate and include:

• Medical Treatment. Spiraling medical costs are at the forefront of most businesses, and yet strangely, few connect injuries with medical costs. Everything from Band-Aids and aspirin to surgeries and casts and crutches should be calculated in the cost of unsafe workplaces.
• Wages For Medical Personnel. A significant cost of unsafe workplace includes the wages to plant nurses and doctors or the annual fees paid to clinics for those who don’t have on-site medical departments. These wages and fees are often paid irrespective of whether or not any medical care is provided. This having been said, the more unsafe the workplace the larger the medical infrastructure.
• Record Keeping and Paperwork. Injuries require a high volume of paperwork and record keeping.  Every page of paper work has some wage associated with it, and the clerical and administrative
• Workers’ Compensation costs. Workers’ Compensation payments are determined by the cost of worker injuries, but often these figures are treated as independent overhead costs.  It is mind-boggling how many company controllers jealously guard these figures from safety professionals and operations leadership.  In too many organizations, Workers’ Compensation is seen as a problem of fraud, poor case management, or even overhead.
• Loss of production/Downtime. Time is money, and any organization needs to keep the machine running.  Injuries are a major disruption and the resultant loss of work is wastrel and expensive.
• Scrap. Contamination of products (in food production, the chemical industry, and some other industries where blood can destroy substantial amount of goods produced.)
• Wages paid to first responders. First responders to work place injuries are seldom paid emergency response professionals.  Instead, coworkers and supervisors are typically the first on the scene and when they are dealing with injuries they aren’t doing the work for which they are paid.
• Legal Fees. Where there’s an injury there is typically a legal fee. Whether it’s the fee paid to an attorney to defend against a lawsuit or fees paid to case managers the money paid in response to worker injuries is often sizable.
• Wages Paid to Investigate the Injuries. Workplace injuries must be investigated and these investigations consume considerable resources and as I say, time is money.
• Fines. Fire code violations, OSHA citations, and fines associated with injuries are all under the umbrella of “fines”.  High profile disasters tend to draw expensive fines that draw public scorn.

Indirect Costs

Indirect costs are far more difficult to calculate and quantify.  Indirect costs include things like:

• Increased insurance rates. When the workplace is unsafe insurance companies, worried about high cost claims, raise the rates.
• Negative public relations. Companies spend millions on marketing and advertising only to have their good names smeared because of a high profile safety incident.
• Increased employee turnover. Organizations with high injury rates tend to have higher turnover rates than their safer counterparts. The costs associated with increased employee turnover are well documented and significant.
• Greater recruiting costs. Recruiting costs are correlative to the hiring company’s reputation.  As organizations are known for poor safety records job candidates are increasingly reluctant to join the ranks of bad corporate citizen.
• Increased absenteeism. People who don’t feel safe at work tend to be absent a lot.  It’s a vicious circle; injuries lead to absenteeism that in turn puts the workers who do report to work at greater risk of injury.
• Lower efficiency. Efficiency is calculated by determining the number of hours it takes to produce goods or deliver services. Since time is lost to worker injuries and all the factors related to those injuries companies that hurt more workers are less efficient than those who hurt fewer workers.

Bringing It All Together

The unsafe workplace costs a lot of money, but some safety management systems require such high upkeep costs that any savings associated with their successful implementations are essentially a wash.  Many safety professionals make the mistake of spending more on prevention than anyone could ever hope to recoup.

By Phil La Duke

Thou shalt not kill. People have been using rules to protect people since man left the primordial forest and walked up right for the first time. For people some rules are sacred—they are worshipped for their own sake. For others, rules were meant to be broken. Irrespective of your view of rules, they form the foundation of society of all levels. But when we rely on rules to keep workers safe we delude ourselves into thinking that rules alone can protect workers (or anyone else, for that matter) we imperil workers, customers, vendors, and ourselves.

People don’t follow the rules. I’ve written and spoken extensively on why we don’t follow the rules (http://www.fabricatingandmetalworking.com/2011/05/why-we-violate-the-rules/) so I won’t prattle on about the whys here. The fact that people don’t follow the rules really isn’t the problem. The real problem lies in safety professionals and Operations officials expecting people to follow really burdensome and in, many cases, stupid rules when they know that they won’t. For rules to be effective there must be a reasonable expectation of compliance.  In other words, if you know in your heart of hearts that nobody in their right mind will do what is prescribed, then irrespective of you employee handbook, it really isn’t a rule.

A Bit On Rules

To understand this issue, we need to understand rules a bit more.  We live and work according to a codified set of behaviors that we give a variety of names—norms, laws, work rules, regulations, etc.—but they all boil down to “rules”.  In general, rules exist to keep us from killing one another—both accidentally and on purpose.

While ostensibly this is the reason for all rules, in reality that’s not always the case. In many cases, rules exist primarily to enable us to punish those people who don’t behave the ways we want them to.  I suppose that serves a purpose, but it sure doesn’t make us safer, and it flies in the face of the idea that safety should be primarily about proactive reduction of risk.

Control freaks love to govern the most basic things in life, and the most lethal tool in their arsenals are rules.  They talk about the rules in the hushed reverence typically reserved for the divine.  Rules afford them an opportunity to control other’s behavior and give them some peace.  If someone violates their precious rules, they react in righteous indignation. But beyond the nuances of rules, rules exist in the workplace primarily to help us to decide who should be punished and even fired.

A Fool’s Paradise

But people, as I’ve said, don’t follow the rules, and organizations that pretend that people do follow the rules put workers at risk.  If we were to shift away from codifying behaviors in favor of mitigating risk, we can prevent more injuries and save more lives that increasing the consequences for violating the rules.

If work rules exist to identify the people who need to be punished and who need to be knocked back in line, how can these rules protect the many innocent bystanders? Even if you believe that over 90% of injuries are caused by behavior, you must admit that rules are fairly ineffective in keeping people safe. (In fact, rules, aka “administrative controls” rank only above personal protective equipment as the least effective safety measures on the Hierarchy of Controls).  The fact that someone got written-up for violating a rule has never saved a single life, at least not directly.  And often it is not the rule breaker who gets injured. The violation that becomes the proximate cause of an injury may happen so far upstream that it seems like the consequence is completely independent from the violation.

So What’s the Solution?

Organizations need to have fewer rules and more guidelines.  A rule is really a reactive measure: Thou shalt not…or you will be… whereas a guideline provides…well, guidance.  Most rules I’ve seen can only govern about 80% of the situations that workers face, and the workers are forced to cheat in the other 20%.  Guidelines can be put in place such that workers are given advice on how to make safer choices and better decisions. By providing more flexible expectations workers can be held accountable for their decisions without the binary and predetermined punishments.  Also, by reviewing the choices workers make instead of whether or not they violated the letter of the law, the organizations can hold workers accountable irrespective of the outcome.  The risks associated with the decision become the issue, not whether or not a rule was followed or whether or not someone was injured as a result of the choices a worker made.

Guidelines also allow organizations to treat workers as accountable adults instead of mewling children.  When an individual is given guidelines coupled with expectations about their behavior it eliminates excuse making and whining.  I think about times when managers defended their avoidance of holding workers accountable by whining, “well, there isn’t a rule against it so there is nothing I can do”. I would answer their arguments by pointing out that there isn’t a rule against me defecating in their wastebaskets, but if I did it they would quickly find a way to stop me.  It is, I admit, a crude example, but it elicits a visceral response that proves my point.  We have some reasonable expectations that people will behave as grown ups, and grown ups can be held accountable to behavioral norms that can be spoken or unspoken.

Common Sense Isn’t Common Practice

We walk a fine line between communicating our expectations and holding people accountable for egregious behavior and really, REALLY stupid decision-making.  In the end the line is where we as individuals draw it.  Generally speaking,  we should err on the side of caution and communicate our expectations, provide guidelines for decision making, and hold people accountable for the decisions they make and risks they take, irrespective of the outcome.

By Phil La Duke

By far the most universal belief in worker safety is that safety is impossible without top management commitment and action.  It’s also the most offered excuse for the failure of a safety management system.  I don’t think I have ever attended a safety conference where I didn’t run into at least one caterwauling, simpering, burnt-out safety professional who blamed all his failures on a lack of support from leadership, or management.

Too many safety professionals are orphans of the modern workplace; helpless eunuchs who are afraid to do their jobs.  In most cases, the safety professional is both leader and management.  What’s worse is that they don’t want their jobs to get better; they would rather have sympathy.  Too many safety professionals would rather stand on the sidelines and grouse that the game is fixed and they have been cheated than to get in the game and win.

Deming believed that organizational transformation was everyone’s job; that everyone in the organization played an integral role in moving the organization away from outdated methodologies and obsolete values and toward a high-functioning organization that is capable of competing on a global scale.

Deming was big on vision but offered little in instruction as to exactly how we are supposed to achieve the desired state.  A lot of people criticize him for that, but I think Deming’s lack of prescriptive tools is the greatest manifestation of his genius.  There is no magic bullet in business, and there is no one solution that every organization can implement that will guarantee success.  Ideas need to be adapted to the business conditions of each individual organization and environments. And while there is no magic recipe for transforming a corporate culture, here are some general guidelines for exactly who owns what in cultural transformation.

Top management commitment and action

This step resonates with safety professionals who desperately want operations leadership to assume ownership of safety. Certainly senior leadership must be committed to an efficient and safe workplace. If the C-suite doesn’t value safety, then safety cannot exist.  Unfortunately, many senior leaders don’t have a clue as to exactly what it means to transform the workplace into one that values safety. This issue underscores the on-going need for safety professionals to educate leaders in what they need to do to achieve true workplace safety. It’s unfair for safety professionals to expect management support and commitment until they provide, in specific, measurable terms exactly what their goals and methods are, and the tasks necessary to achieve them.

Transformation of Safety

The definition of insanity is doing the same thing over and over and expecting a different result. This idiom nicely describes many in safety. If we are going to transform our organizations into high-functioning, highly effective organizations that value worker safety as essential to business excellence then perhaps the biggest transformation must come in the safety professionals themselves.  It’s time to reengineer safety—scrape away all the fads, the vestigial practices based on junk science, and commit to change.  Changing the safety professional begins in academia.  We need to stop producing generation after generation of safety professionals who are trained to perpetuate safety superstitions based on eighty-year old research. We could quickly add safety professional organizations to this list of institutions in need of transformation. Professional conferences must stop pandering to the safety demagogues and hucksters who gather to tell each other what they already believe. The safety media has to stop buckling to safety vendors who, in many cases, dictate which stories are permitted in print (and before anyone accuses me of belly aching, I have never had a story squelched because of an advertiser, but I have been asked to tone down my rhetoric a bit in response to an advertiser complaint.

Operations

Operations must invest in core skills training and stop pressuring the training function for less time spent in classrooms.  Training remains the single best way to improve workplace safety, and yet Operations often fights to get workers back into production quicker.  This is short-sighted; studies have shown that there is a direct correlation between quality worker training and workplace productivity and worker safety.  Operations must come to realize that there is no such thing as profitability and profits without safety.

Maintenance

Poorly maintained facilities and equipment are significant sources of workplace risk. Unfortunately, too often, the maintenance and facilities departments are given passes for not meeting their obligations for worker safety.  All maintenance and facility managers need do is howl that they don’t have enough resources and too often senior leadership let’s them off the hook.  Lack of resources is not an excuse for not containing a hazard. While it is often impossible to correct a hazard, it is seldom impossible, or even prohibitive to contain a hazard using low-cost alternatives.

Purchasing

Too often purchasing does not look beyond cost.  Buying equipment, tools, machines, and materials without taking the safety of these items into consideration often undermines the overall safety of the workplace.  In some cases, an investment in purchased goods that are more safe to work with and operate will pay off significantly by creating a safer work environment.

Continuous Improvement

In many organizations the continuous improvement group is completely removed and independent from the Safety function.  This organization needs to change quickly if the company is to steward its resources and to improve safety through process improvements. The internecine rivalries between Safety and CI are destructive and should be sought out and exterminated.

Deming was right.  Transformation IS everyone’s job and transforming the organization to one that values worker safety and sees safety as an integral element in workplace efficiency will require unprecedented cooperation between traditional rivals. The work will be hard, but the benefits will make this work worth the effort.

By Phil La Duke

People make mistakes; it’s what makes us human.  The propensity for human error is practically embedded in our DNA. While the idiom holds that there is no use crying over spilled milk, might there not be some benefit in examining the causes, contributors, and catalysts associated with poor decision-making?

Unless safety professionals stop trying to prevent injuries by reminding people not to make mistakes and focus instead on a real course of protecting people from the injuries resultant from the natural mistakes people make there can never be an appreciable advancement in workplace safety. The secret to prevention is predictability, and the secret to predictability lies in understanding of the underlying factors that increase the likelihood of human error, and interferes with our ability to make sound choices and good decisions.

A scientific look at where our systems are likely to fail, and the most likely injuries that will result from those failures are paramount to the successful management of injuries.  The most sophisticated employers use a tool called a Failure Mode Effects Analysis (FMEA) to predict and mitigate the risks associated with process and product failures.  Quality FMEAs require skills and discipline that are sorely lacking in most organizations so even when they are completed it is not uncommon that the analysis is substandard. But even a substandard FMEA is better than being surprised by an injury.

FMEAs aren’t just for predicting hazards, rather, it is a living document that is updated, as injuries are evaluated and new causes and catalysts are discovered.  This newfound data should include information about human error and poor decision-making.  For more than 70 years too many incident investigations have concluded that the cause of an injury was merely human error. This culture of blame and shame meant that once the responsible party was found and blamed there was no further need for investigation, why keep looking once, the cause has been found?

Most of us understand the need to understand the need to repeatedly ask why when investigating the causes, contributors, and catalysts associated with an injury. But the most common mistake in this process is the practice of asking the wrong “whys?” This is especially common when investigating why someone made a mistake or why someone made a poor decision.  Let’s say that a person chose to run a red light and was struck by a car.  The temptation is to have an incident investigation that goes something like this:

Q:     Why did the person run a red light?

A:      Because he was hurrying to get to the job site.

Q:     Why was the person hurrying to get to the job site?

A:      Because he was late for an appointment with the customer.

Q:     Why was he late for an appointment with the customer?

A:      Because he didn’t allow for sufficient time for travel during heavy traffic.

Q:     Why didn’t he allow for sufficient time for travel during heavy traffic?

A:      Because lost track of time.

Q:     Why did he lose track of time?

A:      Because he was busy.

Q:     Why was he busy?

A:      Because business has increased faster than the company’s ability to hire and on-board.

I could go on, but I think you get the point. This kind of linear and stiff investigation doesn’t really work all that well for determining the causes, contributors, and catalysts of human error or poor decision-making. In fact this type of limited, root cause analysis often misses key elements of the situation. A better approach to the same poor decision is a process that looks something like this:

Q:     What was the poor decision?

A:      Running a red light.

Q:     What factors contributed to the poor decision?

A:      Running late, increased traffic, driver distraction (referencing a global positioning system, driver fatigue, and an increased tolerance for risk (he had run yellow lights before and suffered no meaningful consequence).

Q:     What was the catalyst for the incident?

A:      The presence of cross traffic.

Q:     What controls could have been put in place that would have prevented this accident or mitigated the risk of injury?

A:      Training, risk awareness, calendar software, policies prohibiting the use of GPS devices in the car.

Q:     Which of these controls can be practically implemented?

A:      Calendar software and training.

Q:     To what extent is the worker effectively managing the things in his life that are likely to undermine his decision-making?

A:      Poorly, this is the fourth case this year in which this employee has taken unreasonable risks that resulted in a near miss or injury.

Q:     What measures have been taken to improve the worker’s management of the factors that contribute to poor decision-making?

A:      Counseling, training, and a verbal warning.

This type of investigation (and there are scores more questions along these lines) provides a far better view of the situation and therefore affords a far better opportunity to correct the system issues that are likely to create or contribute to risk. Under the current system, if safety professionals were coroners the causes of most deaths would be that the person stopped breathing or that their hearts stopped beating. There is far more to understanding safety than determining a fraction of what caused the injury.  Safety is detective work and too many safety professionals get it wrong.

There may well scant little use in crying over milk spilled, but in understanding the context in which an injury or near miss occurred, one can not only prevent similar incidents in the future, but can prevent a host of other injuries that result from the same system failure; injuries hard to imagine or measure. It’s only through this kind of holistic and contextual view of safety that we can ever truly achieve more robust processes that greatly reduce the likelihood of injuries.

You may not prevent every injury, but that doesn’t make it impossible. FMEA’s and other predictive tools should be used to identify areas of greatest risk and efforts should be made to reduce the risk of injuries to the lowest practical level. Sometimes the true nature of safety lies less in the prevention of injuries and more in the disappointment when we fail to do so.

By Phil La Duke

I was raised that litigation, that is suing someone, was a last resort. My father believed that a man tried everything in his power to resolve his differences through assertive negotiation, and only after every other method had been exhausted he should then, and only then consider suing. Even then he was as likely to forget it than he was to file a lawsuit. I inherited those values.

I have only been in one lawsuit (I had to sue a crooked landlord for return of my security deposit) and in retrospect despite winning, I still debate whether it was worth the trouble. Ironically, my father, as he lay dying of mesothelioma, was embroiled in lawsuits with the companies who willfully and negligently killed him.

“First the we do, let’s kill all the lawyers.” This quote from Henry VI (which is not the fifth sequel to Henry) is among William Shakespeare’s most famous. It would seem that even back then lawyers were a less than loved profession. Unlike many, I don’t hate lawyers. Heck, I don’t even hate frivolous lawsuits. Are we too litigious a society? Maybe. It’s also likely that we have a lot of people who take reckless chances that results in injuries to others. Do people get ridiculously big settlements on dubious claims? Sure. And I say “so what?” It’s a small price to pay for changing people’s view of risk. I live in an area of the world that gets snow practically half the year. I hate snow. I hate every breathing moment of the time I spend shoveling snow, salting walks, and everything else that I do to make sure that pedestrians have a safe pathway through my property. Why do I do something I hate? because I don’t want to get sued.

Lawsuits, even some of those frivolous ones brought by ambulance chasing television lawyers, make us think, and if the consequence is big enough and frequent enough it changes our behaviors both as individuals and a society. People who aren’t afraid of jail (having never watched OZ apparently) will shrivel in fright at the mention of a lawsuit. We owe a lot to the threat of lawsuits. Businesses take lawsuits seriously, and often we feel that our hands are bound because the lawyers upstairs (or across town, or where ever) are afraid our actions will get us sued.

Lawsuits have changed the way doctors treat patients, the way jobs are designed, and have resulted in a whole lot of product improvements that would never have happened without at least the threat of lawsuits. Sure it limits our freedom. I used to take a decongestant that has been taken off the market after half a dozen people died from taking it. If it were still available I would take it now. Right now. And I’m not even feeling congested. But it was taken off the market. Companies’ responses to lawsuits force them to protect us from our own stupidity, carelessness, and human errors. And companies have that responsibility.

Companies know, or should know, the risks of using their products or following their procedures far better than I will ever know, and with that knowledge comes a greater responsibility for protecting the less informed, less capable, or plain old stupid. I know some of you are thinking, if your dumb enough to do…you deserve to die. Hitler felt much the same way when he justified killing off Jews, gypsies, the mentally or physically infirm, or anyone else his eugenic philosophy deemed not worthy of life. People are forever making mistakes, but no one should have to die because of an error.

It’s easy for you to sit there and think, yeah, but some of these lawsuits are just ridiculous, but I’ll bet you’ve done some pretty stupid and dangerous things (probably while driving and probably while dinking around with your phone) that could have easily gotten someone killed. It’s easy to think that strangers who do stupid things should have known better and deserve to die, but what about you or your loved ones? Do they ever do stupid things? Should they have to die because of it, or is it sometimes okay to hold someone accountable who knew of a danger and decided to conceal it?

Lawsuits (or the fear of lawsuits) force companies to protect workers when it would otherwise be judged too costly or impractical to do so. Drunk driving wasn’t really judged to be all that serious a problem until high profile lawsuits and settlements created a public awareness and dissatisfaction. And the same can be said for a host of other socially unacceptable behaviors that were once the norm.

It’s okay to resent the loss of freedom, and that’s what lawsuits have done, taken away our freedom. But I don’t think that it’s the loss of freedom that most of us resent, it’s the loss of ignorance. Once we knew that there was lead in the paint, carcinogens in the artificial sweeteners, and that windshield glass was likely to decapitate us life got a little less fun. It’s not that lawsuits prevent us from doing the things we used to love, it’s the knowledge that the things we used to love are far riskier than we used to believe. It’s the disappointment of knowing that it’s too dangerous to do the things we used to enjoy. Gone are the free prizes in cereal boxes and cracker jacks; sure they choke a good bunch of kids each year but is that too high a price to pay for the blissful joy of getting a free tattoo? So let’s not blame the lawyers (damned their oily hides!) or the people who unknowingly take stupid risks for our disappointment.

Let’s place the blame squarely where it belongs on our own shoulders. Because somewhere deep down inside us we’d all rather not know the risks and live in a fool’s paradise instead of living and working harmoniously with houses and jobs filled with toxins, poisons, and death traps.

And let us never lose sight of the fact that the best way to avoid being sued is not to subject others to unnecessary risk or harm.

By Phil La Duke

Many safety professionals are ignorant of, or actively ignore, one of the primary elements of worker safety: risk. At this point, those of you who read my posts primarily to take offense are huffing and puffing while secretly excited while muttering, “how dare he”.  It’s a fair reaction; most of us feel that a good portion of our time is spent managing risks. Unfortunately, most people define risk as the probability that someone will get hurt.  They’re not far off, to calculate risk we need to calculate the probability of an undesired outcome and multiple that figure by the severity of the most likely outcome.  The problem with this approach is that neither figure is calculated in any sort of fixed, standard approach, which leaves safety professionals to calculate both the probability and the severity by using the PIDOMA method (Pulled It Directly Out of Mid Air) or as I like to refer to it as the “Rain Man” method (“It’s about a hundred hours”).

The true key to managing risk isn’t in calculating it. After all, as long as we calculate risk the same way every time we assess it, and we treat risk as relative to all other conditions then we have a useful tool for managing risk. No, the true secret to managing risk lies in understanding where risks come from.  Risk is everywhere, and people manage it intuitively.   We put ourselves at risks when we get up in the morning, drive to work, interact with people, and basically DO anything.  Managing the risks involves recognizing the risk, making smart choices based on our values and priorities, and doing our best to make sure that we’ve covered our bases in terms of the path not taken.

Whenever we are forced to choose between competing or concurrent priorities we have risk and we are asked to make these choices a lot. The role of the safety professional is never to be the barking rat that harangues Operations into choosing safety in all cases.  Too often safety professionals get all twisted up whenever Operations decides that safety isn’t, in a very tightly controlled and managed situation, the biggest problem afoot.  Sometimes, safety it competes with other priorities, and the safety professional must be a key resource for managing the risks when safety isn’t the biggest fish to fry at the moment.

Personal values can compete with in us AND they can also compete from worker to worker.  There aren’t any easy answers and it’s easy for some to dismiss the argument as reckless or deliberately provocative, but consider an ambulance. The ambulance crew must balance public safety, their own safety, the safety of other drivers, and the safety of pedestrians. Clearly most of these groups would be safer if ambulances stopped at traffic signals, obeyed the speed limit and drove only in accordance with normal traffic laws.  But as a society, we judge ambulances as serving a greater good by speeding, driving through red lights and driving around other vehicles.  The wellbeing of a single patient is deemed a “justifiable breach” of the rules. Even though only one person is at risk, the relative risk of catastrophic outcome far outweighs the risk posed to other drivers by an ambulance.  The risk of collision with other drivers is real, however, and as a society we manage the risks. First, we make special provisions in the law that give ambulances the right of way; they are held to a different legal standard and are given the right of way in most instances.  Next, we equip ambulances with lights, sirens, and other visual and auditory equipment to alert other drivers and pedestrians of the presence of ambulances. Finally, people who are caught failing to yield the right of way are subject to legal punishment.

Of course not all priorities are so cut and dried. Sometimes the priorities are as vulgar as safety and cost.  I know of one large manufacturer who decided not to correct a high-risk hazard because removing it would cost over a million dollars.  Clearly an evil corporate villain right? Wrong.  After analyzing the risk of the hazard and judging that removing it would be too costly, the company decided to contain the hazard and manage the risk until the process became redundant.  By recognizing the conflicting priorities and managing the risk, the company was able to make the condition safer (although not removing it all together) without incurring the cost associated with the ideal solution.

Value Conflicts

Some conflicts go deeper, like when you have to choose between two or more conflicting values.  Just as with conflicting priorities, sometimes we are forced to choose between the things we cherish the most. There are times when we are forced to choose the least loathsome option, the lesser of two evils. Value conflicts tend to put us at far greater risk than priority conflicts.  Because we are forced to compromise one of our values in pursuit of another, we tend to feel guilty and even angry.  The temptation to make ethically sketchy choices becomes very strong. Furthermore it is easy to justify making poor, even unethical decisions when we need only justify the outcome with a shrug and a “what was I supposed to do?”

The greater the risk, the greater the need for mitigation and risk management.  Instead of treating the decision as a binary choice (right or wrong/yes or no) we need to look for other options.  Even in the worst value conflict usually can be made less risky by acknowledging that the conflict exists and by looking for ways to minimize the likelihood of a catastrophic outcome. You should notice that I said “catastrophic” and not “undesirable”; whenever we are forced to make this kind of choice all alternatives are likely to be undesirable to some degree.

We live in a complex world where we are routinely asked to make tough choices between completing priorities and conflicting values.  If we recognize that we aren’t the only ones who are forced to make tough choices, we might come off a little self-righteous and a lot more valuable.

For years I have been advising the leaders of organizations to meet regularly to, among other things, review the efficacy and appropriateness of their policies and rules. An important element to any organizational governance is to review all policies regularly and in the context of a changing business environment. Safety trends and leading indicators should lead senior leaders to anticipate future issues and concerns and policies and rules should proactively address future needs.  Not only should the rules make sense now but they should also be positioned to address emergent needs. Policy review can be tough.  It can sometimes be tough to differentiate between rules that are important for protecting both the organization and workers and those rules set in place by an irrational human resources fusspot or a megalomaniac attorney.

As I reflected on policy[1] review it occurs to me that every rule should meet three basic elements.  So when you’re safety strategy committee reviews your organization’s policies, there are three basic tests that every policy (not just safety) should pass:

The Compliance Test

In the law[2] for a loan to be enforceable there is generally a requirement that the person who “loans” another money must have a reasonable expectation of repayment.  Basically, that means that one can’t give money to someone they know will never be able repay it and then enforce it under the law.[3] I think this is a legal principle that you should be applied to any and all policies in an organization.  Any policy must have a reasonable expectation of compliance. In other words, if you know good and well that the majority of the population won’t comply to the rule you should dump it.  Take for example rules against speeding.  If you are running a trucking firm (or any company that requires many or most of its employees to drive significant distances) you may be tempted to institute a “zero-tolerance” for speeding. But if you, at the same time, you expect productivity levels that essentially require the drivers to speed, then you really don’t have a reasonable expectation of compliance.

This test is also good for exposing “nod-and-a-wink” policies where organizations outlaw practices on paper on which they rely for the completion of day-to-day operations.  These can include using unsafe vehicles or machinery, concealing noncompliance during government audits, or knowingly establishing processes that are unsafe.

A reasonable expectation of compliance cannot be claimed in cases where the policy prohibits where long-standing practice of the population deems the practices in question as acceptable.  This particular criterion can be dicey—there are things that people have done for years that may suddenly become illegal and in these cases it doesn’t matter how many people have been engaged in a practice or for how long they’ve been doing it.  The law supersedes corporate policy, after all.

A final group of policies that will likely fail this test are policies that because of custom are considered voluntary. When the corporate culture tacitly encourages noncompliance (for example when supervisors openly ignore a rule) it cannot claim reasonable expectation of compliance.

The Test Of Higher Order

All policy should serve a greater good. By that I mean that all policies must do more than impose order in the workplace they must also serve a greater good. The rule should do more than restrict an individual’s freedom because a given behavior irritates a leader, appeals to a leader’s whims, or otherwise restricts liberty and freedoms guaranteed by law simply to meet the capricious demands of heavy-handed corporate despots. In other words, is there a legitimate business reason for the rule or is it more about pandering to the infantile fits thrown by the baby in the corner office playpen? When examining this test, ask yourself, why do we need this rule? If you find yourself hemming and hawing as you look for a reason, or if people roll their eyes when you insist that civilization will end if you repeal the rule, you had ought consider revising or repealing the rules.

The Fairness Test

Organizations should be able to enforce all their rules and policies fairly and equitably. Equitable consequences for non-compliance are more than just important for the sake of fairness or morale, but for legal reasons as well. If a disciplined employee of a protected class can demonstrate that he or she has been punished for violating the rule while people outside the class have been allowed to violate the rule with impunity.  If said employee can demonstrate a pattern of such behavior the organization can find itself in significant peril. But forget whether or not the enforcement of the law is legal for the moment—let us never mistake that which is legal for that which is right—and let us focus on what is fair. Unless a policy can be unequivocally and without reservation be seen by the population as fair and just it can never be considered a valid policy.

Everyone knows that any organization that cares one whit about safety has to have a safety committee. But do they? Most safety committees that I have seen are little more than opportunities for people to eat doughnuts and bitch about how little the rest of the organization cares about safety.  These gripe sessions afford the safety professional to play the role of the of the long-suffering martyr while frustrated team members complain that Operations leadership won’t invest in safety, maintenance won’t address the things that need to be fixed. Nothing much is produced by the committee beyond carbon dioxide and occasionally methane.

But it need not be this way.  An effective safety committee can manage hazard correction, inform safety strategy, and help to foster a culture that truly and deeply value worker safety.

While there are many reasons why a safety committee can fail—probably as many reasons as committees themselves—there are a critical few reasons that are nearly universal to the ineffective safety committees:

• Poor Meeting Skills. The poorest performing safety committees all seem to share the same crappy meeting skills. There are no agendas (or if there are agendas they are so poor that they are essentially just pieces of paper with no value), little courtesy (people talking over each other, wandering wildly off-topic, or just generally behaving rudely), and meeting notes, if issued at all, are largely ignored.  The lack of meeting skills isn’t limited to safety committees of course, but the need is more acute when the purpose of a meeting is to make the workplace safer.
• The Committee Lacks A Clear Definable Purpose.  Safety committees should start with a charter. A charter is a document that identifies the purpose for the committee and the parameters under which it will operate.  The committee should periodically review the charter, and if it has wandered off path the chairperson should adjust the activities such that the committee returns to task.  Each member should have a clear understanding of the goal of the committee, and for that to happen the goal must be expressed in tangible observable terms. Goals like “make the workplace safe” or “protect workers” aren’t useful.  The charter must describe the goal in operational terms, as tasks that lead to a greater end.
• The Role of the Committee is Murky. In the worst performing safety committees it’s difficult to tell exactly what their roles are. Are they tactical? Are they strategic? Are they supposed to inform policy? Should they be monitoring and directing corrective action? In most cases, the safety professional associated with a poor performing safety meeting can’t answer these questions with certainty or honesty.
  Personally, I have found greatest success in dividing the safety committee into two teams, a tactical team that is focused on hazard management and incident investigation, and a strategic team that focuses on policy updates, emergent trends, and an overarching strategy for dealing with foundational issues that jeopardize worker safety.
• The Committee Has an Inappropriate Make Up.  The biggest issue facing ineffective safety committee is that membership is voluntary.  Voluntary membership creates a committee comprised with the greatest desire and or devotion, but not necessarily the greatest skills, power to make decisions, or power to persuade. That’s great if you are organizing a rummage sale or a church picnic, but it’s inappropriate for a group where the output is meaningful and truly important (if you think that organizing a rummage sale or church picnic is important—on the level that worker safety is—you are delusional and dopey)
  An Operations leader who has the power to make the decisions with which the committee is tasked leads the most effective committees.  Furthermore, the committee itself should be comprised of empowered representatives from materials, maintenance, and each operating departments.
• The Committee Lacks Effective Tools. Too many safety efforts miss a key element of hazard management: a database that electronically tracks the progress of hazards from identification to correction.  I used to sell an off-the-shelf software that tracked hazards, emailed the responsible parties, and tracked many of the key metrics.  What I learned from selling this database was that for most companies it is far more effective and valuable to develop their own software than it is to force fit an off-the-shelf solution to its needs.

A good safety committee can be an indispensible part of a high functioning and robust safety management process, but it doesn’t just happen.  An organization needs to carefully design its safety committee such that it aligns with, and supports, the overall safety strategy.

Years ago I read an article by a researcher in sexual harassment. The article was called something like Is Your Company Ripe for Sexual Harassment it was an excellent article that I have long since misplaced and whose author I have forgotten. The basis of the article was that there are clear cultural warning signs, risks factors if you will, that greatly increase the risk of a sexual harassment incident. This got me thinking about all the hullaballoo about creating a “Safety Culture” and what the warning signs might exist to tip off safety professionals that the lack of injuries has been more about luck than about safety management.

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• An Unstable Process. Process variability has been identified by Continuous Improvement/Lean advocates as widely destructive to quality and efficiency, but it also creates an increased probability that workers will be injured. Things like parts shortages, falling behind in production, or widespread process inefficiency are key indicators of heightened risks of worker injuries. To that end, any good safety program should monitor these indicators as part of a balanced scorecard program.
• Lack of a Formal Training Process/Weak Training Infrastructure. I’ve been pontificating for years that the best way to protect workers is to ensure they have completely and accurately mastered the core skills associated with their jobs. A lack of formal training or a weak training infrastructure are clear indicators of risk.
  One of the great dangers, unfortunately, is that many organizations erroneously believe they have adequate training. A formal training process should be rooted in needs identification—that is, training needs to be based on a gap between the skills that workers have and the skills that they need to safely and accurately do their jobs. The characteristics of an effective training program are:

1. The Effectiveness of Training is Regularly Evaluated. Training is typically evaluated at four levels and the data derived from these evaluations are used to make the necessary improvements to the courses.
2. All training is tracked. Keeping training records is a component of certification programs like ISO, VDA, etc., but third party auditors rarely look beyond records of classroom training. On-the-job training, or training delivered at the workstation also need to be tracked and evaluated.
3. Training Supports Operations Strategy. Too often training departments are left to their own designs and there is often a disconnect between training and the overall Operations strategies. This disconnection effectively emasculates the effectiveness of the training to the point where funding training is a waste of resources.

• High absenteeism, High employee turnover. High absenteeism and or Employee turnover can be symptomatic of several things. First, it is a good indication of poor morale, which in itself a risk factor (it is often both a cause of increased risk AND symptom of poor safety practices). Second, it means a great deal of churning of the population with new and inexperienced workers continually entering a chaotic workplace that substantially increases the risk of injuries.
• Lack Of Formal Processes. It might surprise you to learn how many companies don’t have a single, standard way of doing a job. In many companies workers are given a goal and expected how best to accomplish it.; this is particularly true of office environments, warehouses, and transportation companies. Because there is no single correct way of doing things there is dangerous levels of variation between the ways two different workers approach the same task. And where there is variation there is risk.
• Lack of Compliance. Companies that only think about compliance when an auditor shows up for a surprise inspection are far more likely to injure workers than those who understand that compliance is not enough. While it is true that compliance does not save lives, noncompliance is a strong indicator of the relative value the organization places on safety but on following procedures and rules overall. Regulations exist in part to impose order on chaos, and organizations that ignore them tend to put themselves at risk.
• Incentive-Driven Organization. Incentives are a cornerstone of most behavior-based safety programs. But these cherished practices (fairly naive and arrogant when you consider it; it supposes that the primary reason that people are getting hurt is because working safely doesn’t get them a Frisbee with the company logo and a safety slogan blazoned on it) can create under-reporting, which in turn, masks real dangers in the workplace. Of course some incentive programs (those which provide incentives for participating in safety initiatives, suggesting safety improvements, or finding and correcting hazards are appropriate and desirable, but these aren’t indicative of an incentive-driven organization, instead, they indicate an efficiency-driven organization.
• Lack of Discipline. Rampant violation of safety policy (for example an organizations seeming inability to enforce PPE usage) tends to belie an attitude that says, “safety isn’t really a priority”. Unless the workers and their supervisors show a real commitment to safety protocols there will always be significant risk of injuries.
• Weak Management. Ineffectual managers increase the probability of injuries because ineffectual management tends to increase process variability and as I have mentioned again and again, the greater the process variability the greater the risk of injury.
• Misalignment Between The Company ‘S Stated Vision And Organizational Norms. In many organizations the company mission and vision are merely words on a poster, and in those organizations this misalignments usually indicates a leadership team that has no real understanding of why a company needs to have a vision or mission. Not only can a house divided against itself not stand, it tends to hurt a bunch of its occupants in as it teeters on the brink of disaster.
• A Lack of Near Miss Reporting or First Aid Tracking. One of the most important sources of information about the risk of injuries can be inferred from Near Misses and first aid cases. Companies that fail to effectively identify and manage these indicators tend to be at greater risk of injuries.

Of course there are other indicators of risk, some are universal and others are esoteric to an industry, organization, or even a specific location. Safety professionals should look to design and build their own safety indicators that they track and interpret.

If you enjoyed this post, I hope you will consider sharing it. There are buttons that will allow you to tweet this, share it on Facebook (think of it as payback for all those “if you love your mother you will repost this” crap your friends subject you to), post this to LinkedIn groups, or emailing it to people. Don’t be afraid, the life you save might be mine!

I hope you will join me at my National Safety Council speech, Social Networking and Safety, this Tuesday in Orlando, Florida. It’s at 4:00 p.m. and by then you will be so sick of other presentations you will likely be praying to die. Don’t die; come to my presentation. I also will be at the Facility Safety Management magazine’s booth meeting readers and signing people up for free subscriptions.

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